The benefits of international volunteering in a low-resource setting: development of a core outcome set

Volunteering, or temporarily working in low-resource settings, is often seen solely as a means of helping those in poorer economies [1]. Many professionals find it difficult to obtain support to volunteer and report lack of recognition upon return, which is disincentive to volunteerism [2]. Furthermore, health professionals that volunteer abroad predominantly do so using annual leave, rather than recognised study leave for continued professional development [3, 4]. The notion that those from high-income countries (HICs) are altruistically offering ‘help’ to those in low- and middle-income countries (LMICs) can also lead to a distortion of the partnership relationship between high- and low-income partners in health partnerships. The low-income partners can be seen as beneficiaries and the high-income partners seen as donors [5‐7]. Furthermore, a tension often exists between UK healthcare professionals and local international staff, as the intentions or role of healthcare professionals and students is often not explicit to the teams with whom they are working. However, the donor-recipient relationship is becoming increasingly contested in recent literature and policy and mutual benefits realised [8, 9].

There is an imperative, therefore, to fully understand the learning outcomes that are possible for HIC health professionals working in low-resource settings and, in particular, to help recognise these activities as educational development [2, 3]. Understanding ‘what’ is gained would allow specification of intended learning outcomes for training and continuing professional development and to make the gain for the HIC more explicit. Understanding under what circumstances learning outcomes occur would result in an understanding of how to maximise that gain.

Literature that explores what and how healthcare professionals learn from temporarily working or volunteering in a low-resource setting tends to report anecdotes or single reports, which provide a lower level of evidence [4, 10]. Furthermore, benefits are detailed in broad categories, with ‘leadership’, ‘communication’ and ‘cultural awareness’ being frequently reported [3, 11‐13], with a focus on one of these skill sets in depth or a list of outcomes under umbrella terms, such as communication or leadership skills [3, 14]. These broad labels make an assessment of the learning outcomes difficult as they might contain multiple underpinning knowledge, skills, practice and attitudes. Self-assessment of broad terms is not well associated with objective performance [15]; individuals struggle to assess themselves in relation to ambiguous or ill-defined traits [16, 17]. Specifying learning at this broad level means that the more granular levels remain unspecified. A higher-level group might contain a wide range of lower-level outcomes and might not contain others, which would reduce the content validity of an assessment.

Understanding the metrics of health professional volunteerism would have a significant impact on current continued professional development (CPD) policy because international experiences could be evidenced as beneficial to personal and professional development. Numerous policy documents about future health workforce highlight the importance of skills such as leadership, communication and adaptability [18, 19]. Such skills have been described as key outcomes of international placements in LMICs, but have yet to be quantified to enable comparison with other learning opportunities [3].

In a systematic review of the evidence of the benefits to the United Kingdom of health partnership work, Jones et al. reported 40 individual benefits grouped within seven key domains (communication and teamwork, clinical skills, management skills, patient experience and dignity, policy, academic skills and personal satisfaction and interest). There were a number of features of this review that makes it insufficient for the purposes of measuring learning outcomes from international volunteering. Firstly, this review focused only on health partnerships, a specific type of health link, and not all types of volunteering or international placements. Secondly, the findings were categorised broadly, with the difficulties of broad measurement specified above. Thirdly, the professions in their search terms were only doctors and nurses. Finally, it did not extract factors that may affect learning outcomes. For the purpose of measurement, we needed to include literature from a broad range of experiences, extract outcomes at a granular level, include all healthcare staff groups and extract variables that may affect these outcomes.

The outcomes for health professionals are not always positive and the costs of international placements in literature have included health consequences, skills degradation and financial cost [3, 20, 21], reputational, health and opportunity [3]. Research has explored the costs and benefits of international placements [13, 20, 22] and barriers to volunteering, but no research has yet listed all reported negative outcome [23].

Many aspects of LMIC placements are different from working in a HIC. Relationships between outcomes and these aspects have been proposed, for example that individuals learnt from the opportunity to interact with more patients or conditions than in the United Kingdom [10, 24] and that longer stays may be more beneficial than shorter stays [25, 26]. These variables have not been systematically reported.

This current paper presents two studies: a meta-synthesis and a Delphi. The meta-synthesis aimed to (a) detail the personal and professional development outcomes of international work, at a granular level, i.e. ‘knowledge about procedures rarely conducted in the United Kingdom’ (rather than at a too broad level, i.e. clinical skills or too specific level, i.e. experience conducting vesico-vaginal fistula surgery); (b) to report the variables that influence these personal and professional development outcomes; and (c) to explore if the review including all types of UK health professional placement and all cadres of staff found the same categories as the most recent review of Jones et al. [3]. The Delphi study aimed to gather consensus from those with knowledge and expertise in international health professional learning and development, to refine a set of agreed core outcomes.

This study aimed to generate a list of core learning outcomes which might be developed through international placements and variables which might affect their development. We found 55 peer-reviewed papers and extracted 133 outcomes and 34 variables Table 3. The most recent research to summarise learning outcomes [3] found 40 individual benefits in seven domains: clinical skills, management skills, communication and teamwork, patient experience and dignity, policy, academic skills and personal satisfaction and interest. Our results support the domains but present the outcomes at a more granular level. For example, the previous review reports ‘management skills’ as a domain, which includes the outcome of ‘leadership and management’. We extracted more granular knowledge, skills and attitudes which would map into the domain of ‘management’, such as ability to manage self, ability to lead by example and ability to manage risk. These more specific outcomes would lend themselves more to measurement due to the reported difficulties with assessment of domains [15, 16]. By extracting outcomes at a granular level, we were also able to highlight many outcomes that do not fit neatly into any of the pre-defined categories of previous research such as ‘ability to cope’ or those that fit into more than one, i.e. ‘ability to disseminate best practice globally’. Our study is the first to summarise the variables which have been assumed or proposed to influence learning in international placements, which will allow for hypothesis testing in the future. The outcome set provides a framework of personal and professional learning across healthcare professional groups. This is important as previous literature has tended to focus on specific professional cadres, so this COS would allow comparison and collation across professional groups [35, 36].

Our study generated a list of 28 potential negative outcomes. It is interesting that only eight of these were retained in the Delphi, i.e. stakeholders were in agreement that these negative outcomes were either not likely to happen or likely to happen to a range of healthcare professionals. Only one negative outcome was considered core: ‘health consequences’. This indicates that stakeholders believe almost all negative outcomes do not happen on many or most placements. There is much less consensus about the negative aspects of placements.

The literature contains stated or implied variables which might influence learning on international placements, and this study has synthesised these, finding 33 variables. This provides a framework for future research that aims to study the interactions between variables and outcomes by empirically testing some of the hypotheses reported or assumed in the literature.

Historically, international volunteering has been conceptualised as a benefit to the LMIC and a loss to the HIC [8, 9]. Recent policy documents explicitly discuss the benefit to UK health professionals in terms of personal and professional development and the necessity to develop competencies to be used in training curricula [9]. This study will facilitate the specification and exploration of learning outcomes and so in the future help in addressing the imbalanced discourse of the “benefitting LMIC” and the “donor HIC”. Additionally, a recent Royal College policy describes what competencies paediatricians need to work globally, or with a global population in the United Kingdom [37]. Many of the competencies described map onto the core outcome set suggesting that international placements themselves may provide a vehicle for developing these necessary competencies. In fact, the core outcome set maps onto policy documents such as the Health Education England (HEE) Framework 15: 2014–2029, which suggests the future NHS workforce needs to be flexible, open to innovation and change and life-long learners (all components of the COS) [18]. The core outcome set provides a way of framing and evidencing the NHS benefits. Future work will focus on how the core outcome set can be used as a tool to measure outcomes. The research has also influenced the production of the Health Education England Global strategy, which aims to embed global learning opportunities into NHS training [38].

In summary, there is a broad range of learning outcomes which we have synthesised into a set of 116 core outcomes agreed by a group of 45 stakeholders from various invested groups that could be used in future assessment of learning and testing of hypotheses about what leads to or detracts from learning. We also extracted 33 variables from the literature. We reported a list of negative outcomes, as well as every variable that has been reported (implicitly or explicitly) to affect learning. The core outcome set and variables will enable the development of assessments of health professional learning in international placements, which has implications for how international placements are created and on the support for international placements amongst UK healthcare organisations.