RESEARCH METHODOLOGY

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LITHUANIAN UNIVERSITY OF HEALTH SCIENCES MEDICINE FACULTY

LANGUAGE BARRIERS AND COMMUNICATION PROBLEMS AND ITS IMPACT ON STUDENTS IN THE MEDICAL FIELD

Department of Anesthesiology Author: Bassel Kanj, MF

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SUMMARY

“A different language is a different vision of Life.”- Federico Fellini

The language has always been the best communication tool ever used, it is the ability to understand and implement complex system of communication, specifically the human ability to do it, making the language the perfect example of such a system.

Many barriers exist in the world and the top barrier used to be the language. Today, while more people are learning different languages aside of their native one, the world is becoming a smaller society where people are feeling more comfortable in communicating.

Today, and due to globalization, we can find that the English language is becoming the number one used language to break barriers between different countries and different cultures.

This research is divided into 5 parts:

- The first part, the introduction discusses the communication system and its development, the language and its barriers and the importance of language in scientific communication.

-The second part, the literature review, it focuses on communication problems and language barriers regarding foreign students .Different articles and studies were used , some conducted in Spain , Italy and Japan about studying abroad and the use of a second language to communicate . Examples were given about Lithuanian and foreign students concerning this matter as well at LUHS.

In addition this part also focused, on communication barriers and its impact on theoretical/practical part of medical knowledge, these barriers that have been found between teaching physicians and international students at LUHS.

-The third part, the research methodology discusses the method used to collect data from students at LUHS. A questionnaire was distributed to Lithuanian and international students from 4^th to 6^th year

medicine, the questionnaire is a self-developed Likert scale (4) structured. In this part results were showed in percentages present in a form of tables.

-The fourth part, the discussion interpreted the data collected from questionnaire in order to clarify the research problem and explain the results. In this part articles supporting the major role of language in communicating with others and its impact on the effectiveness of teaching physicians were used a

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discuss about the measure that should be taken by teaching physicians to facilitate the learning process in classrooms.

Finally, what are the most suitable recommendations to solve this problem or to improve it ,in order to establish better communication, which leads to a better relationship and a healthier study environment.

SANTRUMPA

Šiandien ir dėl globalizacijos mes galime suvokti, kad anglų kalba tampa viena iš pirmaujančių kalbų, jog būtų įveikiama bendravimo kliūtis tarp skirtingų šalių ir skirtingų kultūrų.

Šis tyrimas yra padalintas į 5 dalis:

- Pirmoje, įvadinėje dalyje, aptariama komunikacijos sistema ir jos raida, kalba ir jos kliūtys bei kalbos svarba moksliniame komunikate.

- Antroje dalyje, literatūros apžvalgoje, daugiausia dėmesio skiriama komunikacijos problemoms ir kalbos barjerams, susijusiems su užsienio studentais. Buvo naudojami įvairūs straipsniai ir studijos. Kai kurios buvo atliktos Ispanijoje, Italijoje ir Japonijoje dėl studijų užsienyje ir bendravimui vartojamos antrosios kalbos. Taip pat buvo pateikti LSMU pavyzdžiai apie Lietuvos ir užsienio studentus.

Taip pat šiame skyriuje dėmesys buvo skiriamas komunikacijos kliūtims, jų įtaka teorinėms ar praktinėms medicinos žinioms, šios kliūtys tarp gydytojų ir tarptautinių LSMU studentų.

- Trečia dalis, tyrimo metodika. Šioje dalyje apibūdinamas metodas, naudojamas LSMU studentų duomenų rinkimui. Klausimynas buvo išsiųstas Lietuvos ir užsienio IV-VI metų medicinos studentams.

Klausimynas yra savarankiškai sukurta Likerto skalė (4). Šioje dalyje rezultatai buvo rodomi procentais, pateiktais lentelėse.

- Ketvirta dalis diskusijoje aiškina duomenis, surinktus iš klausimyno, siekiant išsiaiškinti tyrimo problemą ir paaiškinti rezultatus. Šioje dalyje yra nuorodos į straipsnius, kuriuose remiamas svarbus kalbos vaidmuo bendraujant su kitais ir jo poveikis gydytojų mokymo efektyvumui.

- Penktoji dalis, išvada ir rekomendacijos, apibendrinamas LSMU atliktas tyrimas ir gauti rezultatai.

Nurodoma, kaip ši problema įtakoja studentų gyvenimą, jų suvokimą apie studijas užsienyje ir jų sėkmę medicinos srityje iš skirtingų aspektų. Trumpai aptariama, kokių priemonių turėtų imtis dėstytojai, siekiant palengvinti mokymosi procesą klasėse.

Taip pat pateikiamos tinkamiausios šios problemos sprendimo ar tobulinimo rekomendacijos, siekiant sukurti geresnį bendravimą, dėl kurio atsiranda geresni santykiai ir sveikesnė studijų aplinka.

ACKNOWLEDGEMENTS

I would like to thank Professor Andrius Macas, MD, PHD for his fine discernment, attentive advice and support, without which this research would not have been possible. His persistent criticism gave me the desire to accomplish my study. Prof. Macas not only inspired me but made me insist on achieving my

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goals with his impressive ideas that created a small model to ease fulfilling the purpose of the study. I would like to also thank my reviewer Prof. Darius Trepenaitis.

CONFLICT OF INTEREST

To complete this project, 40 students were chosen divided into: 20 Lithuanian and 20 international students from 4^th, 5th and 6^th year medicine and surveys were conducted.

Some of the limitations have been faced during collecting the data:

-Some of the participants were not sure about their answers and others seemed to regret it making them change the pattern of answers

-The personal conversations were short with not much time to get deep

-It was hard to find a large and specific number of students having time to answer the questionnaire due to the amount of work they have.

SOURCES OF FUNDING None.

CLEARANCE ISSUED BY THE ETHICS COMMITTEE

Data analysis was issued by the Center of Bioethics of LSMU no: BEC-MF-111

ABBREVIATIONS

LUHS, Lithuanian University of Health Sciences; LSMU, Lietuvos Sveikatos Mokslų Universitetas;

MENA, Middle East And North African Regions.

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INTRODUCTION

From the beginning of time, humans communicate, and over the years the communication system

developed, and humans started using words and signs. According to Australas Med (3) the communication and the ability to express ourselves satisfy one of our most basic human needs. We engage and

communicate with several people throughout our typical day. Commonly we assume that others hold similar values, beliefs and aspirations as our own. Any deviation from our own views may seem strange, unreasonable and ‘wrong’. As dynamic individuals dealing with equally dynamic ‘others’, our daily experiences shape our perceptions and develop our perspectives throughout our lives.

The implementation of words in the communication system was not that easy, as it took thousands of years to develop the letters, to put them together, to create a word and to give this word a meaning;

following the implementation and definition, languages began to develop, where every group had its own language; these groups emigrated, discovering new lands and settling in, where countries began to exist and develop, adopting the groups’ language.

Common languages exist in border sharing countries such as the MENA region or the North America; and existed due to colonization such as the French and British colonization in Africa.

The language is not only a communication system that helps you send and receive messages, it is a powerful two-edged sword, that defines your identity, your culture and the area you belong to, but it can also categorize you, stereotype you and differentiate you from your surrounding making you a total stranger.

Today, and due to globalization the world is becoming a small society, a society that has many problems, from religious diversity, political disagreements to communication barriers. However, the English

language is playing a major role as a mediator between countries, being the number one used language around the world; it is able to slowly break these communication barriers and be a savior for most of us.

As Meneghini (6) states:’’ Initiatives to increase the quality and visibility of non-English publications might help to break down language barriers in scientific communication’’

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AIMS

The aim of this research is to emphasize on the importance of linguistic performance/competence in medical teaching. This research discusses the importance of language and its effects on the medical students studying at the Lithuanian university of life and sciences in regards to their acquired knowledge.

OBJECTIVES

-To study the variables and facts responsible for the language barriers at LUHS.

-To highlight on the importance of the language in giving medical courses and practices to international students.

-To highlight on the role of professors in facilitating the comprehension of the courses for international students.

-To show how badly the language can affect the relationship between local and international students.

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LITERATURE REVIEW

The Language

The language is a tool in the communication system that consists of words, their pronunciation, and the way of combining them in order to be used and understood by a community; the language can be either spoken or written, used by a particular society or country. It is also used in many ways and for many reasons. The book ‘’study abroad and second language use: constructing the self’’ by Valerie Aveni(1), shows that Humans use language for many reasons, including communication of thoughts, recording of events, and the establishment of relationships. Yet language plays an even more significant social role for the individual. It is through the use of language that we create and develop our own self-image and convey our personality to others.”

Having an additional language to use can cause a certain dilemma, especially if the second language is not well mastered. Aveni (1) purported “With imperfect command of a new language, learners’ ability to reveal their true thoughts and identity becomes severely impaired. A paradoxical conflict results in that the language learner wishes to create and maintain an ideal sense of self in the second language, yet the very act of language use threatens that image.” analyses indicated that intercultural communication emotions were strongly and uniquely related to prejudice toward a culturally diverse out-group: foreign students.

A study conducted in Japan 2016, on the deeper understanding of dental students willingness to study abroad. This study took place at the faculty of dentistry, Tokyo medical and dental university. Students from 1^st to 6^th year participated in the assessment. The results showed that the main obstacle for theses students was the English language.

Communication problems

Throughout the years, communication faced a major barrier called “language”, as it is until today with all the progress and development of the human’s communication system and education, we are still able to find communication barriers between people. According to Australas Med (3) the language we use and our ability to share language with others impact these perceptions and perspectives, and ultimately impacts upon our effectiveness as entrepreneurs, educators, collaborators, etc. Removing that ability or diminishing it in some way can seriously impact how we perceive others and ourselves.

As we know, thousands of languages exist around the world, making building relationships and friendships a hard mission.

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This mission impossible begins when you decide to study abroad, seeking for maturity, adventure and change, believing it is as easy as filling the university’s application form. This is when students face the hard reality; living and studying abroad is very challenging, a new country with a new culture and to get things harder a new language.

Even though the courses are given in English at the Lithuanian University of Health and Sciences, but we are still able to find communication barriers between professors and international students; these barriers play a major role in sending and receiving scientific information regarding medical terms and practices. A research study was conducted in Italy in 2001, about the effect of the language barrier on intercultural communication between study abroad students and the host population. As highlighted by Wolfe (2) which he stated that the language barrier perceived in study abroad programs as it may limit students’

opportunities to interact with the local culture.

In a study conducted in Spain in 2018 regarding studying abroad, a foreign student discussed his

experience in Madrid at a nursing school. This study resulted in 2 different dimensions for communication barriers first: the everyday communication was a hard challenge as it regularly tested his second language proficiency and non-verbal communication skills. As he mentions: ‘one day I was assigned a patient who was status post-caesarian section, who experienced syncope episode. A physician was in the room at the time and began the shout orders at me a in a frantic manner. I couldn’t understand what she was saying because she was using words I’ve never herd before. Fortunately, I managed to call for more help and the health care team was able to stabilize the patient.’

Second: the cultural differences and competencies make it hard for foreign to integrate, as mentioned in this study it is very critical for students planning on studying in a different country to research the culture of the country in advance. Thus the importance of culturally competent health care professionals, whom are able to incorporates the essence and importance of culture in teaching and assessment of cross - cultural relations. According to the National center for cultural competence: linguistic performance ensures effective communication and provides the capacity for conveying information in a manner that is easily understood by diverse and multicultural audience.

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The Communication System Barriers and their impact on theoretical and practical part of Medical Knowledge

The communication system has created different barriers between cultures and countries making it difficult for people to properly build offshore relationships as well as sending and receiving the right idea or information.

When studying abroad, and even though a mutual language is being used, professors and international students are finding difficulties in sending and receiving information.

At LUHS, students come from different countries, cultures and backgrounds united by one language that is the English language. The lectures at the university are given in both Lithuanian and English language;

however international students seem to find difficulties in information processing in certain courses. These difficulties derive from the communication barriers that are found between professors and the

international students, some difficulties are found in the understanding of the theoretical part of medicine, some in the practical part of medicine and others in day to day tasks and assignments.

The professors at LUHS, like many other professors in different universities and countries, do not always find the correct way to send the precise information they would like to share with their students, because expressing in another language and not your native language is somehow very challenging.

The medical field is divided into two parts: Theoretical and Practical parts.

In order to succeed in medicine, students should be able to understand and master the two parts of the medical field; thus understanding and mastering the practical part students should have understood and processed all the information given in the theoretical part.

The difficulties in medical knowledge are due to:

1- The professors’ English vocabulary field is weak

2- The substitute teacher sometimes, do not speak fluent English 3- The professors explain their idea better using the native language 4- International students do not master the Lithuanian language

5- Sometimes Lectures are given in Lithuanian to international students

All these difficulties have led to lack of communication between these students and their professors thus creating tension in their relationship; as well as making the students skip lectures and searching for alternatives such as online tutorials and online video lectures.

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RESEARCH METHODOLOGY

Methodology is the systematic, theoretical analysis of the methods applied to a field of study. It constitutes the theoretical analysis of the methods and principles linked with a branch of knowledge.

Typically, it contains concepts such as paradigm, theoretical model, phases and quantitative or qualitative techniques (Howell, K. E., 2013).

In this study the quantitative technique is used, this research method is the objective measurements and the numerical, statistical and mathematical analysis of data collected through surveys, polls and questionnaires or by manipulated pre-existing statistical data using computational techniques such as the SPSS (Statistical Package for Social Sciences). In this study 2 questionnaires were used and handed out to students, one questionnaire in English and the other in Lithuanian language.

To complete this project, 40 students were chosen divided into: 20 Lithuanian and 20 international students from 4^th, 5th and 6^th year medicine and surveys were conducted.

-Male contributors 60%

-Female contributors 40%

-4^th year students’ contributors 23%

The quantitative method in this research was conducted in the library where a variety of students from different years are present. This study was only intended to 4^th, 5^th, 6^th year medical students due to the fact of clinical medicine are implemented in their programs allowing us to asses the extent and satisfaction regarding the practical knowledge acquired. An example of the questionnaire given is found in the

appendix.

The quantitative method used in the study is the questionnaire that is a Self- developed Likert scale (4) structured, Likert (1932) developed the principle of measuring attitudes by asking people to respond to a series of statements about a topic, in terms of the extent to which they agree with them, and so tapping into the cognitive and affective components of attitudes. Likert-type or frequency scales use fixed choice

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strongly agree to strongly disagree, and makes the assumption that attitudes can be measured. Respondents may be offered a choice of five to seven or even nine pre-coded responses with the neutral point being neither agree nor disagree.

In its final form, the Likert Scale (4) is a five (or seven) point scale which is used to allow the individual to express how much they agree or disagree with a particular statement.”

A Likert type scale of measurement ranging from Strongly Agree to Strongly Disagree has been used. A Likert scale constitutes the sum of responses to many Likert items. A Likert item is a statement that the respondent is asked to evaluate in a survey. The questionnaire included 6 questions that are Likert type questions. The questions were designed related to the topic from different angles.

The main purpose of the questionnaire, found in the appendix, is to highlight the importance of the language used in medical teaching for international students.

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RESULTS

The results of the study are presented through statistical tables and per the responses taken from participants. The responses recorded are represented in tabulated forms.

Characteristics of the respondents surveyed

Table 1 below shows the demographic characteristics of the respondents

Table 1. Profile of the respondents

Variable Category %

Gender Male 60%

Female 40%

Year in Medicine

4^th 23%

5^th 17%

6^th 60%

Nationality Lithuanian 50%

International 50%

The participants are divided into 2 groups, Lithuanian students and international students with a 50% for each group.

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International Students’ Answers to the Questionnaire

Table 2. I have complete ability to communicate with teaching physicians

Table 3. I received a lot of benefits from teaching physicians in practical knowledge

Scale %

Strongly agree --

Agree 66,6%

Neutral 20%

Disagree 13,4%

Strongly disagree --

Table 4. I received a lot of benefits from teaching physicians in theoretical knowledge

Scale %

Strongly agree 13,4%

Agree 20%

Neutral --

Disagree 33,3%

Strongly disagree 33,3%

Scale %

Strongly agree --

Agree 26,6%

Neutral 10%

Disagree 63,4%

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Table 5. I have complete ability to understand physicians’ spoken directions regarding tasks and objectives

Scale %

Strongly agree --

Agree 13,4%

Neutral --

Disagree 66,6%

Strongly disagree 20%

Table 6. I have complete ability to understand the main idea and their supporting information

Scale %

Strongly agree --

Agree 33,3%

Neutral 13,4%

Disagree 53,3%

Table 7. I am satisfied from the problem-based learning

Scale %

Strongly agree --

Agree --

Neutral 6,6%

Disagree 33,3%

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Lithuanian Students’ Answers to the Questionnaire:

Table 8. I have complete ability to communicate with teaching physicians

Scale %

Strongly agree 90%

Agree 10%

Neutral --

Disagree --

Table 9. I received a lot of benefits from teaching physicians in practical knowledge

Scale %

Strongly agree 10%

Agree 73%

Neutral 7%

Disagree 10%

Table 10. I received a lot of benefits from teaching physicians in theoretical knowledge

Scale %

Strongly agree 12%

Agree 63%

Neutral 8%

Disagree 17%

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Table 11. I have complete ability to understand physicians’ spoken directions regarding tasks and objectives

Scale %

Strongly agree 85%

Agree 15%

Neutral --

Disagree --

Table 12. I have complete ability to understand the main idea and their supporting information

Scale %

Strongly agree 78%

Agree 22%

Neutral --

Disagree --

Table 13. I am satisfied from the problem-based learning

Scale %

Strongly agree 13,4%

Agree 33,3%

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DISCUSSION

After collecting data from the questionnaires distributed to the Lithuanian and international students, we are able to clarify the research problem and explain the results.

Regarding international students, the majority don’t have the ability to communicate with teaching physicians, thus the second language in use does not help both parties express themselves well, making the majority of these students unable to understand the physicians’ spoken directions for tasks and objectives. This poses a problem on many levels and aspects, which compromises the normal relationship a student must normally have with his tutor in order to understand and execute the tasks required. On the other hand it is , causing hesitations, confusion and tension in the classrooms. In addition, this makes the majority of these students incapable of understanding the main idea and its supporting information of the physicians’ from here arises the importance of linguistic performance in ensuring that both the teacher and the student have a better relationship by adapting a way of communication that makes it more interesting, and catching, a manner that presents complex information’s and idea in a simplified way. The book

‘’study abroad and second language use: constructing the self by Valerie Aveni (1) , shows that “With imperfect command of a new language, learners’ ability to reveal their true thoughts and identity becomes severely impaired” therefore the student and the teacher cannot have a proper exchange of knowledge . In my opinion this is a major issue because in this case neither the student nor the teaching physician in giving his fullest, a set-back presents which is affecting the student primarily in regards to his educational performance. The presence of multi-cultural classrooms in itself is a challenge. because in my opinion understanding the cultural backgrounds and traditions, and a proper cross-cultural exchange is necessary in order to find the optimal way to overcome this communications barriers, and enhances the relationship students have with their teachers.

However, when it comes to the practical and theoretical knowledge parts, the majority of international students agree that they have received a lot of benefits from teaching physicians in the practical knowledge part unlike in the theoretical part where there are less benefits received. In my opinion this is due to the direct interaction with the teacher when working in small groups, rather than giving a long lecture to a big audience.

In the end, with the majority of international students being unsatisfied from the problem based learning, we realize that many of the students are facing problems and lack of satisfaction regarding this issue demonstrating that the language is a very important base to any information sent or received. Aveni (1) discussed: “Humans use language for various reasons, communication of thoughts, recording of events,

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and the establishment of relationships.” When studying and or working in a medical environment its crucial to have understood the information or message passed on by the teaching physician, due to high responsibilities and full attention and awareness this field requires. Especially when dealing with human life , health and concerns will be part of their everyday carrier .

After having illustrated and discussed the results of the international students’ surveys, we have the results of the Lithuanian students’ survey to compare with.

When it comes to the ability to communicate with teaching physicians and unlike international students, the majority of the Lithuanian students have the complete ability to communicate, to understand physicians’ spoken directions regarding tasks and objectives, and understanding the main idea with its supporting information. This is difference in opinion between the two categories of students is mainly due to the language/communication barrier that arise upon the use of second language. According to Australas Med (3) it is the language we use and our ability to share language with others that impact these perceptions and perspectives, and ultimately impacts upon our effectiveness as entrepreneurs, educators, collaborators, etc.”

Adding to that, a vast majority of Lithuanian students stated that they received a lot of benefits in both practical and theoretical knowledge parts. This also difference in opinion between the two categories is due to the ability of the teacher to express himself better in his native language, as well as addressing the Lithuanian students while having the same cultural background.

On the other hand, agreeing with the international students, there is no significant satisfaction from Lithuanian students regarding the problem based learning.

The university is not playing a key role in approaching local students from international students to create a pleasant atmosphere. According to Jon G (7): ’’Attention is focused on linguistic, rhetorical, and psychological aspects of classroom communication‘’ the importance of integration of international students with local students, is of great importance as it introduces the international student to the local culture of the country and helps him become part of what’s going around in the society, enabling more encounters with locals.

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CONCLUSION

Many factors played a key role in creating these barriers. First, the international students do not master the Lithuanian language and are unable to express themselves correctly in Lithuanian. Second, the university does not offer intensive courses of the Lithuanian language because 2 sessions per week are not that much in order to become fluent in the language. Third, not all instructors are fluent in the English language and some have a very weak vocabulary in it.

The lack of communication between the students that is due to the language barriers. Second, the diversity of cultures and lack of integration can be an obstacle in creating relationships between students. Third, the university is not playing a key role in approaching local students from international students to create a pleasant atmosphere.

Professors should create a familiar atmosphere in the classroom in order to break the ice between him and the international students who come from different cultures and backgrounds. Second, when handling the course to a substitute instructor the professor should make sure the substitute instructor is fluent in English and the presentation is given in the English language. Third, time should be given to questions and

answers to make sure that these students comprehend the tasks designated to them. Fourth, create activities or give mix session in order to integrate local students with international students.

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RECOMMENTDATIONS

Some recommendations were made based on the findings of this study:

-LUHS should increase their efforts in approaching local and international students.

-Professors should implement more mixed activities between local and international students.

-LUHS should increase the number of sessions of the Lithuanian language course given per week.

-LUHS should create an anonymous ranking system, where students rank their professors’ performance and are able to write their satisfaction or complaints.

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APPENDIX A

QUESTIONNAIRE

This study aims at providing general opinion related to the topic above by as many persons as possible All information’s is strictly confidential and used for educational and research purposes.

Gender:

a. Male b. Female Year in Medicine:

a) 4th b) 5^th c) 6^th Nationality:

a. Lithuanian b. International

Check to what extent you agree with the following statements using the following scales:

1-Strongly disagree 2 =disagree 3= Neutral 4 = agree 5= strongly agree

5 4

3 2

1 1. I have complete ability to communicate with teaching physicians

2. I received a lot of benefits from teaching physicians in practical knowledge

3. I received a lot of benefits from teaching physicians in theoretical knowledge

4. I have complete ability to understand the main idea and their supporting information

5. I am satisfied from the problem based learning 6. I am satisfied from the problem based learning

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REFERENCES

1- Valerie A. Pellegrino Aveni. Study Abroad and Second Language Use: Constructing the Self. Cambridge:

The press syndicate of the University of Cambridge;2005

2- Kara Wolfe .the Effect of the Language Barrier on Intercultural Communication. Journal of Teaching Travel and Tourism. -2009,9: 104-123

3- Thomas J, McDonagh D. SHARED LANGUAGE: TOWARDS MORE EFFECTIVE COMMUNICATION. Australasian Medical Journal. 2013;06(01).

4- McLeod S. Likert Scale | Simply Psychology [Internet]. Simplypsychology.org. 2018 [cited 17 April 2018]. Available from: https://simplypsychology.org/likert-scale.htm

5- Spencer-Rodgers J, McGovern T. Attitudes toward the culturally different: the role of intercultural communication barriers, affective responses, consensual stereotypes, and perceived threat. International Journal of Intercultural Relations. 2002;26(6):609-631.

6- Meneghini R, Packer A. Is there science beyond English? Initiatives to increase the quality and visibility of non-English publications might help to break down language barriers in scientific communication.

EMBO reports. 2007;8(2):112-116.

7- Penner J. Why Many College Teachers Cannot Lecture: How to Avoid Communication Breakdown in the Classroom.

8- Communication - Definition for English-Language Learners from Merriam-Webster's Learner's Dictionary [Internet]. Learnersdictionary.com. 2018 [cited 24 April 2018]. Available from:

http://www.learnersdictionary.com/definition/communication

9- Marris E. Language: The language barrier. Nature. 2008;453(7194):446-448

10- Takehara S, Wright F, Kawaguchi Y, Ishida Y, Morio I, Tagami J. Characteristics of undergraduate dental students in Japan: English competency and willingness to study abroad.

International Dental Journal. 2016;66(5):311-317.

11- Munro T. Studying abroad stays with you. Nursing. 2018;47(2):69-70.

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RESEARCH METHODOLOGY

TABLE OF CONTENTS

SUMMARY

INTRODUCTION

LITERATURE REVIEW

RESEARCH METHODOLOGY

RESULTS

DISCUSSION

CONCLUSION

RECOMMENTDATIONS

APPENDIX A

REFERENCES