Impact of the COVID-19 Pandemic on Allied Health University Education Programs: A Scoping Review.

The COVID-19 pandemic triggered the mass transition of tertiary education to virtual delivery or a hybrid learning approach. This scoping review aims to identify the nature and extent of the current literature on how the COVID-19 pandemic impacted the allied health student education experience and the delivery of teaching and learning materials. A scoping review, performed following the PRISMA-ScR guidelines, was conducted for standard databases and the grey literature published after 2019 that focused on allied health education. Study quality was critically appraised and narrative analysis was performed. Of 6,509 papers identified from the literature search, a total of 68 articles were selected for data extraction. Out of the final 68 studies selected for inclusion in the scoping review, all universities were impacted by the transition to virtual or hybrid learning. Students reported that virtual learning increased flexibility and examinations were considered less stressful. Negative aspects of virtual learning were health issues such as anxiety and depression, technical difficulties, and the lack of interaction with peers and educators. Overall, the studies included in the scoping review reported that allied health students preferred conventional face-to-face learning opportunities over virtual learning experiences. High student satisfaction levels in institutions using a hybrid approach were common. Further research is needed on a wider range of educational experiences (e.g., placements and academic performance).

Evaluating the perceived impact and legacy of master's degree level research in the allied health professions: a UK-wide cross-sectional survey.

BACKGROUND: Post graduate master's degree qualifications are increasingly required to advance allied health profession careers in education, clinical practice, leadership, and research. Successful awards are dependent on completion of a research dissertation project. Despite the high volume of experience gained and research undertaken at this level, the benefits and impact are not well understood. Our study aimed to evaluate the perceived impact and legacy of master's degree training and research on allied health profession practice and research activity. METHODS: A cross-sectional online survey design was used to collect data from allied health professionals working in the United Kingdom who had completed a postgraduate master's degree. Participants were recruited voluntarily using social media and clinical interest group advertisement. Data was collected between October and December 2022 and was analysed using descriptive statistics and narrative content analysis. Informed consent was gained, and the study was approved by the university research ethics committee. RESULTS: Eighty-four responses were received from nine allied health professions with paramedics and physiotherapists forming the majority (57%) of respondents. Primary motivation for completion of the master's degree was for clinical career progression (n = 44, 52.4%) and formation of the research dissertation question was predominantly sourced from individual ideas (n = 58, 69%). Formal research output was low with 27.4% (n = 23) of projects published in peer reviewed journal and a third of projects reporting no output or dissemination at all. Perceived impact was rated highest in individual learning outcomes, such as improving confidence and capability in clinical practice and research skills. Ongoing research engagement and activity was high with over two thirds (n = 57, 67.9%) involved in formal research projects. CONCLUSION: The focus of master's degree level research was largely self-generated with the highest perceived impact on individual outcomes rather than broader clinical service and organisation influence. Formal output from master's research was low, but ongoing research engagement and activity was high suggesting master's degree training is an under-recognised source for AHP research capacity building. Future research should investigate the potential benefits of better coordinated and prioritised research at master's degree level on professional and organisational impact.

Exploring individual character traits and behaviours of clinical academic allied health professionals: a qualitative study.

BACKGROUND: Clinical academic allied health professionals can positively impact patient care, organisational performance, and local research culture. Despite a previous national drive to increase these roles, they remain low in number with no clear strategy for growth. Reported barriers to this growth cite organisational and economic factors with little recognition of the challenges posed to individuals. There is a lack of research to help allied health professionals understand the personal challenges of clinical academic training and practice. The aim of this study is to explore the character traits and behaviours of clinical academic allied health professionals to understand the individual attributes and strategies taken to pursue a career in this field. METHODS: A semi-structured interview study design was used to collect data from aspiring and established clinical academic allied health professionals. Participants were recruited voluntarily through social media advertisement (aspiring) and purposively through direct email invitation (established). Participants were asked about their experience of pursuing a clinical academic career. The interviews were conducted virtually using Zoom and were audio recorded. The data were transcribed verbatim prior to reflexive thematic analysis. Informed consent was gained prior to data collection and the study was approved by the university's research ethics committee. RESULTS: Twenty participants from six allied health professions were interviewed. We developed five themes: risk and reward, don't wait to be invited, shifting motivations, research is a team sport, and staying the course. Clinical academic allied health professionals demonstrated traits including inquisitiveness, intuition, motivation, and resilience. The source of their motivation was rooted in improving clinical services, conducting research, and personal achievement. CONCLUSION: Clinical academic allied health professionals describe personal traits of high inquisitiveness, opportunism, motivation, and determination in pursuing their career ambitions. The tolerance of rejection, failure, and risk was considered important and viewed as an essential source for learning and professional development. Future research should concentrate on ways to reduce the over-reliance on individual strength of character to succeed in this field and explore programmes to increase the preparedness and support for clinical academics from these professions.

Changes in Student Perceptions after Participating in a High-Fidelity Simulation-Based Interprofessional Education Activity at a Historically Black University.

OBJECTIVE: This study aimed to assess the impact of a high-fidelity simulation interprofessional education (IPE) activity at a large, historically Black university (HBU) on perceptions of IPE. PARTICIPANTS: Student participants represented various allied health care professions; the majority were female and enrolled in the pharmacy professional program. Health administration, nutrition and dietetics, nursing, respiratory therapy, and clinical lab science programs were also represented. METHODS: Participants were randomly assigned to IPE teams of 6-7 individuals. The 1-day activity transpired at a high-fidelity simulation facility and included a pre-briefing, simulated scenario with high-fidelity mannequins, and a faculty-guided video-assisted debriefing session. The patient scenario was designed by subject area faculty experts and featured an adult patient on hemodialysis. Participants completed pre and post-activity questionnaires that included the Student Perceptions of Interprofessional Clinical Education-Revised (SPICE-R) instrument. RESULTS: Participants completed pre (n=107) and post-activity (n=81) questionnaires. There was a significant increase from the pre-event (M=3.90, SD 0.91) and post-event score (M=4.22, SD 0.84) for the SPICE-R item regarding understanding "the roles of other professionals within the interdisciplinary team"; t(186)= -2.471, p=0.01. The SPICE-R item score for "health professionals should collaborate in teams" also significantly increased from the pre-event (M=4.28, SD 0.80) to the post-event (M=4.53, SD 0.73); t(186)= -2.209, p=0.03. CONCLUSIONS: Participation in a 1-day high-fidelity simulation-based IPE activity at a HBU has the potential to positively change students' perceptions of IPE. Future studies should consider the impact of IPE on perceptions of diversity.

The lived experiences of racial bias for Black, Asian and Minority Ethnic students in practice: A hermeneutic phenomenological study.

AIM: This study explored the lived experiences of racial bias for Black, Asian and Minority Ethnic students undertaking an undergraduate or post-graduate degree in nursing, midwifery and allied health courses in the United Kingdom. BACKGROUND: Previous research indicates that students from Black, Asian and Minority Ethnic groups have fewer opportunities to succeed at university and this has brought about a race awarding gap in their degree attainment. The reasons for this awarding gap are complex and multi-factorial and it is crucial that the lived experiences of racial bias are explored from the student perspective. DESIGN: A hermeneutic phenomenological approach was adopted to elicit individual and collective experiences in the practice environment, a mandatory component of the student's degree. METHODS: A focus group and individual semi-structured interviews were conducted to collect data from sixteen participants and analysed using thematic analysis RESULTS: Three encompassing themes were identified which included a sense of not belonging, trauma impact on mental health and understanding covert and overt racism. Participants reported incidences of racism and appeared to be traumatised by their experiences within practice and the university. They also reported poor mental health and well-being as shared experiences and a lack of confidence in the university and practice to mitigate racial issues. CONCLUSIONS: Meaningful action must be taken by universities and practice partners to advance racial inequality initiatives by having robust anti-racism action plans and processes. These should be co-created with students and staff to reduce the race awarding gap.

Delegation of patient related tasks to allied health assistants: a time motion study.

BACKGROUND: Allied health assistants (AHAs) are support staff who complete patient and non-patient related tasks under the delegation of an allied health professional. Delegating patient related tasks to AHAs can benefit patients and allied health professionals. However, it is unclear whether the AHA workforce is utilised optimally in the provision of patient care. The purpose of this study was to determine the proportion of time AHAs spend on patient related tasks during their working day and any differences across level of AHA experience, clinical setting, and profession delegating the task. METHODS: A time motion study was conducted using a self-report, task predominance work sampling method. AHAs were recruited from four publicly-funded health organisations in Victoria, Australia. AHAs worked with dietitians, occupational therapists, physiotherapists, podiatrists, social workers, speech pathologists, psychologists, and exercise physiologists. The primary outcome was quantity of time spent by AHAs on individual task-categories. Tasks were grouped into two main categories: patient or non-patient related activities. Data were collected from July 2020 to May 2021 using an activity capture proforma specifically designed for this study. Logistic mixed-models were used to investigate the extent to which level of experience, setting, and delegating profession were associated with time spent on patient related tasks. RESULTS: Data from 51 AHAs showed that AHAs spent more time on patient related tasks (293 min/day, 64%) than non-patient related tasks (167 min/day, 36%). Time spent in community settings had lower odds of being delegated to patient related tasks than time in the acute hospital setting (OR 0.44, 95%CI 0.28 to 0.69, P < 0.001). Time delegated by exercise physiologists and dietitians was more likely to involve patient related tasks than time delegated by physiotherapists (exercise physiology: OR 3.77, 95% 1.90 to 7.70, P < 0.001; dietetics: OR 2.60, 95%CI 1.40 to 1.90, P = 0.003). Time delegated by other professions (e.g. podiatry, psychology) had lower odds of involving patient related tasks than physiotherapy (OR 0.37, 95%CI 0.16 to 0.85, P = 0.02). CONCLUSION: AHAs may be underutilised in community settings, and by podiatrists and psychologists. These areas may be targeted to understand appropriateness of task delegation to optimise AHAs' role in providing patient care.

Exploring research capacity and culture of allied health professionals: a mixed methods evaluation.

BACKGROUND: Despite the myriad benefits of research to patients, professionals, and organisations, fewer than 0.1% of the Allied Health Professions workforce are employed in clinical academic roles. Identified barriers include a lack of role modelling, management support, funding, and availability of clinical academic roles. Research capacity building is critical to improving Allied Health Professional research capability. The aim of this evaluation was to explore the current research capacity and culture of Allied Health Professionals to inform future tailored research capacity building strategies at a local level. METHODS: A mixed methods evaluation of research capacity and culture was conducted within the Allied Health Professions department of a large National Health Service Foundation Trust using an online research capacity and culture questionnaire, followed by focus groups. Staff were recruited using a purposive method with the questionnaire and subsequent focus groups completed between July and September 2020. Data from the questionnaire was analysed using simple descriptive statistics and after inductive coding, focus group data was analysed thematically. RESULTS: 93 out of 278 staff completed the questionnaire and 60 staff members attended seven focus groups. The research capacity and culture survey reported the department's key strength as promoting clinical practice based on evidence (median=8, range=6-9). A key reported weakness of the department was insufficient resources to support staff research training (med=4, 3-6). Respondents considered themselves most skilled in finding relevant literature (med=6, 5-8) and least skilled at securing research funding (med=1, 1-2). Greater than half of the respondents (n=50) reported not currently being involved with research. Five themes were identified from the focus groups: empowerment; building research infrastructure; fostering research skills; access for all; and positive research culture. CONCLUSIONS: Allied Health Professionals recognise the benefits of research at teams and departmental level, but marginally at an individual level. Local research capacity building strategies should aim to address the role, responsibilities and barriers to Allied Health Profession research development at an individual level. To ensure all staff can engage, research infrastructure and empowerment are essential.

Career motivation and satisfaction of dental hygiene students in associate versus bachelor degree programs: A national survey.

OBJECTIVES: Entry-level dental hygiene programs give associate (AD) and bachelor degrees (BD). The objectives were to compare how AD versus BD students differ in career-related role models and information sources, career motivations, and satisfaction and to explore the relationships between career motivations and satisfaction. METHODS: Two hundred seventy-one students in AD and 269 students in BD programs responded to a survey. RESULTS: AD students were older than BD students (26.71/23.6; p < 0.001). Both groups were most likely to name a nurse/dental hygienist (37.6%/37.3%) as role models in their families, were likely to have shadowed a dental hygienist (77.6%/75.0%), and had talked to a health professional (27.7%/23.7%) prior to program application. BD students decided earlier to become dental hygienists (17.20/19.97 years; p < 0.001) and were less likely to have been dental assistants before than AD students (28.3%/36.9%; p = 0.034). Both groups agreed strongly that they wanted to become dental hygienists to help patients (5-point scale with 5 = agree strongly: 4.88/4.86), make a difference in the life of patients (4.88/4.86) and because it is a flexible career (4.83/4.80). Open-ended responses showed that 62.4% of AD students compared to 35.3% of BD students choose their career because of lifestyle considerations (p < 0.001), while 47.2% of BD students versus 38.0% of AD students wanted to work in the healthcare field (p < 0.001). Both groups had high job satisfaction (3-point scale: 2.94/2.97). For AD students, job satisfaction correlated with wanting to help patients (r = 0.49; p < 0.01) and with making a difference in the life of patients (r = 0.52; p < 0.001). For BD students, wanting to work in a team (r = 0.34; p < 0.001) and having a dentist in the family (r = 0.32; p < 0.001) correlated with job satisfaction. CONCLUSIONS: Dental hygiene students in AD versus BD programs differ in the factors that are associated with job satisfaction. Dental hygiene educators can utilize these findings when recruiting future students. The findings related to motivational determinants of job satisfaction can guide educational efforts.

Enablers and barriers to progressing a clinical academic career in nursing, midwifery and allied health professions: A cross-sectional survey.

AIMS AND OBJECTIVES: This study aimed to understand the routes by which nurses, midwives and allied health professionals (NMAHPs) pursue and sustain a research career and the enablers and barriers to career progression. BACKGROUND: Robust evidence is central to practice and professional decision making of NMAHPs, with generation and translation of research arguably best led by those clinically active. Whilst countries like the UK and USA have fellowship schemes to support research career development, anecdotal reports suggest barriers exist in translating these opportunities into sustainable clinical academic careers. DESIGN: Online survey. METHODS: An online questionnaire addressing career choices, facilitators/barriers and support was emailed to 1074 past applicants (doctoral and post-doctoral) to National Institute of Health Research fellowship schemes (awarded and rejected) in England between March and May 2017; 231 responded (25.6%). Study reporting adheres to STROBE checklist. RESULTS: Overall, 134 doctoral and 96 post-doctoral applicants participated; two-thirds were from allied health professions. Most were early in their research career. Interest in research was most frequently sparked by interaction with people in research positions. Nearly half had their first research experience during their BSc project; though less often for nurses/midwives/health visitors (37.5%) than other NMAHPs (51.6%). The award of a fellowship resulted in higher likelihood of being research-active (doctoral level). Nearly three quarters pursuing a clinical academic career indicated 'clearer career paths' and 'greater integration across clinical and academic departments' were desirable. Most common barriers related to research roles, availability of positions and funding. CONCLUSIONS: Fellowship schemes are important to NMAHPs' research careers, but there are serious challenges to establishing and sustaining a career. RELEVANCE TO CLINICAL PRACTICE: Lack of a clear model of career progression, at national and local level, and barriers to creating joint posts impacts on capacity of clinical academics to strengthen integration of research with practice.

Socio-environmental models of allied health disability support: an exploration of narrative experiences in the Australian National Disability and Insurance Scheme.

Objective The primary aims of this study were to explore: (1) manifestations of socio-environmental models of allied health support provision in the disability sector; and (2) narrative experiences of individual allied health professionals in the disability sector. Methods A narrative qualitative study using interviews from a purposive sample of two allied health professionals working in the disability sector explored manifestations of socio-environmental models of allied health support provision and their experiences from case examples. The key informants had more than 10 years of experience in the disability support services setting. Results Seven key themes exploring manifestations of socio-environmental models of allied health professional practice in the disability sector emerged: (1) dignity of risk; (2) models of care; (3) considerations when working in the supported person's environment; (4) goal-oriented work; (5) informed choice and informed consent; (6) reactive and flexible plans; and (7) training and education role. Conclusions Socio-environmental models of allied health support provision in the disability sector focus on empowering people with disability to achieve their goals. This may require displacement of cultural norms within the allied health professions. What is known about the topic? Socio-environmental models of allied health support provision in the disability sector focus on empowering people with disability to achieve their goals. What does this paper add? Displacement of cultural norms within the allied health professions may be needed to promote positive risk taking. Challenges for allied health professionals remain in navigating conflicting goals between clients and family members, empowering informed choice and consent, and working in uncontrolled environments. What are the implications for practitioners? Adopting training and education roles for clients, family members and carers when implementing National Disability and Insurance Scheme plans may represent one of the many pragmatic and flexible approaches to achieve people's goals.

Rationale and protocol for the Nursing and Allied Health Graduate Outcomes Tracking (NAHGOT) study: a large-scale longitudinal investigation of graduate practice destinations.

INTRODUCTION: Inequitable distribution of health workforce limits access to healthcare services and contributes to adverse health outcomes. WHO recommends tracking health professionals from their points of entry into university and over their careers for the purpose of workforce development and planning. Previous research has focused on medical students and graduates' choice of practice location. Few studies have targeted nursing and allied health graduates' practice intentions and destinations. The Nursing and Allied Health Graduate Outcomes Tracking (NAHGOT) study is investigating factors affecting Australian nursing and allied health students and graduates' choice of graduate practice location over the course of their studies and up to 10 years after graduation by linking multiple data sources, including routinely collected university administrative and professional placement data, surveys of students and graduates, and professional registration data. METHODS: By using a prospective cohort study design, each year a new cohort of about 2000 students at each participating university (Deakin University, Monash University and the University of Newcastle) is tracked throughout their courses and for 10 years after graduation. Disciplines include medical radiation practice, nursing and midwifery, occupational therapy, optometry, paramedicine, pharmacy, physiotherapy, podiatry and psychology. University enrolment data are collected at admission and professional placement data are collected annually. Students' practice destination intentions are collected via questions added into the national Student Experience Survey (SES). Data pertaining to graduates' practice destination, intentions and factors influencing choice of practice location are collected in the first and third years after graduation via questions added to the Australian Graduate Outcomes Survey (GOS). Additionally, participants may volunteer to receive a NAHGOT survey in the second and fourth-to-tenth years after graduation. Principal place of practice data are accessed via the Australian Health Practitioner Regulation Agency (Ahpra) annually. Linked data are aggregated and analysed to test hypotheses comparing associations between multiple variables and graduate practice location. RESULTS: This study seeks to add to the limited empirical evidence about factors that lead to rural practice in the nursing and allied health professions. This prospective large-scale, comprehensive study tracks participants from eight different health professions across three universities through their pre-registration education and into their postgraduate careers, an approach not previously reported in Australia. To achieve this, the NAHGOT study links data drawn from university enrolment and professional placement data, the SES, the GOS, online NAHGOT graduate surveys, and Ahpra data. The prospective cohort study design enables the use of both comparative analysis and hypothesis testing. The flexible and inclusive study design is intended to enable other universities, as well as those allied health professions not regulated by Ahpra, to join the study over time. CONCLUSION: The study demonstrates how the systematic, institutional tracking and research approach advocated by the WHO can be applied to the nursing and allied health workforce in Australia. It is expected that this large-scale, longitudinal, multifactorial, multicentre study will help inform future nursing and allied health university admission, graduate pathways and health workforce planning. Furthermore, the project could be expanded to explore health workforce attrition and thereby influence health workforce planning overall.

Evaluation of the Allied Health Rural Generalist Program 2017-2019.

OBJECTIVE: To evaluate the development and implementation of the Allied Health Rural Generalist Program, a two-level online post-graduate education program, which includes Level 1, an entry-level non-award pathway program, and Level 2, a Graduate Diploma in Rural Generalist Practice. DESIGN: A convergent mixed methodology evaluation in two overlapping stages: a process evaluation on quality and reach, together with a mixed method case study evaluation on benefits, of the program. SETTING: Rural and remote Australia across ten sites and seven allied health professions: dietetics; occupational therapy; pharmacy; physiotherapy; podiatry; radiography; speech pathology. PARTICIPANTS: Process evaluation included 91 participants enrolled in all or part of the Rural Generalist Program. Case study evaluation included 50 managers, supervisors and Rural Generalist Program participants from the ten study sites. INTERVENTIONS: The Allied Health Rural Generalist Program. MAIN OUTCOME MEASURES: Process evaluation data were derived from enrolment data and education evaluation online surveys. Case study data were gathered via online surveys and semi-structured interviews. Quantitative and qualitative data were collected concurrently, analysed separately and then integrated to identify consistency, expansion or discordance across the data. RESULTS: The Rural Generalist Program was viewed as an effective education program that provided benefits for Rural Generalist Program participants, employing organisations and consumers. Key improvements recommended included increasing profession-specific and context-specific content, ensuring Rural Generalist Program alignment with clinical and project requirements, strengthening support mechanisms within employing organisations and ensuring benefits can be sustained in the long term. CONCLUSION: The Rural Generalist Program offers a promising strategy for building a fit-for-purpose rural and remote allied health workforce.

Destinations of nursing and allied health graduates from two Australian universities: A data linkage study to inform rural placement models.

OBJECTIVE: Combined, nursing and allied health constitute most of the Australian health workforce; yet, little is known about graduate practice destinations. University Departments of Rural Health have collaborated on the Nursing and Allied Health Graduate Outcomes Tracking to investigate graduate entry into rural practice. DESIGN: Data linkage cohort study. SETTING: Monash University and the University of Newcastle. PARTICIPANTS: Graduates who completed their degree in 2017 across seven disciplines. MAIN OUTCOME MEASURE(S): The outcome variable was Australian Health Practitioner Regulation Agency principal place of practice data. Explanatory variables included discipline, age, gender, location of origin, and number and duration of rural placements. RESULT: Of 1130 graduates, 51% were nurses, 81% females, 62% under 21 years at enrolment, 23% of rural origin, 62% had at least one rural student placement, and 23% had over 40 cumulative rural placement days. At the time of their second Australian Health Practitioner Regulation Agency registration, 18% worked in a 'Rural principal place of practice.' Compared to urban, rural origin graduates had 4.45 times higher odds ratio of 'Rural principal place of practice.' For graduates who had <20 cumulative rural placement days, compared to zero the odds ratio of 'Rural principal place of practice' was the same (odds ratio = 1.10). For those who had 20-40 rural placement days, the odds ratio was 1.93, and for >40 rural placement days, the odds ratio was 4.54). CONCLUSION: Rural origin and more rural placement days positively influenced graduate rural practice destinations. Outcomes of cumulative placements days may compare to immersive placements.

Profile and rural exposure for nursing and allied health students at two Australian Universities: A retrospective cohort study.

OBJECTIVE: Linking enrolment and professional placement data for students' from 2 universities, this study compares characteristics across universities and health disciplines. The study explores associations between students' location of origin and frequency, duration and type of placements. DESIGN: Retrospective cohort data linkage. SETTING: Two Australian universities, Monash University and the University of Newcastle. PARTICIPANTS: Students who completed medical radiation science, nursing, occupational therapy, pharmacy or physiotherapy at either university between 2 February 2017 and 28 February 2018. INTERVENTIONS: Location of origin, university and discipline of enrolment. MAIN OUTCOME MEASURE(S): Main measures were whether graduates had multiple rural placements, number of rural placements and cumulative rural placement days. Location of origin, discipline and university of enrolment were the main explanatory variables. Secondary dependent variables were age, sex, socio-economic indices for location of origin, and available placements. RESULTS: A total of 1,315 students were included, of which 22.1% were of rural origin. The odds of rural origin students undertaking a rural placement was more than 4.5 times greater than for urban origin students. A higher proportion of rural origin students had multiple rural placement (56.0% vs 14.9%), with a higher mean number of rural placement days. Public hospitals were the most common placement type, with fewer in primary care, mental health or aged care. CONCLUSIONS: There is a positive association between rural origin and rural placements in nursing and allied health. To help strengthen recruitment and retention of graduates this association could be further exploited, while being inclusive of non-rural students.

International allied health student placements: A meta-synthesis.

BACKGROUND: Increasingly universities are offering international student placements as part of the global internationalisation movement. This review sought to synthesize the findings of studies to further understand the learning outcomes described by allied health students. AIMS/OBJECTIVES: To contribute to the understanding of the learning outcomes described by allied health students who have undertaken an international placement. METHODS: A qualitative meta-synthesis was conducted. From six databases, twenty-one studies were identified and critically appraised. Data were meta-aggregated, integrated and interpreted to develop new themes, with the experiences of over 259 allied health students synthesized. RESULTS: Themes include: the intertwined personal and professional development experienced by the students; confidence and independence, relationship building, insight into culture, service provision and differences in socio-economic and political contexts. CONCLUSION: Universities offering students international placements provide their students with opportunities to achieve unique learning outcomes with significant personal and professional transformational development that cannot be replicated by local placements.