Table 5.

How the data extracted was coded, including higher-level outcomes, lower-level outcomes and examples from the data

Outcome: highest-order theme	Second-order theme	Example data from source
Knowledge
Increased awareness of and knowledge about how communication between two people can affect understanding	Effectively conveying ideas in an contextually appropriate way	‘Effectively conveying and receiving ideas and messages in appropriate ways so that information is carried in context’ (workshop participant)
Increased awareness of and knowledge about conditions and procedures rarely encountered in the United Kingdom	Greater knowledge of procedures not used in the United Kingdom Better management of conditions that are not common in the United Kingdom	‘Experience of unfamiliar pathologies’ [14] “Experience has been gained in open operations now rarely performed in the UK, including vesico-vaginal fistula surgery” (Gujral 2002)
Increased awareness of and knowledge about the importance of assessing healthcare on an individual basis	The uniqueness of each patient	“Enhanced the students’ cultural awareness and made them more aware of the need to assess healthcare needs on an individual basis” [25]
Increased awareness of and knowledge about the importance of community participation in health	The importance of community involvement in health Awareness of the role of the community in improving healthcare Understanding the importance of community work	“The investigators reported a significant growth in participants’ awareness of how nurses interacted with the village as a community” [36]
Increased understanding of basic skills and ideas	Core skills often replaced by technology (basic observations, using eyes, relying less on lab tests)	‘It kind of makes you go back and think about things in their fundamental…of course physics and that kind of thing’ (workshop participant)
Increased awareness of and knowledge about clinical knowledge in relation to other professions	Doctors about nurses and vice versa	‘Facilitate exploration of a different health care profession’. [36] ‘Improved interdisciplinary teamwork’ (Lee et al. 2011)
Increased awareness of and knowledge about the importance of mutual learning and respect		‘Acknowledgement from the participants that the learning was a two way process’ (Standage et al. 2014) ‘Mutual respect’ (workshop participant)
Understanding how to be a good teacher	Understanding how to target training most effectively Ability to suggest and acknowledge improvements in teaching Understanding importance of experiential learning	‘Makes you drill down more and more what makes a good teaching programme’ (workshop participant) ‘Learning in this context has enabled me to suggest ways to improve the facilitation of learning’. (Lovatt et al. 2011)
Increased awareness of and knowledge about the importance of relationship maintenance skills	Consciously making an effort to get on with colleagues Learning colleagues names	‘Increased appreciation of and skills in maintaining of relationships’ [3]
Increased awareness of and knowledge about the positive impact of clinical policies and governance	Greater policy skills	‘Work overseas will enable the health care worker to develop a greater understanding of socioeconomic and political determinants of health and consider the benefits of alternative health systems and health care initiatives’. (Banatlava, 1997)
Increased awareness of and knowledge about tropical diseases	New knowledge of tropical diseases and increasing existing knowledge	‘Knowledge of tropical diseases has increased’ (Wood et al. 1994)
Increased awareness of and knowledge about appropriate clinical behaviour	Knowing when to ask for help Knowledge of different populations needs	‘Specifically for people from other cultures’. Remembering to let people speak to husband or want to pray. Not talking to baby when it comes out. ‘(workshop participant)
Increased awareness of and knowledge about the cultural aspects of health	Greater understanding and appreciation of health promotion Understanding how culture affects daily occupation Increased understanding of cultural differences in health Understanding the effects of politics on health Understanding how culture affects you professionally Understanding how to incorporate health beliefs into a shared decision Greater understanding of sustainable healthcare	‘The noticeable lack of parental input in caring for their hospitalised children compared with UK culture and practice’. (Standage et al. 2014) ‘Increased understanding of the importance of culture in health care and the degree of variability in the countries they visited’ [25]
Increased awareness of and knowledge about global issues	Re-evaluation of world issues Deeper engagement with issues of equality and diversity Greater global knowledge	“Both learners and institutions potentially will gain from an enhanced awareness of global health issues”. (Lumb, 2014)
Increased awareness of and knowledge about cultural differences and similarities	Understanding key issues within a culture Understanding culturally acceptable behaviour Learning about other cultures Being more attentive to subtle clues about cultural differences Accepting cultural differences Understanding of cultures of UK immigrants Changed assumptions of culture	‘In Mexico it was inappropriate for them to discuss family planning methods with females because it was common for the males to exert control over such matters’. (Standage et al. 2014) ‘They could apply this new understanding to immigrant communities in the UK who had come from these cultural backgrounds’. (Standage et al. 2014)
Increased awareness of and knowledge about ethical considerations	Through experiential learning	‘This process of challenging assumptions appeared to help student to appreciate the child rights stance promoted in the UK’. (Standage et al. 2014)
Increased awareness of and knowledge about the need for/importance of training	Understanding how important effective training is in the United Kingdom and overseas	‘I recognised the need [for] teaching, so trained as a GP trainer’. (Smith et al. 2002)
Increased awareness of and knowledge about how other healthcare systems function	Developed insight into disparities within healthcare systems Increased understanding and awareness of other systems	‘Gain a more effective measure by which to evaluate the strengths and weakness of their own country’s health care system, and further develop insights into disparities’ [36]
Increased self-awareness	Awareness of own skills and limitations Able to challenge own beliefs Able to reflect on own situation Able to self-define	‘Also made me more aware of my own values and beliefs and broadened my mind’ (Greatex-White, 2008)
Increased awareness of and knowledge about finance in healthcare	Awareness of the costs of healthcare	‘There is an acute awareness of the costs of healthcare delivery especially when confronted by patients who have to pay for each intervention’ (Longstaff, 2012)
Increased awareness of and knowledge about the resistance of culture	Understanding how to make small changes Being innovative in overcoming language and cultural difference Understanding not to enforce your perspective onto others	‘To demonstrate cultural competence, nurses should reflect on and recognise their own biases and be open to other perspectives, rather than trying to persuade others to see things their way’. (Paterson, 2014)
Increased awareness of and knowledge about culture in practical assessments	Understanding importance of collecting relevant cultural information about people’s presenting health problems Learning how to conduct cultural assessments and culturally based physical assessments	‘Better understanding of cultural differences and of the need to acknowledge them in the delivery of health care’. (Paterson et al. 2014)
Increased awareness of and knowledge about the importance of trust within healthcare systems and staff	Understanding other people’s perceptions of trust	“Understanding of perceptions of trust, risk taking behaviour and approaches to risk management style”. [6]
Increased awareness of and knowledge about how systems work	Able to identify stakeholders and change agents Awareness of value systems Understanding influencing patterns of those in power Ability to assess impact of healthcare systems Understanding the difficulty of questioning an organisation	‘Had come to understand a lot about how host countries health systems operate. They were also able to make direct comparisons with the British health care system’ (Standage et al. 2014)
Skills
Ability to overcome communication challenges	Liase between groups Engage senior people Negotiate with senior people	‘Ability to have challenging conversations about sustainable change’ (workshop participant)
Ability to communicate non-verbally	Developed non-verbal techniques	‘Developed nonverbal techniques’ [36]
Ability to provide better care	Ability to provide multicultural care Ability to develop most effective approaches to care Taking responsibility for providing quality care	‘Taking responsibility for developing quality of care’ (Banatlava, 1997)
Ability to observe and examine patients	Increased intuitive knowledge of clinical signs Ability to make diagnosis without investigations Increased clinical judgement	“In particular, UK doctors ‘honed’ their clinical diagnoses when laboratory confirmation was not available”. [24]
Ability to be innovative with clinical skills	Use of innovative techniques New ways of working)	‘Innovation in healthcare delivery and use of resources’ [3]
Ability to use a broader range of clinical skills	Enhancing existing skills and acquiring new clinical skill	‘Clinical skills were better and that the trainee had a broader range of skills’ [35]
Ability to apply clinical skills to another context	A more challenging environment or a low resource setting	‘They gained hands-on experience of care and developed a keen awareness of how the principles of nursing were applied in contexts very different from that to which they were used’. [25]
Ability to work with limited resources	Being more resourceful Ability to target resource Ability to find solutions despite limited resources Ability to work without reliance on technology Ability to manage in a low resource setting Understanding the reasons behind lack of resources	‘The nurses and doctors there are resourceful with what they have to use. I have learnt a lot and it has made me think differently. [4]
Ability to ‘get the best out of people’	Encouraging people to work together Empowering people to recognise their own strengths and to take possession of their own work/projects Ability to assess the capability of others Encouraging people to work together	‘Empowering them to recognise their strengths and not deskilling them’ (workshop participant)
Ability to manage risk	Manage risk in advance Evaluation of environment Understanding the clinical importance of risk management Understanding the wider implication of poorly managed risk	‘To manage risks they would not normally be exposed to’ (Morgan, 2012)
Ability to negotiate with multiple stakeholders		‘Improved skills of negotiation with multiple stakeholders’ [3]
Ability to make independent clinical decisions	Ability to make an urgent decision in an emergency Dealing with uncertain outcomes	‘More independent clinical decision making, eg in an emergency situation’ (workshop participant)
Ability to manage time and prioritise	Ability to respond quickly in an emergency Prioritisation of limited resources	‘Time management and prioritisation’ (workshop participant)
Ability to work within a system with unfamiliar power systems		‘Power relationships very difficult to manage’ ‘understanding the power context’ (workshop participant)
Ability to fulfil future leadership roles		‘Prepare them for future leadership roles within their profession’ [36]
Ability to plan and organise	Able to set direction	‘Planning and organisation’ (Pearson et al. 2014)
Ability to improve service	Including renewed enthusiasm for service improvement	‘Service improvement’ [11]
Ability to transfer skills and knowledge to another context		‘Applying those skills in a different context’ (workshop participant)
Ability to work towards solutions	Solution focused approach	‘Solutions despite resource constraints’ [36]
Ability to find facts to solve problems		‘They all recognised improvements in their ability to problem solve’ (Longstaff, 2012)
Ability to make decisions	Understanding who the decision is for Taking action on decision Make judgements	‘Better able to make decisions and take action’ [36]
Ability to co-operate		‘Enhancing their own cooperation and communication skills’ [24]
Ability to work as part of a team	Understanding team group norm Perception of roles within the group Managing personal objectives within a group	‘At a professional level, the experience enhanced team-working skills’ Longstaff, 2012)
Ability to develop friendships	Relationship formation skills Developing new friendships	‘Fostering friendships’ (Smith, 2012)
Ability to build a global network		‘They provide opportunities for personal and professional development of staff and promote the development of friendships and supportive networks between diverse communities”’ (Bagguley et al. 2006)
Ability to give and accept praise		‘Appeared to be related to the giving and accepting of praise. In this context praise was meaningful and valued and often contrasted with the inanition of the home situation’ (Greatex-White, 2008)
Ability to disseminate best practice globally		‘Fosters international networking, which leads to the dissemination of best practices’ (Horton, 2009)
Ability to be professionally competent	Wider view of profession Intellectual development Reminder of professional responsibilities Stronger work ethic	‘A wider view of their profession’ (Horton, 2009)
Developed research skills	Grant application skills Greater research skills	‘Experiential engagement with research is a desirable outcome’ (Pearson et al. 2014)
Ability to present work	Greater presentation skills	‘Ive seen them change considerable as people – by the end they are standing up and presenting their work and they really value that’. (workshop participant)
Ability to write reports and academic pieces		‘I believe this not only enhances my effectiveness as an NHS consultant, hut also the lecturing, teaching and writing that I do reflects favourably on my hospital and university’. (Banatlava, 1997)
Ability to apply knowledge gained in host system to the United Kingdom	Relating experiences back to the United Kingdom Using knowledge gained overseas to improve UK systems	‘Renewed enthusiasm for service improvement’ (Conference)
Ability to cope	Better coping strategies Ability to deal with knock backs Being unfazed by things Learning to deal with stress	‘I am more adaptable and can cope much easier with change’ (Longstaff et al. 2012)
Ability to adapt social norms to meet needs of another culture	Change behaviour to fit with social norms	‘Transcultural adaptation’ [37]
Ability to lead by example		‘Leading by example with consistency and perseverance can be successful ways to improve practice’ (Dowell et al. 2014)
Ability to exchange ideas with those from another culture	Communicate effectively with those from another country or culture	‘Interpersonal skills to live and work together with people of all nationalities and cultures’ (Paterson, 2014)
Ability to encourage others to take responsibility for own health		‘Encourage taking responsibility for health’ (workshop participant)
Ability to manage self	Own expectations Self-reliance Self-management Self-assurance	‘Self-management’ (Lumb, 2014)
Ability to manage projects		‘I gained significant experience in report writing, project planning, managing budgets and particularly human resources’. [11]
Ability to think through problems in a logical way	Analytical thinking Lateral thinking	‘The experience of clinical practice in a low resource environment stimulated lateral thinking’ (Lee et al. 2011)
Ability to establish communication systems	Formal and informal	‘Establishing communication systems, both formal and informal’. [6]
Developed teaching skills	Greater training delivery skills	‘But nurses/midwives - confidence and skills really increase, do not do teaching in the UK’ (workshop participant)
Ability to use evidence based practice	Ability to apply theory	‘Use evidence-based practice effectively and develop a broader and more sophisticated understanding of occupation’ (Dowell et al. 2009)
Ability to speak host language		‘Some people would learn new language, this could depend on how rural you are’. (workshop participant)
Attitudes
Confidence to work in other locations	Confidence to move to another city/country Working with UK multicultural/ underserved populations	‘To live and work independently in a new community and culture’. (Morgan,2012)
Independence		‘Autonomy/independence’ [36]
Integrity		‘Integrity’ [11]
Diplomacy		‘Utilising diplomacy skills’ (workshop participant)
Humility		‘Knowing that you are sometimes wrong’ (Conference notes)
Judgement	Non-judgemental attitude Changed self-judgement	‘Yes and taking things less as face value and less judgemental’. (Workshop participant)
Proactivity	Using initiative	‘Initiative’ (Pearson et al. 2014)
Increased cultural sensitivity	Sensitivity to reasoning behind cultural differences Sensitivity towards feelings of minority Sensitivity towards language barriers	‘It involves an awareness and acceptance of cultural differences’ (Paterson, 2014)
Increased respect for other cultures		‘An understanding of and respect for other cultures’ (Horton, 2009)
Reinforced ethnic and cultural identity	Positivity about being British	“Having become a foreigner in the host country, there remained a sense of being tied to the home culture” (Greatex-White, 2008)
Patience and tolerance	Accepting and working at other peoples pace More tolerance	‘Made them more tolerant of others’ [25]
Increased confidence	In caring for clients from another culture In quality improvement methods To take bolder steps Self-confidence Confidence in professional ability In ability to address challenging situations	‘Confidence about caring for clients whose culture differed from their own’ (Briscoe, 2013)
Flexibility and adaptability	Acceptance of other ways of working Adaptation to responsibility Able to adapt more easily to unfamiliar situations Able to cope more easily with change Able to manage change Gaining a wider perspective Understanding the flexibility of roles	‘Flexibility/humility: Accepting different ways of working’ (workshop participant)
Emotional intelligence	Changed engagement with self Knowledge and world	‘Emotional intelligence’ (workshop participant)
Appreciation of importance of care and compassion	Empathy	‘Greater empathy and understanding’ [37]
Changed perception of otherness	Understanding importance of being a friendly stranger in the United Kingdom Experienced feeling like a foreigner whilst away	‘Learning cultural differences gave students the rare chance of being in a minority status, with the consequential experience of living and surviving in a foreign culture – an experience that students reported as ‘more valuable than a mere excursion’ (Morgan, 2012)
Appreciation of excellent human resource in the NHS	Multidisciplinary teams HR structures Appreciation of own profession Understanding hierarchy and the importance of each person within it Interaction between healthcare professionals	‘Through lack of team working they appreciated Resources - material and human’ (workshop participant)
Appreciation of having the right tools and equipment to be able to do the job	Resources: technical equipment, disposal equipment, cleaning products and protective equipment	‘Greater appreciation of the resources’ (Lee et al. 2014)
Appreciation of free universal health	NHS system of free healthcare for all Privilege and opportunity for UK citizens Understanding the expectations that are placed on NHS by service users	‘Able to comment and reflect on issues around the perceived inequalities of insurance based healthcare systems’ (Standage et al. 2014)
Appreciation of clinical governance procedures within NHS	Waste disposal Audit Teamwork Education system Tests and investigations Understanding that systems are not restricting	‘And a greater understanding of why we need to do the things that we do, like gaining consent from a child’ (Standage et al. 2014)
Organisational outcomes
Increased staff knowledge and skills	Increased staff knowledge of low-cost healthcare More knowledgeable staff Staff able to discover better ways of doing things Staff more aware of waste reduction	‘Makes people more adaptable when they come back because in some areas if you have not move ward for twenty years, it is trauma just to be asked and work in ward X in the same hospital is not it? If you have got somebody that has been exposed to a range of environment, they are more likely to cover shifts’. (workshop participant)
Increased international reputation of NHS	Greater fulfilment of social responsibility)	‘Reputational development’ [3]
NHS becomes a more attractive employee (If offers staff opportunity to volunteer)		‘Link attracts potential staff’ [24]
Increased patient satisfaction	Staff better able to respond to UK multicultural populations Staff have greater relationships with multicultural patient population Staff more in tune with patients Staff more aware of individual needs of patients	‘Patient experience and dignity: understanding of patients from different areas’ [3]
Medical school more attractive to students (if allow students to go abroad)		‘Medical school benefits (programme are increasingly attractive, potentially providing a strong tool for recruitment)’ (Miranda et al. 2005)
Increased workforce productivity		‘Increased workforce productivity’ [3]
Reduction in NHS drop outs	Increased staff retention	‘Attraction & retention of (more/better quality) workforce’ [3]
Increased international reputation (of the United Kingdom)		‘96 per cent of health professionals interviewed for the study thought that the reputation of the NHS could only be enhanced by involvement in international health links’. (Longstaff, 2012)
Miscellaneous outcomes
Upper hand when competing for careers		‘Working internationally is beneficial when competing for future employment’ (Paterson, 2014)
Increased job satisfaction	Increased motivation and morale with profession Renewed passion for work Sense of reward	‘They came back with greater job satisfaction’ (Longstaff, 2012)
Influence career pathway	Affects specialism choice Exploration of potential career pathways Pursuing careers in primary care, family practice, and public service Sub-specialism in global health, Teaching or lecturing careers Teaching responsibilities within clinical position	‘Such broadening experiences are recognized to impact upon the likelihood of working with underserved populations, and pursuing careers in primary care or public service’ (Lumb, 2013)
Refreshment and reinvigoration	Coming back to the United Kingdom refreshed and reinvigorated Bringing new ideas to the United Kingdom	‘With a rekindling of that initial desire to “change the world and help people” and refresh those values underpinning their initial vocational drive to enter the profession’. (Lumb, 2013)
Personal satisfaction	Personal achievements and challenges New experiences Experiencing a different lifestyle A holiday Personal fulfilment	‘An opportunity to travel, experience and work in a different setting, and to make a positive impact’ (Elanaway et al. 2014)
Increased motivation to learn a language		‘Enhanced your motivation and/or ability to learn a foreign language after returning to Northern Ireland?’ (Thompson 2000)
Development of a new perspective	Revising assumptions Reassessed outlook on life Seeing things differently Changed world views Changed outlook Look at everything in a new light Openness to new experiences Put things into perspective	‘They were beginning to see differently and to compare aspects of the host environment with those of home, leading to new perspectives on life’ (Greatex-White, 2008)
Escapism	Escape from agendas and workload A chance to take time out of training and practice Space to think and clarify career objectives	‘They want to escape the hassle of home’. (workshop participant)
Negative outcomes
Costs to British patients	Bringing tropical illness to the United Kingdom	‘It is not uncommon for a few students each year to return from their elective unwell, with some of the infectious diseases occasionally brought back from electives not becoming apparent for some time, e.g. tuberculosis or malaria. This has significant public health implications’ (Lumb, 2013)
Developing redundant or bad skills/attitudes	Non-transferable skills Bad habits Deskilling Overconfidence in ability Poorer communication skills Loss of confidence	“They may be left to ‘do their best’ to manage heavy workloads with limited or no supervision, leading to the acquisition of poor practice habits”. (Barnabas, 2012)
Difficulty getting the job you want on return	Permanent jobs or training contracts	“Many of them experienced discouragement and warnings of ‘career suicide’ when proposing to opt out from accepted career pathways in Britain to work in the developing world for a short period’. (Connelly, 1995)
Loss of trained staff	Utilisation of key staff time Financial cost of losing staff Having to find cover for staff	‘Trained staff leaving their post following links’ [3]
Negative perceptions of NHS	Reputational When program run badly	‘Negative perception of the UK institution where links are run badly’ [3]
Distracted staff		‘Distracts staff from their work at the institution’ [3]
Exposure to ethical dilemmas	To work outside of competency Lack of regulation Too much responsibility	‘To encounter challenging ethical scenarios, particularly those students venturing to developing countries’ (Banatlava, 1998)
No recognition of accreditation upon return		‘Training and accreditation issues’ (Banatlava, 1998) ‘Lack of accreditation/recognition’ (workshop participant)
Reduced experience and exposure to UK procedures, protocols and research	No experience with NHS procedures that do not exist in host country Missing out on formal training and conferences No experience with chronic disease management over time No experience with health conditions that are common in the United Kingdom and not in host country Unaware of NHS protocol and updates Loss of professional networks and relationships	‘Referral experience more limited’ [35] ‘Things might be outdated’ (workshop participant)
Affects professional progression	Lengthens training Less time to prepare for exams Loss of partnerships	“The threat of having to ‘retrain’ is ludicrous when I am working in a developed country in a primary care setting essentially modeled on the British system”. [2]
Negative colleague perceptions	Colleagues have to cover	‘Negative perception of gaps in training programmes’ (workshop participant)
Use of time	Annual leave General time consumption	‘Staff generally use their ‘annual leave for the trips’. [4]
Professional revalidation issues	For consultants	‘Another common barrier was keeping up appraisal in light of the recent changes to GP revalidation’. [11]
Litigation	Legal issues involving clinical/professional risk	‘Clinical-professional risk- litigation’ (Morgan, 2012)
Security	Exposure to aggression Violence and death Becoming a victim of crime Political unrest	‘Examples range from involvement in criminal activity (either as perpetrator or victim)’ (Lumb, 2014)
Carbon footprint		‘Another health and safety issue is the carbon footprint’. (Pearson et al. 2014)
Culture shock		‘Culture shock due to the contextual differences and challenges faced in resource poor settings’. [3]
Environmental and infrastructural risk		‘Physical risk to person- environment, infrastructure’ (Morgan, 2012)
Extreme nationalism towards the United Kingdom		‘Developing negative attitudes towards host culture- causes retreat back to culture of origin and even extreme nationalism’ (Greatex-White, 2008)
Experiencing negative feelings	Feeling as though imposing on UK colleagues to provide cover Feeling out of depth Frustration Guilt and regret about death	‘I was subjected to the feelings of guilt and regret which accompany the death of a patient under one’s care’ (Robinson, 2014)
Financial loss	Costs of getting involved Loss of earnings Loss of pension or employment entitlement	‘Costs of getting involved’ [4]
Health consequences	Animal bites Tropical diseases Sexually Transmitted Disease Injuries and transport accidents Infection Jet lag Skin disease	‘11.1% were concerned that they had placed themselves at risk of HIV and STIs. Unprotected sexual intercourse was the most commonly reported reason’. [20]
Psychological consequences	Depression Anxiety Stress Nervousness	‘Psychological problems on return from their placements’ [20]
Exhaustion and burn out		‘Exhaustion/Burnout/Stress’ [3]
Loneliness	Isolation Social isolation No or few friends in host country	‘You will often be doing lone working which will be very high risk and that happens an awful lot’. (workshop participant)
Missing things at home	Missing life in the United Kingdom Time away from family and friends	‘Time away from their family’ [36]
Loss of interest in global health and international placements	Negative perceptions of volunteering and international placements	‘Many reported negative experiences and never wanted to do it again’ (Conference speaker)
Socio-cultural risk	Exposure to corruption Experiencing resistance to western influence	‘Socio-cultural risk- dress like them, did not want English influence, corruption’ (Morgan, 2012)
Become judgemental		‘Go home with a judgmental opinion of some of the people I look after’. (workshop participant)