Supervisors of International Occupational Therapy Students on Clinical Placement: Perceived Tensions and Hidden Expectations

ABSTRACT This study aimed to explore supervisors’ perceptions of working with international occupational therapy students in Sweden. Learning in clinical placements abroad may be challenging for international students and supervisors. Yet, most research has focused on exploring students’ experiences of international programs and little has been reported from the supervisors’ perspective. A qualitative descriptive design was utilized. Six clinical supervisors recruited through one of the largest educational institutions in Sweden. Thematic analysis was used to analyse the data. The findings were categorized into four themes; “Balancing students’ expectations and formal learning possibilities”, “Navigating students’ need for understanding differences in resources, legislation, and other factors differing from their context”, “Acknowledging students’ different perceptions of dialogue and reflection”, and “Being aware of the impact of socio-cultural situations on students’ learning”. This study provides valuable insights that support understanding of cultural differences and expectations that could be applied to international students’ clinical practice.


Introduction
Clinical placements are central to health professional undergraduate programs to provide a highquality learning experience in students' clinical area and bridge the gap between theory and practice (Attrill et al., 2016;Bull et al., 2020). Undergraduate international exchange programs have become popular among allied health and nursing programs as this type of exchange is focused on acquiring cultural competence and awareness to attend patients' healthcare needs in growing and complex societies in relation to cultural diversity (Bagnasco et al., 2020;Bohman & Borglin, 2014). As such, international literature has largely focused on exploring students' participation in international exchange programs and the impact of these experiences on professional education and cultural awareness of different cultures and healthcare systems (Browne & Fetherston, 2018;Bull et al., 2020;Eden et al., 2021). Universities have also incorporated systematic processes to integrate international, intercultural and/or a global dimension into their curriculum by providing learning opportunities such as clinical placements abroad (Leask, 2011). Thus, it is not surprising that students in allied health programs, i.e., occupational therapy, physiotherapy, speech language pathology, have increasingly been participating in international mobility programs, such as the Erasmus + European program, in the last years. These international mobility opportunities, for allied health professional programs, include either exclusive clinical placements and/or courses with examinations (Bagnasco et al., 2020).
A plethora of research has described challenges and opportunities related to clinical placements abroad from the student perspective (Bagnasco et al., 2020;Lalor et al., 2019;Mashizume et al., 2020;Mattila et al., 2010;Mikkonen et al., 2017). Students have reported that support especially in terms of adequate clinical supervision has been crucial to successful learning (Bagnasco et al., 2020). This support has been described as ensuring that students are prepared for clinical placement through orientation, acting as a liaison with other health care staff and patients to ensure that students receive opportunities to meet their learning goals, and supporting the student's adaptation to a new and unfamiliar environment and health system (Bull et al., 2020;Maginnis & Anderson, 2017). Some of the challenges reported by international students working with local clinicians as supervisors are related to the significant amount of energy that clinical placement requires, particularly regarding cross-cultural communication, fully understanding a situation from an international perspective, and a lack of culturally safe facilitation within clinical settings (Attrill et al., 2016;Bull et al., 2020;Jeong et al., 2011;Mattila et al., 2010;Mikkonen et al., 2017). These challenges can often precipitate moral and ethical dilemmas in the clinical settings with inconsistencies between host countries resources and constrains, and students' values and beliefs (Gower et al., 2017).
Beyond a general understanding of the importance of supervisors in international exchange programs from the student perspective, few studies have focused on clinical supervisors' perspective on receiving international students (Attrill et al., 2016;Bull et al., 2020;Newton et al., 2016Newton et al., , 2018. These few studies reveal that international students may present supervisors with complex and interrelated challenges including language barriers and cultural differences (Bull et al., 2020), social barriers such as loneliness, social isolation and discrimination, and differences in teaching and learning expectations (Attrill et al., 2016;Newton et al., 2018). A review of the limited studies available (Newton et al., 2016) suggests that language and culture present significant challenges to supervisors and that supervisors' expectations of international students often conflict with students cultural learning styles. This review also identified inadequate preparation of clinical supervisors as an impediment to the supervision of international students (Newton et al., 2016).
The study of clinical supervisors' perspectives within allied health programs has been limited and most studies concentrate on health programs such as nursing and midwifery. Given the rising number of occupational therapy students undertaking clinical placements abroad, it is essential to understand students' as well as supervisors' views about clinical placement experiences. Although a growing interest in students' perspective within occupational therapy programs has emerged (Lalor et al., 2019), supervisors' perspectives are lacking in this field. This knowledge can assist education programs in understanding the complex situations that clinical supervisors may encounter and support the creation of more supportive learning environments that respond to students' and supervisors' learning needs. Clinical supervision can become more complex when students do not converse in their first language (Newton et al., 2016) which can also be applied to the supervisors as well. This is particularly pertinent in Sweden where supervisors do not use their first language (i.e., Swedish) when communicating with international students during their clinical placements, but for the most part use English, the mutual language for both supervisor and student.
To date, studies have addressed students' perspectives regarding international clinical placements, highlighting complex challenges for supervisors. It is assumed that to best support supervisors and improve the clinical placement experience for all those involved, it is essential to explore supervisors' perceptions of their experiences facilitating international students' placements. This study aims to contribute with an understanding of supervisors' perceptions of their experiences supervising international occupational therapy students in Sweden. Despite the situated nature of this study, the findings are discussed in the context of the international literature to provide relevance for readers outside of Sweden that receive international students and that may come from countries with cultural values and health systems that are significantly different from the clinical supervisors' practice settings described in the present study.

Context of the Study
The study was conducted with clinical supervisors that receive international occupational therapy students in Sweden. International students are enrolled in either a 4 or 5-year undergraduate program or a 2-year master's professional program and come to Sweden for international exchange. During the exchange period, students can take theoretical courses as well as have clinical placements (also referred to as practice placements or fieldwork) ranging from 2 to 5 weeks for each placement. The length of the clinical placement varies depending on how many clinical placements (one to three) students choose to partake in. The clinical placements are within settings where Occupational Therapy services are provided, such as national hospitals, nursing homes, mental health clinics, and public employment services (i.e., reintegration to the workforce after injury and rehabilitation). During the placements, the international students participate in direct collaboration with the clients and their supervisors, taking more responsibility for client care as their competency develops.
Clinical supervisors are registered occupational therapists, and their mission is to facilitate students' development of professional skills through observation, feedback, and discussion. A formative assessment of competency development occurs at a half-way time point, guided by the learning outcomes for the clinical placements. A summative assessment is conducted at the end of the placement period. Clinical supervision of international students is conducted in English and therefore some translation is involved when having client (e.g., patient, or significant others) contact if the client prefers to speak Swedish. The supervisor's workplace receives nominal economical compensation per student and most supervisors have taken part in a non-mandatory, 5-week clinical supervision training-course offered by the higher educational institution that hosts the international students.
For the purpose of this study, clinical supervisors, here after referred to as "supervisors", are defined as practitioners that received students in their workplace, offering on site learning during clinical placements that vary in duration. International students, here after referred to as "students", are defined as residents enrolled in higher Occupational Therapy education programs outside of Sweden. Students should have a good command of English to apply to the exchange, but no English tests are required. Students come predominantly from countries such as the USA, Canada, Chile, Japan, Uganda, Kenya, and several European countries.

Recruitment and Participants
Supervisors receiving students during the spring of 2019 were considered eligible participants for the study. They were sampled from clinical placements connected to the Occupational Therapy undergraduate program at a large educational institution in Sweden. Seventeen supervisors were contacted via email by one of the authors who worked as clinical placement coordinator at the host institution.
Of the seventeen supervisors that were approached, six of them agreed to participate. Participants' experience of supervising international students varied from being the first time to having over 10 years of experience. Of the six participants, five were women and one man. The supervisors' workplaces also varied, including national and children's hospitals, nursing homes, outpatient mental health clinics, and public employment service. All supervisors were registered occupational therapists with a bachelor's degree. Three out of six participants have a masters' degree. The supervisors had a European or North American background. Four of the supervisors pointed out during the interviews that they have participated in similar international exchange programs when they were students. To ensure confidentiality, demographic data that can connect participants to their place of work is not presented.

Ethical Considerations
Supervisors received information via email regarding the purpose of the study and the research process. The email also contained information regarding confidentiality, voluntary participation, and that refusal to participate or discontinuation of participation will involve no consequences or loss of benefits to which the participant is otherwise entitled to by the host institution. Since healthcare professionals (i.e., occupational therapists) are not considered a vulnerable group by the Swedish legislation and sensitive data was not collected, ethical approval by the Swedish Ethical Review Authority was not needed. The study followed international recommendations for research ethics (World Medical Association, 2001). All participants received an information/consent letter and provided written consent.
Only six of the seventeen contacted supervisors agreed to participate. This possibly implies that power differentials were minimal among the participants and researchers, and therefore supervisors felt free to decline participation in the study. It was deemed as important for the trustworthiness of the study that the clinical placement coordinator was part of the research team and conducted the recruitment since her prolonged engagement with the participants could increase rapport leading participants to be more open in their interactions with the researchers (Lietz et al., 2006).

Data Collection
Semi-structured interviews were conducted by the authors with six clinical supervisors. Individual interviews were chosen based on their potential to offer more detail and insights into participants' personal feelings and beliefs than for example, focus groups (Guest et al., 2017).
The authors worked in pairs in which one conducted the interview and the other one listened and took notes. All researchers had prior experience conducting qualitative interviews. Interviews were conducted face-to-face in the place of work of the interviewees or at the educational institution and at a time of their convenience. An interview guide was used to conduct all interviews. The interview guide was informed by the aim of the study and previous discussions between the authors grounded in the literature and previous experiences as supervisors and/or practitioners. It consisted of predetermined entry questions to assist participants to talk about and reflect on their experiences. Examples of questions were "Can you tell us of a supervising experience that went well and another that was more challenging?" "What kind of barriers did you encounter in the case that was more challenging"? When appropriate, prompts were used to encourage each participant to provide examples to make clear the meaning and intent of their statements.
Interviews were conducted in Swedish, or English as preferred by the participants. They lasted between 30 and 45 min and were audio-recorded. Data were transcribed verbatim by the authors. Data were stored using a cloud-based file sharing service with high-security functionality and centrally managed by the authors' workplace.

Data Analysis
Braun and Clarke's (2006) procedures for thematic analysis were followed to enact a rich description of the dataset. Using an inductive approach, the authors started the analysis process by separately reading and re-reading repeatedly the transcripts to gain an overall impression of the data. While reading the transcripts, the authors made notes about the potential meaning of some participants' statements, making preliminary interpretations concerning individual interviews and the complete dataset. The authors' preliminary interpretations were gathered in a shared table and discussed. Then the last author led line-by-line coding using MAXQDA 2000 software taking into consideration previous discussions with the two other authors. Coded data were sorted into firstlevel coding categories and then categorized (collapsed) by the last author into themes that were discussed with the other two authors. The authors discussed the themes to agree upon emerged themes, ensuring rigor. When minor discrepancies emerged, they were discussed among authors until an agreement was reached. The themes were then examined by the authors who carefully revised them in relation to the complete dataset to ensure that the emerged themes were grounded in the data (Braun & Clarke, 2006). The analysis was conducted in Swedish as well as the discussions between the authors. Selected quotes used in the findings were translated by the authors after the analysis was completed. Two of the authors have English as a first language and one has Swedish as a first language.
The authors are women (two with PhD degrees and one with a master's degree) who work as researchers and university educators. They are occupational therapists with clinical experience and previous experiences of clinical and research supervision of occupational therapy students, including international students. Two of them have studied and worked as occupational therapists in English-speaking countries. One of the authors at the time of the study and writing of this paper worked as a clinical placement coordinator with a substantial network and experience in managing and supporting international students. The authors' characteristics were presented to the participants when introducing themselves. While the data analysis was inductive, it is acknowledged by the authors that their background and educational interests may have inevitably influenced data analysis. Yet, investigator triangulation (Patton, 1999) consisting of continuous involvement of all authors in the data analysis was used as a qualitative research strategy to ensure trustworthiness of the results.

Findings
The analysis of the interviews resulted in four themes; "Balancing students' expectations and formal learning possibilities", "Navigating students' need for understanding differences in resources, legislation, and other factors differing from their context", "Acknowledging students' different perceptions of dialogue and reflection", and "Being aware of the impact of socio-cultural situations on students' learning". These themes will be illustrated with the help of quotes from the participants. Pseudonyms are used to refer to the supervisors.

Balancing Students' Expectations and Formal Learning Possibilities
The supervisors often talked about international students in terms of positive qualities such as "they have a lot of knowledge and experience", "are hungry to test themselves", and "are the best" in terms of grades and commitment to the international exchange. This tendency was contradicted by some tensions described by supervisors in terms of balancing students' high expectations and learning possibilities that supervisors could offer to students in their clinical settings. Specifically, supervisors expressed that sometimes they needed to "stop" students from doing more work than they needed for reaching the learning outcomes established for their clinical placement. The student has had high expectations on my part and the learning objective's part […] that they can achieve the requirements and the requirements are reasonable [is more important] (Lena). They do more work than they should. I think it has been at times, a matter of encouraging them to say no, put the books down. You know go out and explore, find out how people do things here you know (Isaac). So, I have to say stop and clear with 'maximum one page and that's enough […] because they have many demands to produce a lot (Ida).
Supervisors tried to handle this situation by discussing with students the learning objectives of their placements and the concrete possibilities to meet students' expectations. For example, Julia explained that it was important for her to discuss expectations about supervision right at the start. I explain very much what is expected of them when they start, and I ask them what is expected of me. Further, Erica also highlighted the importance of talking about expectations with students.

Open clear communication in general like [being] clear with everything that is expected (Erica).
The students' own high expectations were perceived by supervisors as problematic since they wanted to support students in reaching these expectations while knowing that this could be very difficult to achieve in a new context (e.g., managing client cases by themselves when not all clients may speak English).
It is a bit difficult to become completely independent for an international student. So, in their perhaps learning process, they should feel independent […] so it might be a few steps behind at least from what the student is used to do in clinical placements [in his/her country of origin]. (Evelina) Altogether, supervisors' descriptions of students as 'overachievers' and with high expectations reflects a tendency to see students as very good or capable of reaching the requirements and learning outcomes for their clinical placements. Yet, this image created tensions for supervisors whose workplace did not provide all the opportunities for students to demonstrate their knowledge and skills because of language (e.g., not all clients want/can speak English). Another aspect that supervisors described as adding to these tensions was the fact that most international students are the best in their class and therefore they have high expectations of themselves. As such, supervisors pointed out that it was important to acknowledge the students' expectations in relation to the formal learning possibilities of their placements in the new context.
Navigating Students' Need for Understanding Differences in Resources, Legislation, and Other Factors Differing from Their Context Another tension described by most supervisors was balancing some of the students' learning that may not apply to other contexts because of difference in resources, legislation, and other factors. For example, one of the supervisors Ida, works in public employment service (i.e., supporting work reintegration after injury/rehabilitation) regulated by Swedish legislation. Public employment services of this type may not exist in the students' countries. Many [students] think that an occupational therapist only works in healthcare. Students can kind of understand [my work] but then wonder 'how can I benefit from this, this does not exist [in my country], I plan to work in a hospital'. As Evelina also described, it is difficult for supervisors then to prioritize what students should learn if this is not going to be applied later in their context. This is how we work so that the student can understand what it is we are going to do and why. But at the same time, it is not necessary to learn it if he is not going to work here […] Then I think a little like this, how important is that?
The above-mentioned situations can be linked to other supervisors' comments in which they highlight other aspects of Swedish society that students may need to learn or tolerate while doing their clinical placements which may not apply to their countries of origin. These aspects are related to Swedish's style of life, or legislations, e.g., regarding same-sex couples, among other things that students need to manage when meeting clients at their homes or in the clinic. Isaac, explained, a lot of the times when they hear about the policies in Sweden in the health care system and so forth, they are almost shocked. Other supervisors explained how important it was to introduce certain legislation to students while emphasizing that students still need to work with clients and families that may differ from the clients that they usually meet in their countries.
Families look different, constellations and like parents are single many times. Some [students] question like 'but, do women get to marry each other like this?' […] You probably have to accept that too [as a student] that it looks a little different […] or that you can go to school when you have a disability. (Erica) This was a student with a completely different background, who had never been abroad before and probably never seen a naked woman [client] before […] or that with LGBTQ. That it is especially difficult [to understand] in his country. He [the student ] was shocked. It was like telling him it is ok to be a paedophile almost. (Julia) Supervisors described these situations as an opportunity to explain to students the tensions that different social norms can entail when meeting with a client who may be in a position of vulnerability (e.g., being part of the LGBTQ community). Although supervisors described that it was a challenge to make this type of learning meaningful for students when knowing that it will not be applied in the students' contexts, they described it also as an opportunity to provide students with other perspectives. I am also very careful to say that occupational therapy can be practised in many different ways. My way is one way, and you get to find your own way when you go home to your home country because you have completely different conditions (Julia).
Based on supervisors above-mentioned comments, the supervisors seem to implicitly agree on the need of being careful when presenting clients to students that may have different social norms and backgrounds. Most of them expressed that it was important to understand and make visible the different social norms of all those involved in the professional encounters (i.e., practitioner, students, and clients).

Acknowledging Students' Different Perceptions of Dialogue and Reflection
Professional dialogue and critical reflections are often used by the Swedish supervisors as pedagogical tools when students cannot be so active in encounters with the rest of the team or clients because these encounters are mostly conducted in Swedish. Supervisors described that they actively encourage dialogue and reflection with students by asking open questions such as now this situation has arisen, how are we going to solve this? (Erica) what was your take on … what do you think you are going to do now? (Isaac). Julia also emphasized the importance of having a morning and afternoon routine in which she asked students about their experiences.
Every morning I ask 'is there something you want to talk about since yesterday', and every afternoon when they go home 'is [there] something you want to talk about today', all the time, every day and then say I, very early, 'if you have something to say, say it, it is not a test' so you feel that you have been allowed to talk about what you think is important.
Yet, supervisors described that questions that aim to open dialogue can create tensions with students that may have different perceptions about reflection and discussion between students and supervisors. As described by Ida.
[Some students expect from me] that I will be sharp, decide, it is me who decides. For some, they think I will judge them […] But I feel more secure that we work in a different way but if the student has a 10-year habit of the teacher deciding, the student will not question anything more. So, they come here, and I ask, 'What do you think'? It will be different. What kind of culture do they have behind them? Some students will have to turn around the fact that they have never been allowed to question [someone/something].
Supervisors described that some students did not expect to have a reflexive dialogue with their supervisors, hypothesizing that the students came from more traditional backgrounds where students are seen as receivers and supervisors as experts or authority figures. This was described by supervisors as a tension that hindered developing an open dialogue with students. I try to have a dialogue and reflect. I think the student thinks we reflect too much […] if she has been allowed to reflect before … her supervisor in (her home country) did not talk to her (Evelina). The student became very awkward; she probably felt a little non-serious that we could wonder if she had a completely different experience. I have learned to talk about that, that it is not like it is me who decides [what is right or wrong] (Ida). Yet, other supervisors noted that their more equal approach helped to question students' conceptions of power differentials. I think it is quite important that the student is allowed to take control of himself and, as well as he should come up with questions (Erica). For example, Julia described that it was important for her to convey that in Sweden there is a more flat or non-existent hierarchy from day one.
Call me by my first name. Challenge me, question me. You really have to say. Here we are equal. No one is worth more than anyone else. I call my boss by her first name. I explain the [non-existent] hierarchy! They can call me 'yes, mam' the first day but then you explain to them very quickly.
On the other hand, supervisors pointed out that this is not the case for all students, and that there are some students that have a more equal supervisor-student relationship in which students can challenge supervisors' way of thinking and acting about particular cases in a professional way. This way of challenging each other's reasoning was greatly appreciated by most supervisors, as Julia explains, One is questioned but it is useful for me to hear how occupational therapy is practised elsewhere in the world. it is good to explain. That is very good for me. I am learning something new. I have to keep up to date. Do not be lazy.
Being Aware of the Impact of Socio-Cultural Situations on Students' Learning When it came to social expectations, supervisors described how students needed to have some explanations about what is expected at coffee breaks, where and when people each lunch, where people can smoke, but also about social expectations that were more related to students doing outside their clinical placements. For example, Issac emphasized that the Swedish culture may not be easy for students to understand. Sweden is not that easy to, they are not that open in singing and dancing type of people!. Julia also highlighted that the whole clinical placement experience may include aspects that are new to students such as sharing a room or doing their own meals and shopping, Whether you bring a classmate or not. That is pretty important. Some can be terribly lonely if they come without a classmate. And other students come with a classmate that they have to share an apartment with, that they can't stand. That kind of thing matters a lot too, as a supervisor, you sometimes have to take that.
The supervisors described that it was important to make time for listening and allowing students to tell them about their lives outside the clinical placement. As such, most supervisors referred to these occasions as an opportunity to explain to students about the Swedish culture and help them to situate their events within this cultural context to increase understanding. Ida described an opportunity in which one of her students did not understand why people acted in a certain way, The student was so upset that she had fallen, and no one stopped and asked how she was […] but it's just good that she talked about it because then you can explain that it is not meant to be rude that it is different.
This sense of responsibility for explaining to students about the Swedish culture was also extended to helping students to make an international phone call from their clinical placements. This was the case of a student described by Isaac, They end up in the student dorm and they are alone, and I remember one student that came from [country] and she had a big loss and, the poor girl was in tears, and she was not able to call the school and a few things that she could not do […] I learned how to just gently offer and invite them into the culture in a professional way.
Another way of helping students and connecting their experiences to their clinical placements was described by Erica, who realized after some weeks that her student was having problems making all arrangements needed to be actively involved in his clinical placement (i.e., cooking, eating, and resting).
It was a situation where I noticed that the student might not be so very alert […] To have to wake up and cook breakfast before he comes, that you have to recharge with energy, that you have to use public transportation for an hour, and then you have to be social and active for 8 hours a day, and in between, you have to eat lunch as well, you should bring your lunch box and sit and eat lunch in a context where you are not used to […]. It was probably a bit difficult for him [so we decide to shorten his days at the clinic], 'no no no, I want to be there 8 hours', but wait 'you cannot do it'. This was not an isolated case according to supervisors that seem to be aware of the fact that for many students coming to Sweden, this may be the first time away from their family, food, and cultural traditions.

Discussion
Studies on clinical placements of international students have been limited to the student perspective ( Mikkonen et al., 2017), neglecting the clinical supervisor perspective and knowledge about tensions that can affect student-supervisor relationship. This article elucidates some of these tensions in relation to supervisors' expectations, learning possibilities, and sociocultural situations. Supervisors in this study carried out their clinical practices in environments that are familiar to them; the Swedish health, welfare system, culture, and language. Yet, they reported similar challenges described by international students in previous studies regarding navigating differences in teaching and learning expectations (Attrill et al., 2016;Newton et al., 2018), students' values and beliefs (Gower et al., 2017), and enacting cultural facilitation within clinical settings (Attrill et al., 2016;Bull et al., 2020;Jeong et al., 2011;Mattila et al., 2010;Mikkonen et al., 2017). To expand the implications of this context specific study, the findings will be discussed using literature from the fields of higher education and clinical placement where similar discussions on (a) hidden beliefs of students' expectations, (b) power dynamics, and (c) inapplicable knowledge are also found.

Hidden Beliefs of Students' Expectations
Few studies have focused on clinical supervisors' perspectives and therefore there is little insight into their experiences with international students (Attrill et al., 2016;Newton et al., 2018). A study that interviewed Speech-Language Pathology clinical supervisors to international students, indicates that supervisors struggled with students' different expectations about what they can achieve academically and their learning needs (Attrill et al., 2016). In line with this, the findings of this study point out that supervisors' implicit beliefs about what students expect to accomplish during their clinical placements collide with the concrete learning opportunities that they can offer to students. This collision between perceived students' expectations and practical opportunities has been shown to add further workload to supervisors who need to manage multiple demands such as providing client services, participating as a clinical team member, and supervising domestic students (Attrill et al., 2016).
For participants in this study, the Swedish language was an extra obstacle that hindered the provision of learning opportunities that would match students' learning needs, since some clients and staff prefer to communicate in Swedish. The impact of language on students' possibilities to be more active during clinical placements has been described previously in the literature as adding to the time that supervisors need to spend with students, and the complexity of the supervision (Attrill et al., 2016). Yet, supervisors in this study did not emphasize the language aspect as one of the most significant constraints to their work, since they have found ways to work around language issues (i.e., asking staff and others to speak English, translate meetings and encounters to students). Instead, the findings show that supervisors experienced more substantial tensions related to feeling not equipped enough to provide learning possibilities that respond to students' high expectations. This is in accordance with a previous study describing supervisors' concerns about being ill-prepared to support international students whose learning was complicated by cultural or communication differences (Attrill et al., 2016). For the participants in this study, it seems that it was more problematic to not feel capable of meeting students' expectations than to see the concrete possibilities that they could offer students, which could enrich the students' experience and learning from another health system and context than the students own.
Further, trying to fulfill students' perceived expectations, the participants in this study perpetuated a misleading image of international students as wanting to do "more" at their clinical placements that may not reflect students' actual needs. From the students' perspective, supervisors' support in adapting to unfamiliar environments and health systems have been described as key to learning (Bull et al., 2020;Maginnis & Anderson, 2017), and therefore, overfocusing on providing students with opportunities that meet perceived expectations may obscure possibilities for new learnings and students' needs for adjusting to the demands of the new context.

Power Dynamics
Supervisors' acknowledgement of the impact of power, respect, and status as experts on their relationships with students has been previously described in the literature (Attrill et al., 2016;Newton et al., 2018). Western supervisors may utilize a deficit model to understand international students learning and behaviors, comparing them to domestic students that hold the same understanding of power as their supervisors (Attrill et al., 2016;Leask, 2011). For example, in this study, supervisors were challenged by some international students that expressed disagreement or even surprise about being asked their viewpoints, prompting them to explicitly signalize that in Sweden there is an equality of power between supervisor and students. Yet, supervisors did not reflect on how students may have perceived this type of power dynamics and if this "equality" could have been perceived by some students as having little consideration for cultural relevance and/or cultural safe facilitation of students understanding of power within the student-supervisor relationship. From the literature regarding student perspectives, a lack of culturally safe facilitation within clinical settings has been reported as a challenge by international students working with local clinicians as supervisors (Attrill et al., 2016;Bull et al., 2020;Jeong et al., 2011;Mattila et al., 2010;Mikkonen et al., 2017). Considering that there are significant cultural differences in Eastern and Western pedagogy (e.g., having to "save face", using indirect vs direct communication, avoiding conflict, having high respect for supervisors), providing a safe space for students in which their understanding of power is explored could support self-awareness and sensitivity to issues of power influencing the student-supervisor relationship (Mackay et al., 2012).
Studies about how power dynamics influence students international clinical learning experience are scarce. Yet, there are a few studies about clinical placements that highlight whether students are treated as "students" or "workers", or whether feedback is used as "telling" or "dialogue", are found to be keys to understanding students' learning experiences and rebalancing student-supervisor power (Chuan & Barnett, 2012;Rees et al., 2020). Notably, a study about power dynamics in nursing clinical settings shows that students thought that clinical supervisors should possess slightly more power to prevent students from causing harm to clients but that this power should also involve mutual respect, humility, and discussion (Chan et al., 2017). As such, students believed that power was associated with how much knowledge, experience, and seniority supervisors possessed instead of associated with authority or as negative for their learning (Chan et al., 2017). Neglecting the fact that there is an implicit power asymmetry within the student-supervisor relationship risks obscuring the perhaps desired power dynamic that some students may need to feel "safe" by trusting the supervisors' higher expertise providing a safety net that can "catch" their potential mistakes in practice. Considering the role that power has on clinical learning, it is relevant that supervisors reflect on hidden aspirations of power-sharing and acknowledge students' diverse beliefs around power that may not always coincide with supervisors' expectations.

Inapplicable Knowledge
Supervisors in this study struggled with supporting meaningful learning abroad that international students may not be able to apply in their countries of origin. They expressed awareness regarding how different the Swedish system was (e.g., workplaces outside the health system) as well as resources within the country, and how legislation may differ from the students' own country, e.g., legislation about same sex-couples. Further, supervisors' comments also expressed an implicit desire for students to learn from the social norms present in the Swedish context, deemed them as valuable and a help for students to encounter vulnerable groups (e.g., LGBTQ community). However, taken at face value, these comments may come across as very positive, but may risk positioning supervisors as "saviours" or "hero" teachers (Emdin, 2017), (un)consciously using their power to help students or "rescue" them from, in the case in this study, homophobic or traditional social values. The underlying beliefs connected to the "saviour" or "hero" complex is expressed in supervisors' comments that value Swedish social norms as potentially more developed than students' countries of origin. As such, there is a risk that in trying to introduce new social norms to students that come from other backgrounds, supervisors hidden beliefs may enact an unethical and historically problematic mentality (Walsh, 2020). In this context, supervisors could have considered what students may go through when processing and experiencing new social norms and what supervisors actually expect students will do with this knowledge after finishing their placement and returning to their country of origin. Even when well-intentioned, exposure to social norms perceived as extreme or very new can be harmful and perpetuate forms of saviourism that may place students in helpless and powerless positions (Emdin, 2017). This saviourism can potentially have been avoided if supervisors decenter themselves and their own expectations, confronting the privilege and freedom that they have, and show tolerance and humility of students' own understanding of race, class, gender, and ability (Walsh, 2020).

Limitations of the Study
The small sample of participants might appear as a limitation of the study (Krefting, 1991). However, to enhance the trustworthiness of the study and credibility of the findings, the interviews were conducted by two researchers (i.e., one asked the questions, and the other took notes) so that the one taking notes could pay attention to any point that was ambiguous in participants answers and ask follow-up questions. To have another researcher present at each interview together with the author who worked as clinical placement coordinator was meant to provide a "neutral" or emphatic person that could minimize any power relation between the coordinator and the participants. At the same time, having two researchers during each interview could have been experienced by the participants as supporting power asymmetries and domination by the interviewer (Kvale, 2006). The other researcher, that was not the coordinator, had a role that included questioning and challenging the interviewer as well as asking additional clarifying questions.
Notes were used by the first author to keep an audit trail of the decisions made by the authors throughout the data analysis. Moreover, as quotes were translated from Swedish to English, it is possible that some meaning was lost during the translation (Van Nes et al., 2010). To avoid this, translation of participants quotes was performed after the analysis was completed. All three authors have a good command of both Swedish and English. Translation was conducted by the first author, and thereafter checked by the other two authors, one having English as a first language, and the other having Swedish as a first language, to ensure accuracy, credibility, and authenticity of the quotes presented.
It is of note that the participants of the study were well-educated (i.e., having post-secondary education), white, Swedish citizens whose experiences may not represent all supervisors working in Sweden and/or those with experiences of clinical supervision in undeveloped and/or developing countries. Nonetheless, the findings have the potential to provide insights into the tensions that clinical supervisors in modern Western societies may face when receiving international students. Yet, it is important to notice that the impact of the tensions and beliefs raised in this study may vary in contexts with different health and welfare systems and institutional supports.

Conclusion
This study is in line with previous research that illustrates how international clinical learning can present moral dilemmas affecting students' values and beliefs (Gower et al., 2017) and that supervisors' expectations of international students often conflict with students cultural learning styles and learning expectations (Attrill et al., 2016;Newton et al., 2018). Notably, the findings of this study move beyond well-known language barriers (Bull et al., 2020) by focusing on supervisors hidden perceptions and expectations that shape supervision of international students. Further research is suggested to explore gaps related to the role of understandings about power dynamics and student-supervisor relationship within international clinical placements, and how those supervisors and/or students who resist adopting or following dominant expectations manage or create ways to engage in meaningful learning. As such, this study paves the way for future research that can deepen the insights regarding hidden impacts of different understandings of power, student-supervisor relationships, and learning in clinical situations.