Developing professional competence in an unfamiliar setting: Practice learning in Zambia

Abstract Background Higher education needs to provide students with competencies to meet the health and social needs of a society characterised by increased globalisation and diversity. Occupational therapy students from Norway expressed that learning experiences outside their comfort zone within Zambian placements, have had a profound impact on their professional competence. Aims and objectives Enhanced understanding of how learning experiences in international placement impact on students’ professional competence. Material and methods Focus group interviews with three cohorts of students were analysed using thematic cross-case analysis integrated with an iterative reflexive process. Transformative learning was used as a theoretical framework for this analysis. Results Three themes emerged from the analysis; 1) Feelings of uncertainty and emotional distress; 2) Drawing on available resources to meet the challenges; 3) Handling challenges promote professional competence. Conclusion Learning experiences significant for developing professional competence goes beyond students’ habitual practice and previous mindset. Students develop generic skills, such as tolerance, flexibility, creativity, awareness of sustainability and professional confidence. Significance New and more appropriate understandings of students’ placement experiences leading to more adequate and relevant strategies, are in consistence with skills required for twenty first century occupational therapy practice.


Introduction
Health professionals worldwide are faced with globalisation and rapidly changing societies, new technologies and evolving health and social services. Major global challenges of the twenty first century are growing with health inequalities and an increasing number of people living in marginalised life situations. Internationalisation of higher education is considered to strengthen global knowledge and collaboration [1]. Higher education needs to provide students with the necessary competencies to meet the health and social needs of a society characterised by increasing globalisation and diversity. The Lancet Commission [2, p. 1924] highlighted the need for educational reform and produced a vision for healthcare education in the twenty first century to encourage all health professionals globally to: mobilise knowledge and engage in clinical reasoning and ethical conduct so they are competent to participate in client-and population-centred health systems as members of locally responsive and globally connected teams. This statement is followed up in white papers from the Norwegian government [3,4] urging higher education in healthcare to prepare candidates with the capacity to contribute to sustainable development and to see themselves as global citizens. This implies accepting responsibility for thinking and acting on behalf of a community wider than the family, local neighbourhood and national boundaries. The ability to change and continuously develop is of vital importance if the professionals are to contribute to sound social development and maintain a high level of welfare. All programs within higher education in Norway are expected to be involved in international cooperation and networks. The number of students studying abroad aims to increase from 15% in 2015 to 50% and become an inclusive part of the study programs for all students in the years to come [3,4].
Occupational therapy education should ensure that students achieve competencies that enable them to serve a diverse population, provide equal and culturally relevant services and uphold the rights of minority groups [5]. The demographic changes and hanging patterns of disease, disabilities and occupational needs require occupational therapists to apply their knowledge and skills in new areas of practice and in innovative ways [6]. The Occupational Therapy Program at UiT, The Arctic University of Norway (UiT) has been arranging overseas placements for more than 100 students since 1995 and has a well-established relationship with partners in Zambia. Through self-evaluation at the end of their placements in Zambia, many students have identified that learning experiences outside their comfort zone had a profound impact on their professional competence. Until now, the learning experiences of students on these placements have not been systematically investigated. This study specifically explores how the students handle challenges in the encounter with an unfamiliar setting and how these experiences impact their professional competence in ways that are relevant for future occupational therapy practice. Professional competence is often referred to as a person's knowledge, skills, capabilities or individual attributes [7].

Learning in international placements
Studying abroad has the potential to provide learning opportunities that inspire students to develop as critical, morally sound, open-minded, culturally sensitive and engaged practitioners and global citizens [8][9][10][11][12]. Learning in a culturally and socially different environment challenges students' taken-for-granted mindset and is often experienced as transformative and transformational [9,[13][14][15][16][17]. Studies comparing learning experiences in high-income settings and low-income settings suggest that students from western, high-income countries who undertake placements in low-income settings grew significantly more in their international perspectives and in their personal and intellectual development than students who had placements in their own country [17][18][19]. Immersion in a different culture is found to be a significant factor for transformative learning when combined with cultural mentoring. Other critical factors in the learning process are hands-on experiences and reflexivity [9,20,21]. However, current research points to concerns about exploitative and unfair approaches to international education [9,22]. Organising overseas placements where students engage in learning opportunities and then leave, may lead to uni-directional benefits and paternalism. Benham Rennick [9] offers a synthetic approach based on key concepts from Dewey, Freire and Mezirow to encourage transformative learning experiences that are both individually and socially transformational.
Although increasing number, there have been few studies to date investigating occupational therapy students' learning experiences during international placements. Studies of the relevance of learning outcomes to future professional practice are largely non-existent [17,23,24].

The learning context
Students on placement in Zambia are selected by program educators on the basis of application letters and interviews. They participate in preparatory lectures on Zambian demographics, people, culture and daily life and read selected literature on such topics as cultural perspectives on health and illness, poverty, disability and cross-cultural communication. They are given information about occupational therapy in an African setting, the actual placements and own health and safety considerations.
Zambia has a population of approximately 15 million people (2020), with 55% living in rural areas. There are 79 local languages; however, the official language is English. Zambia has widespread and extreme rural poverty, high unemployment rates and relatively high levels of health challenges [25]. The rate of people living with disability is currently 10,9% [26]. Access to health care and rehabilitation is limited, especially for people living in rural areas. Only five occupational therapists are registered to practice in Zambia [27].
The main purpose of practice placements in Zambia is for students to work towards rehabilitation, inclusion and participation of those living with disabilities. Placements are undertaken in the fifth semester of the occupational therapy program, during the hot season when temperatures can exceed 40 degrees, which is a challenge for students from the Arctic region. They are based in an international student hostel on the hospital campus and enjoy privileges such as air conditioning, running water and a washing machine. The work schedule is eight hours a day, four days a week with one day allocated for self-study. One group of students have their placement in a hospital setting in town, while the other group are in a rural village.
The hospital group receive professional supervision from an occupational therapist. They participate in the occupational therapy department's weekly program seeing in-and out-patients with orthopaedic and neurological conditions. Students are expected to organise a four-week group therapy program for carers, mainly mothers of children with different neurological conditions. The main purpose of this group is to empower carers to support their child's development and participation in daily life activities. The carers share experiences with each other; and the students share their knowledge and offer carers advice and supervision on handling the child. They also make adapted seats for children, using disposable materials as described by Barton [28].
The village student group work with a non-governmental organisation (NGO) that facilitates self-help programs in rural areas. The main purpose of the placement is to enhance participation in community life and everyday activities for people living with disabilities. The priority is supporting disabled children to participate in self-care, play and school. Students also work on health promotion by engaging youths with risky health behaviours, such as substance abuse and sexual behaviour, in sports activities. Students are hosted in the village by the family of an NGO volunteer who works as their translator and local supervisor. Being familiar with the local communities, the volunteer coordinates activities for the students, introducing them to families with disabled members and arranging meetings with the school and/or the clinic. These students also receive supervision from the hospital occupational therapist during their weekly visits to town.

Learning in practical placements
Personal and professional competence are found to be intertwined [17,24,29] and requires awareness of one's own capability and the involvement of others when needed. This demands an explorative and reflective practice that incorporates life-long learning [6]. Formation of professional identity is closely linked to competence [7]. Throughout practice learning, students acquire professional competencies by identifying the aspirations and addressing the needs of individuals, groups or communities, using professional actions guided by a university practice educator and/or an on-site learning facilitator [30]. Practice learning offers real-life experiences and provides students with time for personal reflection, development of competencies and consolidation of personal values and beliefs about the profession [7,[31][32][33] Practice learning in Zambia occurs through concrete, hands-on personal experiences as the student tries new things, gets stuck and steps out of their comfort zone. Learning in a culturally and socially different environment challenges students' taken-forgranted mind-set, which makes the perspective of transformative learning relevant for framing this study.

Transformative learning
Transformative learning is a type of deep learning, studied and defined by Mezirow [34, p. 3]

as;
…the process by which we transform our taken-forgranted frames of reference (meaning perspectives, habits of mind, mind-sets) to make them more inclusive, discriminating, open, emotionally capable of change, and reflective so that they may generate beliefs and opinions that will prove more true or justified to guide action.
Transformative learning takes place when we encounter new knowledge or experiences that do not fit into our existing meaning perspectives [32,33]. These encounters are disorienting dilemmas that can shake our understanding of ourselves and the certainty of our knowledge. Disorienting dilemmas are events or situations in which meaning structures are challenged to such an extent that these structures are unsuitable for interpreting the experience [35]. To manage this disorientation, we have to reformulate our meaning perspectives so that they become more inclusive, open, permeable and better justified [34,36]. Within a supportive environment, this examination can result in a more effective meaning perspective [37]. The process of changing our assumptions and underlying beliefs can be stressful and painful, as we tend to be strongly attached to them. Affective learning and a willingness to engage in critical reflection both play a role in the transformative process [38]. Examination of, and critical reflection on, own and others' practice can make students aware of how context and culture influence ways of thinking and acting [35]. The process of transformative learning, as shown in Figure 1, often follows some variation of certain phases of meaning [38, p. 86].
Transformation constitutes a specific domain that influences, colours and creates new understandings in the student's domain of learning. By the time learning becomes transformative, it has already influenced professional identity [39], had an impact on professional values and changed practice [36]. Howie and Bagnall [40] view transformative learning as a conceptual metaphor for revolutionary enlightenment in a person's psyche that which leads to new learning that otherwise would not occur. Mezirow's theory has been criticised for missing out on some elements [40] and for being politically naive and unrealistic [41]. Critical reflection and radical discourses demand high levels of cognitive function [42], however, transformative learning can be seen as just good learning [40].

Method
The main aim of this study is to contribute to the knowledge base on learning in unfamiliar settings and explores which learning experiences are significant for the promotion of professional competence in occupational therapy students.
The study was conducted by two educators from UiT, both familiar with the placement setting. The first author had 25 years of experience from tutoring more than 100 students in Zambian fieldwork. As a tutor and placement coordinator, she prepared the students for the placement, visited them and evaluated learning outcomes. This gave her a deep understanding of the context for students' learning and demand awareness and critical reflection on preconceptions influencing data analysis and interpretation.
This study is based on an understanding that human development and learning are socially situated, and knowledge is constructed by the individual through interaction with the environment. Knowledge is dynamic and changing, constructed and negotiated socially, rather than being absolute and finished [43]. Students' understanding is continuously formed by their everyday experiences and the situations they are exposed to [31]. The object of this investigation is occupational therapy students' experience of practice placement in low-income settings and the meaning they give to their experiences. The researchers took a social constructivist approach to explore the process of meaning construction by students, before and after their placement. The design is retrospective, collecting what students said about their placement experiences after their return to Norway.

Study design and data collection
Norwegian occupational therapy bachelor-level students who had undertaken practice placement in Zambia between 2017-2019 were invited to participate in the study. All students invited agreed to participate; all in their early 20s. They represented three different cohorts of students 2017:1-6, 2018:1-4, 2019:1-5. Seven had their placement at a hospital in an urban setting and eight within an NGO in a rural setting.
The method of data collection was explorative, semi-structured focus group interviews conducted over a period of two years. Each cohort of students was interviewed five months after returning to Norway, a month prior to their graduation as occupational therapists. Both researchers were present, where the first author was leading the interviews and the second author followed up the discussions by actively searching critical incidents and acting stories (45). Each interview lasted approximately two hours.
Focus group interviews allow meanings and opinions to develop collectively through the social interactions between participants. The interactions between participants, and the group dynamic that develops, can generate a rich quality of information [44][45][46]. During the interviews, students were encouraged to reflect on how their practice experience had influenced their performance, values, attitudes and professional competence. The following topics in the interview guide led to discussion among students: • Expectations and presumptions prior to the placement • Unexpected and challenging incidents and situations • Coping and problem-solving strategies • Changes of perception • Benefits and learning outcomes • Personal reflections The students followed up on each others' statements and stories since they often worked together and had processed the same experiences.

Ethical considerations
Students were informed about the anonymity of their contribution and their right to withdraw from the study at any point before publication. All of them signed a consent form. Students' participation in this study was voluntary; however, it was recognised that the first author had authority as their tutor. This power imbalance could have led students to feel pressured to participate and influenced their contributions. The second author did not have a role as tutor for the students on placement and followed up these ethical considerations through interviews and analysis.

Data analysis
The focus group interviews were audio-recorded and further transcribed. Data analysis was performed after each interview through systematic, reflective and iterative processes [45][46][47][48]. The findings from each interview informed how the researchers explored students' stories in subsequent interviews.
Iteration in qualitative data analysis is a deeply reflexive process whereby the researcher seeks to gain insight and develop meaning through the process of revisiting and revising the data to refine focus and understanding [45]. Three reflexive questions from Srivastava [47] informed the data analysis: 1. What are the data telling us, including theoretical, subjective, ontological, epistemological, and field understandings? 2. What is it we want to know in terms of the research aims, questions and theoretical points of interest? 3. What is the dialectical relationship between what the data are telling us and what we want to know in order to answer the research question?
Systematic text condensation (STC) by Malterud [45,48] is suitable for analysing qualitative data, such as focus group interview studies [45]. This involves the following steps: • The transcribed material was read separately by both researchers to get an overall impression and to identify preliminary themes and preconceptions. • Meaning units were identified that represent different aspects of the students' learning experiences. Coding for these units was thoroughly discussed in relation to the research question. • Meaning units within each coded group were condensed and abstracted. • The content of each coded group was summarised into descriptions of and concepts relevant to students' most prominent learning experiences.
When three interview analysis had been conducted, sufficient information was achieved to answer the study question. Meaning units from all interviews were condensed and further organised into themes and sub-themes through a process of systematic abstraction. Illustrative quotations were selected to represent the themes and sub-themes. The validity of the findings and congruence with the original context was strengthened by regularly reading through the transcripts and analysing connections between the research question, meaning units and the researchers' professional understanding. Critical reflection towards researchers' attitude and pre-conception followed the whole analysis process [48].

Results
The study found that students learning in practice placement was an evolving process in different stages that are not mutually exclusive but build on each other. These stages are: 1) Feelings of uncertainty and emotional distress; 2) Drawing on available resources to meet the challenges; 3) Handling challenges promote professional competence.
Each stage incorporates three sub-themes, as described below.

Stage 1: feelings of uncertainty and emotional distress
Working in an unfamiliar practice setting highlighted the gap between students' meaning perspectives and their evolving professional competence. Three factors disturbed the student's emotions and led to uncertainty about how to handle different situations: insufficient cultural and professional knowledge, different perspectives on efficacy, illness and disability, lack of material and professional resources.

Insufficient cultural and professional
Working in an unfamiliar setting challenged students' habitual way of thinking and practising occupational therapy. As muzungos (white people) and professional health workers, the students found that clients and families had high expectations of their performance and the contributions they might make. Some clients had health conditions such as paraplegia, visual impairment, club foot and hydrocephalus. Expectations to help these clients were beyond students' competencies: We didn't even know some of the conditions. It was extremely difficult (2018:4). Practice was experienced as unpredictable and often beyond the students' control. Their professional competence was experienced as insufficient: We were just thrown into situations we were not familiar with and situations that were difficult to grasp. Our habitual ways of doing things were not necessarily working there (2017:2).
The setting for client meetings differed from students' previous, individual-oriented practice experiences. In this community-oriented setting, students had to meet clients in the presence of other clients, colleagues, family members and sometimes neighbours would engage in the therapy. The students felt uncomfortably exposed: We were more visible, more conspicuous than at home. We didn't have anyone or anything to hide behind (2018:2).
Communication was a continuous challenge, as most clients used the local language and had limited knowledge of English, especially in rural areas. Depending on colleagues, family members or others to translate, left the students feeling uneasy and uncertain about the accuracy of information: We couldn't know if they understood what we were trying to communicate, and we didn't know if they translated what we said (2017:1).

Different perspectives on efficacy, illness and disability
Dilemmas relating to professional values affected students' emotions and habitual practice, such as perception of time, efficacy and punctuality. Clients and colleagues would turn up at different times from those agreed, or not at all, sometimes due to lack of transport. Students' values related to performing occupational therapy professionally and effectively were challenged as they felt that precious time which could have been spent with clients, was wasted: Different perception of time was one of the most challenging issues (2018:1).
Another challenge was the encounters with different understandings of health and disability. Traditional beliefs, such as witchcraft and divine and ancestral influences, were common in the communities. Illness and disability were often ascribed to witchcraft, as many clients were unfamiliar with biomedical knowledge. Mothers of disabled children were often blamed for the disability, which affected the whole family and, in some cases, led to exclusion from participation in everyday life and community activities. The students' values of human rights, equity and inclusion of people living with disability were constantly challenged. They felt emotionally affected by the stigma and exclusion experienced by their disabled clients: These beliefs were very challenging, especially hearing from mothers that family members and friends refused to touch their child. It was very tough to witness how everyday life became very difficult for the mothers when nobody else would handle the child (2017:2).

Lack of material and professional resources
Most clients came from extremely poor backgrounds, with little access to money or other material resources. Few could afford to buy assistive devices for the disabled family member, such as special seating or a wheelchair; devices that are given free to clients in Norway. The students' encounter with poverty and lack of material resources was a new experience, which challenged their ability to provide adequate and satisfactory occupational therapy services.
The work environment was also less well-equipped with human resources and professional and learning materials than the students had ever experienced. Access to supervision and other professional support, such as textbooks and internet, was limited, especially for the rural group: You find yourself in the bush in Zambia and you are supposed to help. It can be quite challenging as a student to take that responsibility. Especially when you don't have books or internet or a supervisor to talk to (2017:6).
Encountering these challenges left the students with feelings of uncertainty and emotional distress. Their habitual practice was disrupted, which forced them to examine and reflect on their values and habitual practice and explore new coping strategies and actions.

Stage 2: drawing on available resources to meet the challenges
As students encountered challenges, they learned to deal with the challenges by: familiarising themselves with the local culture and building reflective partnerships.

Familiarising themselves with local culture
Students made efforts to familiarise themselves with life in the host community and adapt to cultural practices by taking advantage of opportunities to participate in everyday activities with clients and colleagues; like drawing water and cooking the traditional maize porridge ('nshima'). Their efforts were highly appreciated by clients and colleagues and promoted better communication and working relationships: We just tried to live the way they did -and I was thinking that this is my everyday life now. It just became -kind of ordinary (2017:6).
The students also made efforts to ease communication in order to promote collaborative relationships with clients, families and colleagues: Our way of communicating must be more explicit and clearer than home (2017:4). They used basic phrases in local language and engaged in small talk with strangers, because: that is what people do here (2019:1) and …you really must work hard to establish confidence in the relationship and to understand each other (2017:4).
Some of the children, not used to white people, were scared of the students, who learned to develop different rapport through other means than talking: We gave them paper and pencils to draw, and they got engaged. You could see their eyes light up and then we could go ahead with the treatment (2017:1).

Building reflective partnerships
The students felt welcome and included in the host community. However, they frequently found their values and beliefs challenged. Conflicting perspectives had to be addressed: We often had to change direction and find ways of doing things that corresponded with the needs and values of our partners, but also to our own needs and values (2018:2). Through an ongoing exchange of perspectives, students had access to clients' and colleagues' knowledge and experiences, which enhanced their own understanding. At the same time, students contributed their knowledge and experience to clients, families and colleagues contributing to new and mutual understandings.
The occupational therapy supervisor, acting as role model and mentor, was key to the students' development of culturally relevant occupational therapy. The supervisor was not present all the time and, for much of the time, students had to rely on their own knowledge and that available in the situation. They consulted each other and benefitted from reflecting on practice together: We could always talk with each other, to discuss and find out what to do next. Make decisions together, and not being alone with dilemmas and decisions (2018:3). These discussions and reflective processes enhanced the students' awareness of themselves as therapists: We had to reflect on what we already knew, how to use that knowledge (…) and to make the right choices -the ethical right choices (2017:6). The students had to assess and re-assess their habitual practices and develop new approaches as they negotiated their clients' social and cultural practices: We wanted to establish good relationships with the clients. We reflected on how we appeared to them, and on our communication (2017:3). Examination of and reflection of on their own and others' practice made the students aware of how people, culture and context influence our ways of thinking and acting.

Stage 3: handling challenges promotes professional competence
Experiences of dealing with challenges in an unfamiliar practice setting enhanced the students' awareness on their own values, skills and identity as occupational therapists. They were able to develop flexibility and sustainable practice. Meeting challenges promoted reflection on their future professional role and promoted their sense of being relevant and competent practitioners.

Awareness of professional values, skills and identity as occupational therapists
Limited professional human and material resources promoted the students' ability to use their initiative and to work independently: In Norway you can lean on colleagues and experts. Here you really had to trust your own competence (2017:2).
When students encountered local, traditional perceptions of health and disability that challenged their own beliefs and values, they found appropriate ways of communicating their own knowledge. For example, the hospital group ran a support group for mothers with disabled children to enhance the mothers' capability to support their children's development. By sharing their understanding of cerebral palsy from a biomedical perspective, the students offered mothers a new way of understanding disability that they felt lessened the burden on the mothers: It was quite emotional to see how grateful the mothers were that they were not to blame for the disability of their child. They expressed enormous relief to have this knowledge (2018:2). Success in achieving some of the core concerns in occupational therapy, such as inclusion and participation in meaningful activities for their clients, strengthened the students' values, identity and sense of proficiency.

Developing, flexibility, and a sustainable practice
During their placements, students became accustomed to the unpredictability in their work and saw flexibility as a relevant skill for their future practice: 'We really had to be flexible and attend to situations ad hoc. Coping with unpredictable situations that arise is something we can draw on as we become practicing occupational therapists' (2017:2).
Students' tolerance and flexibility were also promoted as they developed an enhanced understanding of the cultural setting and clients' social situation: When people turn up, maybe three hours late, you can imagine, it really annoyed me. But towards the end, I just thought, well, they are probably underway, or they are doing something else (2018:2).
Working in a poorly resourced setting promoted creativity and the ability to find sustainable solutions: There are no assistive devices available here. Compared to home, we had to become more creative and solution-focused. We made seats for disabled children using cardboard, wastepaper, flour and water and parallel bars for a young boy, made from trees that the father cut in the bush (2016:1).
When meeting clients, the students had to adapt to the communal setting and relate to the extended family and others in the community. Cooperation with family members was important to making services sustainable: We had to make sure that the family understood the importance of continuing to support these children (2019:1). Students learned the importance of involving others in their work and establishing collaborative relationships, which were important for sustaining the client program: We worked closely with the family. We had to ensure that they could continue the training, since we couldn't be around all the time (2019:1).

Strengthened professional confidence
Learning outside their comfort zone brought emotions of distress and feelings of helplessness to the students. However, despite being emotionally challenged, they persevered, and endured the discomfort and made efforts to better understand their host community by engaging in collaborative practices with them. The students gained new insights and understandings and tried out new roles and strategies. Their feeling of professional proficiency grew as they experienced their knowledge and skills to be relevant and useful for their clients. Their contributions became progressively more relevant, boosting their confidence and enhancing their professional competence: Because of the differences and the huge challenges that I had to overcome, my experience from Zambia is more valuable than experiences from my previous placements. I feel I can face any challenge as a future occupational therapist in Norway (2018:2). As the students gained experience, their practice became incrementally more relevant, and their confidence grew; they began to experience themselves as competent practitioners. For example, two of the students visited a family where the five-year old daughter was unable to walk. The girl had not been in any treatment program prior to the visit. The students assessed the girl and devised a mobility training program to be delivered by the parents. Returning after two weeks, they found that the girl was now able to stand on her own and even walk short distances: The parents told us there was progress only few days after we left. So, they continued the program. And she got up on her own and walked (2017:4). The girl became more involved in play with other children and the parents were more hopeful about their daughter's future and planned to take her to school.
Personal as well as professional competence was strengthened, and students found that they understood themselves better through facing and dealing with challenges: You got to know yourself better. My personality, my strengths and weaknesses became more visible in this placement (2018:4). The students felt positive about a future role as an occupational therapist: I have discovered more about myself as a person and as a therapist. I have really grown (2018:3). Another student reflects on the same: To carry with me the experience of being able to overcome these challenges, and to have made these contributions. It made me feel more independent and prepared to start my professional life (2017:1).
When students reflected on their position as strangers and visitors, they appreciated Zambian hospitality and openness towards visitors; an experience they felt was relevant for their future practice in Norway: Norwegians have a lot to learn about the way people relate to each other and how to receive visitors (2017:3). That experience will make it easier for us to understand the situation of those coming to Norway; the feeling of being small in a big world (2017:2). Experiences from the placement in Zambia promoted an interest in the possibility of working in diverse settings: I have become more aware of cultural aspects, which is relevant for working with services for refugees and migrants. I have applied for positions within this field at home (2018:3).

Discussion
Providing international learning opportunities for students in higher education has become more pertinent as the world becomes increasingly interconnected. Studies of students learning in international placements often report positive long-term effects, such as enhanced cultural competence and global perspectives [17,21,24,49,50]. This study supports this finding.
Focus-group interviews with three different cohorts of Norwegian occupational therapy students indicate that practice placements in Zambia provided rich opportunities for meaningful and transformative learning that impacted on professional competencies relevant for twenty first century occupational therapy practice.
Askeland and Doelie [51] highlight the importance of understanding the social context of the host community. Working and spending free time in the host community provides an extended arena for various learning opportunities and experiences and promotes self-awareness and sensitivity to cultural differences and diverse practices. Placement within familiar settings narrow learning opportunities and limit the opportunities to understand the impact of context [51]. During their placement, the Norwegian students experience cultural, professional and personal challenges in their encounter with the Zambian context. In interaction with the host environment, they developed new understandings and strategies, and their practice became increasingly more relevant and proficient. International placements and encounters with unfamiliar settings expose students to different ways of seeing the world and challenge them to critically question their own beliefs, assumptions and perspectives [24,51,52]. Questioning previous perceptions held about ourselves and the world around us is potentially transformative [17,24,53]. In this study, the process of social learning is evident in how students constantly had to consider and reconsider their perceptions and practices in their encounters with the unfamiliar setting.
The three stages' learning process that emerged from the findings of this study is similar to Mezirow's ten steps of transformative learning [38] (see Figure  1). Transformative learning occurs at the intersection between the personal and the social as the individual student's personal values, mindset and taken-forgranted practice are challenged in the encounter with the unfamiliar experience [24,41]. Students realise that their habitual frame of reference and habits of mind do not fit or are insufficient in the unfamiliar setting; this brings about emotional reactions or disorienting dilemmas. According to Mezirow [38] transformative learning takes place when students re-integrate new experiences and insights into their lives, potentially changing their performance and professional practice. In this study, students examined their knowledge and assessed their practice, together with their supervisor and each other. Through critical reflection and collaboration with clients and colleagues, they acquire new insights that guide incremental development towards a more relevant practice. This process is in accordance with Mezirow's [38] conceptualisation of the learner critically examining and reviewing his/her interpretations and assumptions and exploring and sharing experiences with others to develop new roles and find the best approaches for practice.
The development of professional competence entails not only specific knowledge and skills but also personal competence, through the acquisition of personal attributes such as ability and readiness to meet challenges of changing practice [7,24]. This personal and professional development has implications for the students' future professional practice in occupational therapy. This study found that students valued international experience for the opportunities it gave them to develop a range of transferable skills, such as collaboration, capacity to change, creativity, capability to see situations from different perspectives and cultural competence [43,54,55]. The areas of competence development in this study are consistent with the findings of a study on learning outcomes in allied health students in on international placements [17].
Overseas placements enable students to develop ways of communicating across the boundaries of culture and language, which are core competencies for future practice [6,24,56]. The placements in Zambia provided students with experience of working with clients from diverse cultural and socioeconomic backgrounds, with a variety of occupational needs. The students were exposed to clients living in marginalised life situations, with limited access to health and rehabilitation services. These experiences enhanced the students' understanding of diversity and prepared them to work with people from diverse and marginalised backgrounds. Reflection on their experiences of being newcomers and strangers in an inclusive host community strengthened students' insight into and understanding of future work with a diverse population in Norway [57].
It is expected that future health care and welfare services worldwide will struggle to cope with rising costs and supporting increasing number of people with long-term and complex health conditions [6]. The practice placement setting in Zambia is less well-resourced than the students have ever experienced. Lack of expertise in health service personnel and lack of material resources in the community promoted students' initiatives and creativity in their efforts to provide relevant occupational therapy. The less resourced setting also promoted awareness of sustainable practice. The process of creating assistive technology with limited resources, by engaging families and communities as resources in therapy, developed enhanced sustainable, creative and problem-solving competence in students.
Working with limited professional support, in concrete, hands-on situations, promoted students' ability to make relevant judgements and decisions in accordance with the demands of the situation. This ability is important for being a competent practitioner [7,58,59]. Students developed awareness of their own knowledge and increased independence, autonomy and collaboration with others. This finding is consistent with studies of practice learning in settings where occupational therapy is not commonly known, or even established [60]. Experiences of working independently promoted the students' self-reflection and autonomous thinking, which are important skills for being a safe and reflective practitioner and life-long learner [7,20,29,39,53,61].
In a rapidly changing world, the future is unpredictable and there is need for professionals to be willing to pursue transformative learning experiences, whereby they acquire new and more relevant competencies throughout their lives [7]. The rapid and accelerating pace of technological, political and social changes in society calls for practitioners with the capability to adapt to changes and new situations [7,29,56]. The recent Covid-19 pandemic has showed us that not knowing is the new normal [62, p. 657]. During their placements, the Norwegian students experienced their work situation as unpredictable and often out of their control. These unstable situations promoted personal skills, such as patience and flexibility.
The students experienced their work with their Zambian clients as progressively more comprehensible, manageable and meaningful. The experience of becoming increasingly more relevant and useful in the unfamiliar setting allowed students to develop a strong sense of professional competence. Experience of coping with unpredictable circumstances, inappropriate habitual mindsets and practices strengthened their confidence in their own professional role and prepared them to start their working life as occupational therapists.
The findings in this study point at challenging learning experiences that promote professional competence and to a limited extent highlight some negative aspects of these learning experiences. This might be related to the perspective not having been explicitly explored in the interviews. Also the power imbalance between students and tutors/researchers might have prevented students from talking about it their negative thoughts and experiences. It has been suggested that focus group interviews, as opposed to individual interviews, give little room for individual detailed narratives [45]. However, the lack of negative feedback might also reflect how students perceived their experiences. A further factor is due to the time lapse between entering the international placement and the interviews taking place, students had opportunities to process their learning experiences, and potentially put away the more negative experiences. Sim and Mackenzie [24] found that the students did not dwell on the negative aspects of their placements while describing challenging experiences.
The impact of negative experiences on students' learning might be a topic of interest in future studies. High degrees of discomfort and anxiety might block students' initiative to act or lead to denial of the complexity or seriousness of the situation and it may harm the students' learning opportunities. The student may be left with a sense of failure and surface learning that in turn may contribute to developing poor learning strategies.
Other concerns relate to clients and colleagues. The issues of paternalism, unfair practices and unidirectional benefit are addressed by Benham Rennick [9] and Lees [22]. In this study, students were working independently and experienced high expectations of their professional performance since they were perceived as experts by clients and colleagues. Furthermore, international students are only temporarily present in the lives of those they are working with and leave the scene after few weeks. This requires an ability to critically reflect on their role and practice, high ethical awareness and consciousness on personal and professional limitations.

Conclusion
The findings of this study confirm and extend our existing knowledge about learning in international practice placement. They show how learning experiences in an unfamiliar setting impact on the development of professional competence in occupational therapy students. Learning experiences that goes beyond students' habitual practices and previous mindsets are found to be significant for transformative learning and the promotion of professional competence. Practicing outside their comfort zone promoted new and more appropriate understandings of the sociocultural setting and students become more aware of their own professional performance. They developed generic skills such as tolerance, flexibility, creativity and awareness of sustainability, which are core skills for practicing in a globalised and diverse world where health and welfare resources are increasingly scarce. The experience of becoming relevant and capable in the encounter with the unfamiliar setting promoted a strong feeling of confidence in their own personal and professional capacity to meet challenges in their future practice as occupational therapists. The findings of the study suggests that international practice placements are a relevant arena for transformative learning experiences that promote professional development in occupational therapy students. Furthermore, this development is relevant to the demands placed on practitioners in their future roles working in health and social services. There is need for further studies of practice placements involving host communities to explore recipients' experiences of collaboration and the impact of foreign students' placements. Further, there is need for follow-up studies of how students transformed professional competencies form and inform their future occupational therapy practice.