Setting and participants.

The study was conducted at a university with 2 campuses in Taiwan. Approximately 800 nursing students graduate each year, of whom 64 students are selected to participate in study abroad programs. Students choose a study abroad program depending on the purpose of the program and their personal interests. Purposive and convenience sampling strategies were used to recruit 14 participants. The inclusion criteria were: (1) currently registered as a student at the university, (2) selected for a 4-week study abroad program, (3) chose to study at an Australian university, and (4) consented to having their responses audiotaped. The exclusion criteria were: (1) having withdrawn from a formal course and (2) being selected for a 2-week program of studying abroad. Ten participants, including undergraduate and post-graduate students, consented to be interviewed before and after their overseas trip, and 4 participants were interviewed after their overseas learning experience (S2 Table).

Students who are interested in study abroad programs are required to undergo a screening process that includes a written review and face-to face interview in order to be accepted into a training session. The training session emphasizes language, customs, culture, and the daily lifestyle of the target county. Potential participants in this study were approached after the training session from among the successful applicants. Students selected for study abroad receive substantial finance support from the school and 2 academic credits for their elective course in the nursing curriculum.

Data collection.

Data were collected from August to November 2017 via individual in-depth interviews conducted by the principal researcher (PI). A semi-structured interview guide (S1 File–Interview guide) was used to ensure both consistency and flexibility in the data collection and to maintain focus and avoid any bias toward the researcher’s specific areas of interest. Ten interviews were conducted before and after the participant’s overseas trip to gain insight into their expectations and actual overseas experiences. Four participants were interviewed after the trip because time restricted after admission list released. Interviewing in the participants’ preferred language of Mandarin maximized the data quality. Shared culture and language between the interviewer/researcher and the participants facilitated in-depth understanding and interpretation of verbal and non-verbal cues. The interviews commenced with an open question, “Could you please share your experience of overseas study?”. Further questions varied depending on the participants’ responses. Each interview lasted 45–60 minutes. The interviews were audiotaped to secure an accurate account of the conversations. Research team members, including the PI, were not involved in the process by which students were selected for study abroad programs. Potential participants were approached only after their applications had been accepted.

Relating to the world.

An individual’s worldview is constructed from his or her past experiences and shapes his or her values and interactions with the environment. Because people are social creatures, individuals seek to connect to the environment with a purpose, and the decisions they make predict the eventual achievement of the object [21]. When the environment is unfamiliar, individuals must be willing to modify or change their values and actions in their interactions with others in that environment.

The study participants realized that the world (environment) they were entering would influence their behavior and they would need to make changes to ensure their behavior was acceptable in this new environment as they interacted with others. These changes represented the line between knowing and doing (conducting), as S1 noted in the following statement. The environment was not going to change to meet their needs; rather, they had to adapt to the environment. As they did so, they became immersed in it.

… I felt a bit nervous and embarrassed at the beginning of class because I was surrounded by foreign faces. You were in the minority and knew no one in class. I needed great courage to raise my hand or say something during classes which was different to my study attitude. Nothing would be changed for you unless we changed first. After the second week, I started to preview the class content before attendance, which I had never done before … (S1).

Adapting to a new environment.

After the participants entered the new environment, they attempted to make the best of it. Although there were no standards or rules for them to follow, their understanding of the unfamiliar environment grew out of their close relationships with others. Understanding what others say is crucial to effective communication, as is the ability to voice one’s views and opinions. In other words, language is a vital tool for interacting with the environment, learning from others, communicating with others, and expressing oneself. The study participants were aware that, because English was their second language, they needed to adopt a positive attitude towards overcoming their limitations in order to engage in learning situations. They knew they could not wait for people to actively approach them, and that their language limitation was a weakness that needed to be improved. Being actively involved in the environment requires a positive approach to dealing with situations. On the other hand, people may withdraw from a situation or an environment into their own inner world, thus reducing their contact with that world. Clearly, the latter response restricts the potential outcomes of learning abroad. In this study, participants were well aware of their weaknesses and strengths and modified their actions to adjust to the environment.

… You had to know what people said. It made me listen to people more seriously. You ignore problems at the beginning of studying abroad and solve them autonomously. The more you practiced and experienced, the more you felt confident and not shy…You try to hide from the discussion in the classes. There has no way to dodge changing situations…(S2)

Gaining a deeper understanding of oneself.

The process of interacting with their inner worlds was initiated by a stimulus. The interaction consisted of comparing and judging stimuli from past and present experiences. The outcomes of comparison and judgment were not right or wrong, positive or negative, or better or worse. The participants in this study gained a deeper understanding of themselves, situations, and the world through the process of comparison and judgement. An itemized teaching-learning strategy between the hosts and the study abroad environments enabled the participants to reach a greater understanding of themselves. Knowing and experiencing things from others informed the participants’ own knowledge of their weaknesses and strengths.

Participants understood situations better through the process of comparison and judgment. They soon realized that they would not succeed without changing. They modified their perceptions and actions to interact with the environment, which is known as adjustment. They identified that widening their worldview was a part of growing up.

…We tolerated things and respected people who were more mature than us. It could be said that we rarely had our own thinking or ideas appreciated. We were obedient, shy, and polite in many peoples’ first impression. . . . Things became difficult for us compared to living in Taiwan. Therefore, you were forced to grow up. Our teaching-learning was like a standardized answer was expected, which was different. We had to be more visible and adaptable in a Western country…(S3).

Acquiring a new vision.

By immersing themselves in their new environment, participants acquired a new vision of things. When they confronted something that was completely different, they engaged in a process of comparison and judgment. The new experiences challenged their previous thinking. Through comparison with their previous experiences, they identified their new way of thinking as an international vision. Although they found this vision hard to define, they recognized that it influenced how they thought about the next step in their personal and professional growth.

I used to think my view on things was international. Actually, it was not what I thought after the trip abroad. I did not know how to specifically express my international vision in words …The journey widened my worldview. Meeting people, seeing and experiencing things, I realized that the world was so much fun. My future career and personal life would not be only in a hospital, I had various options… (S4).

Motivating oneself to change.

For the participants, leaving a familiar environment meant leaving their comfort zone and motivated them to make a range of personal changes, which enhanced personal growth. They described the process of adaptation as one of fitting in to a new environment. A change in behavior was necessary to help them feel secure and avoid deviating from accepted social norms. Participants realized that overcoming their insecurity and interacting in the new environment was an opportunity for personal learning and growth.

The atmosphere of the environment compelled everybody to keep quiet and invisible like the Taiwanese student’s style of learning. When [I was] in an active learning environment, I would modify my learning attitude to be more proactive like everyone else. When the surroundings were passive, I would respond passively like everybody else. This was about fitting in (S5).

Inspiring self-confidence.

When in their familiar environment, the participants reported, they had a more limited learning focus because they were not greatly challenged and took things for granted. In the new environment, learning became more diverse, with limited assistance from family or friends. Each issue had to be solved or managed independently, which can be seen as learning. The participants had to modify their attitudes and actions when interacting with and adapting to the new environment, and construct ways of dealing with new experiences. S6 described how she developed the confidence to acquire new information and a new vision from the things that happened. Participants felt that their perspectives had been broadened.

If you have had the chance to go abroad, you would see a different world. You would know that people are under the same sky but are living in different ways, which are varied and beyond our imagination. You would understand the importance of experiencing other lifestyles, and not be confined to your current life… (S6).

Reenergizing nursing education.

The short timeframe of a study abroad program could be used to justify minimal gains in professional development. However, participants renewed their passion for nursing as a result of the discomforting experience of the host country’s working environment. The substantial new environmental stimuli, including people, incidents, objects, and situations, helped them to develop strengths. The participants opened their minds and managed their problems. This reflected positively on their attitudes toward challenges in an unfamiliar environment. Dealing with challenges reinvigorated the participants’ original intention to study nursing. The new environment improved their attitude toward challenges and motivated their interactions. The consequences were significant and reenergized their enthusiasm for nursing. Studying abroad was a remarkable, once-in-a-lifetime experience.

I was under pressure during the internship. Although I studied nursing voluntarily, learning was much like being forced to learn things.…After I returned home, I felt passionate about continuing my nursing education. I did not forget my original intentions for studying nursing… I feel that I have regenerated my enthusiasm for being a nursing student (S7).

Facing the reality.

The participants experienced a direct barrier to learning due to their lack of fluency in English, which may have impacted their comprehension of the topic under discussion. This highlights one of the main difficulties associated with learning in an environment for those with English as a second language. Lack of fluency impeded their learning and affected their ability to express themselves accurately.

The style of having lectures and language had a great negative impact on my learning progression. My English, including vocabulary and phases, tended not to be used in daily life, so it failed to express the meaning of things. I needed more time to respond …(S8).

Confidence, personal growth, and knowing before doing.

Becoming confident stemmed from personal growth following interaction with other people in a new environment. Participants’ satisfaction and confidence increased as their language skills improved. Interactions also provided learning opportunities and required them to adjust their attitudes towards connecting with the world. The participants became more confident as they received positive feedback from others. They knew what they had achieved and were motivated to set new goals, which taught them about planning. This was the first time in their lives that they had had to plan future goals, which was significant for their personal growth and maturity.

S9: I had learned more since I applied to this program. My attitudes towards things were more likely lazy and superficial. I started to modify my attitudes and that gave me a feeling of progression. I achieved my goal to study overseas and it was time to set the next goal and move forward.

Learning from the real world.

Learning from the real world emphasizes the development of soft power. Soft power involves managing daily activity, although it is difficult to teach or learn in the classroom. Learning from the real world made up for the shortcomings of classroom learning; the world provided a practical scenario for personal growth. Soft power encapsulates respecting others, enhancing self-directed learning, being confident, and becoming an active learner and critical thinker. The real world was a grand lecture theater that cultivated the participants’ personal growth. They felt that maintaining distance from others was not a sign of rudeness but a way of showing respect. Maintaining distance enabled them to avoid stress while interacting with others. This feeling could only be experienced in a new environment and was better taught via firsthand experience.

S10: People were respectful to others. I thought they were civilized. People would keep their distance from others…I became confident; it may be because of the change in learning from passive to active. Once you developed the courage to say what you thought in class, you became confident.