quantitative approach guided the first stage of the study, which was appropriate due to the scant research on the international service-learning in medical education and the few existing studies on which to build. This issue is an emerging topic and the
conceptualizations, instruments, and outcomes are still not well-defined in the literature. Stebbins (2001) believed that researchers must look at a phenomenon in broad, non- specialized terms to begin to understand or explore an emerging issue. A quantitative approach with a survey helped identify institutional and organizational factors in which unexplored perspectives of ISL reside and illuminated salient factors that are relevant to future research.
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97 To this aim, I created a survey that contained both closed and open-ended
questions which focused on examining the nature of international rotations in medical education programs at U.S.-based universities, and asked respondents (coordinators of international rotations) about the barriers and facilitators to implementing ISL and the larger contextual factors that influence a medical school’s participation in ISL. There were 35 items on the survey, and it was expected to take approximately 15 minutes for participants to complete the survey. The questions were designed to investigate
implications revealed during the literature review (i.e., perspectives of coordinators, attention to organizational contexts and perspectives of service-learning, etc.) and were intended to collect information on four general concepts:
1) Details about the variety of ways that international rotations are designed and implemented as potential variables that may indicate a predilection for participation in ISL;
2) Barriers and facilitators to implementing ISL from the perspectives of IRC stakeholders within medical education institutions to highlight institutional contexts related to change and incorporation of new pedagogical strategies; 3) Larger contextual factors that might influence a medical school’s participation in
ISL (i.e., institutional contexts, Carnegie Community Engagement Classification, etc.);
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98 4) Non-identifying demographic information about the survey participant and home
institution, such as type of university.
Given the national scope of this investigation, I chose a survey methodology to secure generalizable data from the total target population of institutional stakeholders within medical education. A survey allowed for data to be collected in a relatively short period of time, in consideration of the limited schedule that this population has for activities outside of teaching, research, clinical duties, administrative activities, and other related responsibilities. This approach was cost and time effective and is a common approach to studies performed in medical education.
After I created the survey, it was reviewed for face validity (e.g., ensuring appropriate definitions were used for terms such as clinical service versus non-clinical service) by three medical school stakeholders representing both faculty and staff, who have expertise in international community-based education, and was then pilot-tested for time requirements and usability by three other medical school stakeholders. After the pilot, I sent the survey to IRCs at all 185 medical schools in the United States as described above for stage one of the mixed methods design. This process captured the perspectives of staff members, which have not been adequately explored in the literature, as well as perspectives within the microsystem, mesosystem, and exosystem of each medical school.
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99 Figure 3 below summarizes the systematic process that I used to identify those individuals who were the intended recipients of the survey in their institution’s equivalent of an IRC role. I searched each medical program’s website for a list of organizational roles, and the faculty or staff member responsible for designing, developing, or
implementing international rotations was identified. These positions had varying job titles and were identified by locating the contact person for coordinating rotations listed online. If a specific coordinator was listed for international rotations, I selected that individual. In schools where there were not specific coordinators listed for international rotations, I selected the coordinator listed for all rotations in general. The individuals identified through this process were those who might either influence or implement international service-learning in medical school. This process created a pool of 185 survey
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100 Figure 3. Identification process for survey recipients
A helpful resource during the identification process was a list published by the Association of American Medical Colleges called the Visiting Student Learning
Opportunities (VSLO) database. VSLO combined two previously existing programs, the Global Health Learning Opportunities program, and the Visiting Student Application Service. The VSLO database represents a community of institutions that send and receive medical and public health students in locations away from their home institutions. I utilized the list of participating institutions published on the VSLO website to cross-
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101 reference against the list of 185 medical schools before determining that there was no international rotation coordinator (step 2 in Figure 3).
After identifying individuals, I created a list of survey recipients and assigned a code to each recipient to maintain anonymity of participants (e.g., 01, 02, 03, etc.). This coding system was also used for interview data, in cases where the survey participant was being interviewed. In cases where an additional stakeholder from the institution had been identified and agreed to be interviewed, an additional code was assigned (e.g., 04). After creating the coded system that identified individuals to receive the survey, I sent the survey electronically through Qualtrics, an online platform for survey design and management.
I distributed the survey in the fall of 2018 and it was open for a period of one month. In consideration of the limited schedule that this population has for activities outside of teaching, research, clinical duties, administrative activities, and other related responsibilities, a one-month period was cost and time effective and is a common
approach to studies performed in medical education. An initial email to those participants identified through the systematic process detailed above included information about the study and a consent form, along with an individual link to the survey that was tied with an anonymous code. Participants were informed that their participation in the study was voluntary and that by completing the survey, they indicated their consent to participate in the study. Reminders were sent after a period of two weeks to those who had not
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102 completed the survey, and a final reminder was sent one week after that to outstanding recipients. One week after the final reminder was distributed, I closed the survey. All data were stored in the Qualtrics online platform, which is password protected and secure.
While the survey was open, I also independently collected information related to Carnegie Community Engagement classification. I identified how many of the higher education institutions that encompass the 185 medical schools have a Community Engagement classification. This process helped triangulate relevant information
regarding the awareness of the macrosystem regarding service-learning and international community engagement in any cases where study participants may not be aware of their home institution’s status, which was a question on the survey. It also served to identify and/or verify the macrosystem status as it may have related to particular barriers or facilitators related to the institutional context.
The questions on the survey were a mix of scaled responses and open-ended questions (see Appendix A). Where relevant, the survey included an operating definition of ISL: a structured learning experience that combines community service with explicit learning objectives, preparation, and reflection in an international setting across national country borders (Seifer, 1998). However, most of the survey content referred to
“international rotations” as opposed to “international service-learning” to better fit the language used in medical schools to describe international education experiences.
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103 identifying either outlier or extreme cases that stood apart from the rest of the data set or contrasted with themes that were widely represented in the literature review, and I identified common themes that a majority of survey respondents indicated on the survey. I then used the results to plan the second qualitative stage.
Stage 2: Qualitative procedures and instrumentation. In the second stage of