160  Sodobna pedagogika/Journal of Contemporary Educational Studies  Timea Németh and Alexandra Csongor Let./Vol. 69 (135) Št./No. 2/2018 Str./pp. 160–170 ISSN 0038 0474 Internationalisation at Home: The Case of Non-Mobile Medical Students in Hungary Abstract: The patient population in healthcare has transformed radically in the past few decades, from a homogenous to an increasingly heterogeneous cohort of people. Therefore, it is imperative to educate medical students and increase their intercultural competence to effectively treat a multicultural patient population. One approach is to participate in mobility programmes. However, data implies that only 1% of the Hungarian student population and less than 0.5% of Hungarian medical students are mobile, mainly due to lack of foreign language skills and insufficient financial support from their families. Consequently, non-mobile medical students’ intercultural competence needs to be developed locally. The aim of this paper is to present specifically designed classes in which local and international students study together and participate in collaborative teaching methods, such as intercultural language learning and special telecollaborative projects. Internationalisation at home and internationalisation of the curriculum will work towards a measurable increase in the quality of learning and teaching at the at the University of Pécs Medical school, Hungary. Keywords: internationalisation at home, non-mobile students, medical education, telecollaboration, returnee scholars and academics, intercultural competence, intercultural language learning UDC: 378 Professional article Timea Németh PhD, Assistant Professor, Medical School, University of Pécs, Szigeti út 12, 7624 Pécs, Hungary; e-mail: nemethtimi@yahoo.com Alexandra Csongor PhD, Assistant Professor, Medical School, University of Pécs, Szigeti út 12, 7624 Pécs, Hungary; e-mail: alexandra.csongor@aok.pte.hu  Németh, Csongor 161 Introduction “Internationalisation is changing the world of education and globalization is changing the world of internationalisation.” (Knight 2003, p. 3) Today, we live in a globalised world where people are mobile and many can be regarded as ‘citizens of the world’ as they move from one country to another for better or just different education systems, work options or living conditions. In this environment, intercultural competence and skills related to cultural sensitivity are more essential than ever, regardless of profession. As a consequence of globalisation, worldwide migration and the development of multicultural societies, the patient population has been transformed across the globe, from a homogenous to an increasingly heterogeneous cohort of people in need of proper healthcare. These immigrants bring their beliefs and practices into the healthcare system of another culture, which often leads to misunderstandings and difficulties. Healthcare professionals must diagnose and treat patients from diverse backgrounds on a daily basis. Therefore, it is imperative to teach medical students how to broaden their intercultural competence, knowledge, awareness, attitude and skills in order to treat a multicultural patient population effectively in their future jobs as doctors and healthcare professionals (Betancourt 2003; Németh 2015). One approach, as part of internationalisation in Europe, is to participate in various study abroad and mobility programmes, like the Erasmus programme. International organisations, including UNESCO (2009, pp. 48–53) and economic and political partnerships such as the European Union (Erasmus statistics 2014), consider it imperative to encourage worldwide mobility and exchanges of students and staff. However, data implies that only 1% of the Hungarian student population and less than 0.5% of Hungarian medical students are mobile (Tempus 2014). There- 162 Sodobna pedagogika/Journal of Contemporary Educational Studies Németh, Csongor fore, the implementation of an international dimension in the medical curriculum is imperative, as the lack of a common language between patient and healthcare provider can result in misdiagnoses and may lead to improper treatment. Cultural beliefs and values have implications on how symptoms are recognized, interpreted and when medical services are sought. The inability to communicate appropriately can be an obstacle to proper medical care and undermines trust in the quality of the system (Goode et al. 2009, pp. 507–510; Voigt 2003, pp. 18–22). As the number of non-mobile medical students is still high due to lack of foreign language skills and insufficient family income to financially support their mobility, their intercultural competence needs to be developed locally as internationalisation at home, and alternative teaching methods and classes need to be introduced into the curricula to assist students’ intercultural competence and skills (Németh 2015, pp. 65–66). The process of internationalisation and internationalisation at home According to Olander (2012), today the need for an international approach to higher education cannot be ignored. However, internationalisation is a relatively new concept in several countries, including Hungary. It has been in use for several centuries in political science and governmental relations, but has only become a buzzword in higher education since the late 1980s and early 1990s. Bentling and Lennander (2008, p. 15) maintain that “internationalisation promotes cultural competence”. Nonetheless, it means different things to different people and is often confused or used interchangeably with the term globalisation. Knight (1997, pp. 5–7) argues that whilst globalisation is the flow of technology, economics, people and cultures across borders, the internationalisation of higher education is one of the ways a country can react to the challenges of globalisation. Therefore, these terms can be interpreted as different in meaning but closely related dynamic processes. As Knight claims (1999, p. 14), “globalisation can be thought of as the catalyst, whilst internationalisation as the response, albeit a response in a proactive way”. One of the earliest and most commonly quoted definitions of internationalisation also originates from Knight (1993, p. 21), who defines it as the process of incorporating international and intercultural dimensions into the various functions of higher education including, but not limited to research, teaching and services. The importance of including both an international and an intercultural approach underscores that internationalisation is not oriented towards countries and nations exclusively, but also cultures, minorities and ethnic groups within their territories. Sheppard and Bellis (2010, p. 37) argue that internationalisation is a more holistic approach to embedding international and global values into all aspects of institutions, as it also highlights other issues and agendas including employability, lifelong learning and curriculum development. Altbach (1998, pp. 347–348) implies that institutions of higher education have always been international and global in terms of knowledge, research and mobility of students and researchers. Internacionalizacija doma: primer študija medicine na Madžarskem/  Internationalisation at Home: The Case of Non-Mobile Medical Students in Hungary 163 In the past internationalisation has centred on mobility throughout Europe. The Erasmus programme in particular was a strategic step toward internationalisation. Migration trends also had an impact on the environment in higher education across the globe, and are undergoing radical change. More students have decided to study abroad for their degrees through bilateral agreements or European Union-level mobility programmes (Erasmus statistics 2014), thus enabling increased contact among diverse cultures. As a result, the internationalisation of higher education is an inevitable, (Knight 1993; Barakonyi 2002; Betlehem et al. 2003) long-term process which benefits all stakeholders throughout higher education. In consideration of continuous and rapid changes, Knight (2003) felt the classification of internationalisation had to be updated in the early 21st century, and developed the following definition, “internationalisation at the national, sector and institutional levels is defined as the process of integrating an international, intercultural or global dimension into the purpose, function or delivery of postsecondary education” (ibid., p. 2). She uses the three terms international-intercultural-global intentionally as a triad, whereby international refers to the relationships between nations, intercultural the diversity of cultures within a country and global the worldwide scope of the term. Moreover, Knight (ibid) claims that with the use of the more generalized terms in the updated version, the meaning of internationalisation can be relevant for various sectors and institutions as well as providers of postsecondary education. Internationalisation has presented unique and unfamiliar responsibilities, new opportunities and risks throughout higher education. The increasing number of students from diverse backgrounds teaching and working in a multicultural environment has provided numerous challenges for all participants. Peček and Skubic Ermenc (2016, pp. 20–22) suggest that teachers and pedagogical staff need special training to work more effectively in multicultural environments. In Bester and Medvesek’s view (2016, pp. 27–28) the implementation of the concept of interculturalism is inevitable, and significant changes are imperative in teacher education to support the development of intercultural competence. Internationalisation at home is an important pillar in the internationalisation strategy, as not all stakeholders have the opportunity to study, work, teach or do research abroad. According to Knight (2008) internationalisation has two fundamental components: internationalisation abroad and internationalisation at home. Beelen and Jones (2015, pp. 62–65) suggest that internationalisation at home is the purposeful integration of international and intercultural dimensions into the formal and informal curriculum for all students within domestic learning environments. They also stress that the presence of international students is beneficial and offers opportunities for a successful and meaningful intercultural learning and teaching process. The primary aim of internationalisation at home from a healthcare perspective is to teach graduates how to function and operate across borders and backgrounds to provide culturally competent healthcare (BIHUNE Project 2003). 164 Sodobna pedagogika/Journal of Contemporary Educational Studies Németh, Csongor This paper seeks to present internationalisation and internationalisation at home processes as well as curricular development and teaching methodologies based on an understanding of these two concepts. Returnee scholars and academics: An opportunity for internationalisation at home With the passing of each year, Hungary is becoming increasingly multicultural. Comparing the latest census data with that of 2001, there is a significant increase in the number of foreign nationals residing in the country (KSH 2013), whereas the number of those claiming to be Hungarians has decreased by more than one million. This trend suggests the outward migration tendencies of the Hungarian population, including a significant number of professionals from the medical field. As demonstrated by Figure 1, we refer to this generation as the L+EARNers, as they consider moving abroad to be an excellent opportunity to both learn and earn more. Learn Earn L+EARNer generaon Figure 1: The L+EARNer generation model of migration abroad from Hungary Source: Németh, 2014 However, as Fassmann et al. (2018) claim, this also poses a threat to the country as the migration of highly skilled professionals not only implies a shortage of financial capital, innovation and productivity, but also a loss of significant know-how and expertise. In their view, international labour migration is in fact a circular process, as it facilitates the development of transnational social networks and instigates the transfer of skills and knowledge. They refer to this phenomenon as brain circulation, which can be regarded as an opportunity to reduce the negative effects of brain drain, during which a country may lose many of its talented and educated citizens due to migration. As suggested by Fassmann et al. (ibid.), migration and developmental policies should implement specific programmes for returnees, and thus aim at converging brain drain and brain circulation. The medical school at the University of Pécs has long been providing incentives to Hungarian scholars and academics living outside the country to lure them home. Many have returned, and with their international expertise and know-how they contribute to the internationalisation at home programmes at the university. Scientific laboratories have been set up by and for them, in which local students collaborate and perform research projects enriched by international perspectives. Special seminars and lectures are facilitated by returnee academic faculty, integrating global aspects. Internacionalizacija doma: primer študija medicine na Madžarskem/  Internationalisation at Home: The Case of Non-Mobile Medical Students in Hungary 165 In Knight’s view (2003, p. 2), the internationalisation of education can also be referred to as borderless or cross-border education. Returnee scholars and academics contribute to internationalisation at home programmes by making research and teaching processes transnational while still local. Developing a new course to integrate local and international students Over time, the student body of the medical school at the University of Pécs (UPMS) has grown more and more international (Student statistics 2016). As indicated by enrolment data (ibid.), the total number of students enrolled at UPMS in September 2016 was 3,635. Analysing the data further suggests that Hungarian students only represent 43% of the total student population. The majority of non-Hungarian students (37%) are from Germany, an estimated 14% come from Iran and Norway, and the remainder originate from various countries spanning the globe. Hence, the medical school is internationalized and provides a multicultural environment for both students and staff. However, the courses offered are in three different languages, English, German and Hungarian. As a result, students are not fully integrated during their studies and rarely have the opportunity to work, study, do projects or collaborate with each other. There is a need to improve the intercultural competence of medical professionals at both ends of the system, from students to practising doctors. By the time medical students graduate and find employment as physicians, these skills will be necessary to provide quality medical care (Németh et al. 2017). As an initial step, the first Intercultural Competence in Doctor-Patient Communication elective course was developed and implemented in September, 2016 by instructors of the Department of Languages for Specific Purposes. It was of primary importance to ensure this course was available to students of all three language programmes (Hungarian, English and German), as an intercultural classroom would be valuable in raising intercultural awareness and sensitivity later in their careers. This course aims at increasing medical students’ awareness of sociocultural influences on health beliefs, attitudes and behaviours as well as providing the skills to understand and manage these factors during medical care involving patients from diverse cultural backgrounds. Each semester students who sign up for this course represent several countries and cultures. These include China, Germany, Hungary, Iran, Japan, Jordan, Korea, Nigeria, Norway, Spain, the USA and many more. The sessions focus on different aspects of providing medical care in a multicultural environment, from the impact of globalisation and migration, stereotyping and gender issues, to culture specific health beliefs, religious views and behaviour. Emphasis is placed on the importance of seeing the world from multiple perspectives. The sessions are interactive to develop proper communication and achieve appropriate effects. Students are continuously engaged and involved through asking questions and listening to one another’s perceptions. This results in dialogue between the students, 166 Sodobna pedagogika/Journal of Contemporary Educational Studies Németh, Csongor with conversations continuing well after the sessions, providing an international dimension to the classes. Telecollaboration projects as a means of virtual mobility Today, digital learning is a key facilitator of internationalisation in higher education. Web 2.0 technologies and online educational tools have grown increasingly significant in teaching and learning. This is particularly important in an intercultural setting, in which students collaborate with one another and with their instructors through technology. With the use of these tools students can interact with their peers, other learners and speakers from the target culture, and skilled professionals (Kern 2013). Telecollaboration uses Web 2.0 technologies to connect students studying foreign languages in different countries. Its primary goal is the improvement of foreign language skills as well as developing intercultural competence (Furstenberg et al. 2001, pp. 56–57). Telecollaborative projects target non-mobile students by establishing the virtual mobility of this group, contributing to both the internationalisation and the internationalisation at home strategies of the university. Students from the aforementioned Intercultural Competence in DoctorPatient Communication elective course have been involved in telecollaborative projects with medical students from the University of Ioannina, Greece, since the spring semester of 2017. These are on-going, long-term projects aimed at not only enhancing the students’ English medical language skills and intercultural competence, but effectively building their awareness of medical culture. The projects also involve constructing an online, technology-driven platform (including vlogs, posts, graphs, infographics and articles) in support of medical culture specifics and increasing students’ awareness of the differences between their home and the target culture. Initial data analysis suggests that these online telecollaborative projects can enhance intercultural learning and dialogue for both students and teachers, provide a preliminary insight into the formation of medical cultural knowledge, and facilitate the co-construction of new cultural knowledge, all significant parts of internationalisation. Intercultural language learning: A collaborative teaching method The medical school at the University of Pécs provides a multicultural work and study environment involving students from diverse cultural backgrounds. At the beginning of their third year, international students perform bedside communication with Hungarian patients in various hospital wards and settings while taking their medical history. They are required to understand the patients’ replies and report the case history to their physician supervisors in English. Students are also expected to perform physical examinations and give clear instructions to the patients in Hungarian. These are challenging tasks, as it necessitates learning Hungarian Internacionalizacija doma: primer študija medicine na Madžarskem/  Internationalisation at Home: The Case of Non-Mobile Medical Students in Hungary 167 medical terminology, understanding authentic medical discourse and communicating adequately in medical settings. International students are encouraged to enrol in elective language courses in Hungarian for Medical Purposes beginning in their first semester to prepare for the requirements of medical training. In addition to language use and situational practice, intercultural issues must be addressed during language courses. A collaborative teaching method was set up in 2015, in which both language teachers and student teaching assistants work together in the language teaching process. The teaching assistants are senior medical students; therefore, in this context they can be regarded as experts, with more experience and knowledge than junior medical students. There are several benefits to using this teaching method. The teaching assistants serve as communication partners. Cultural aspects of language use and typical situations can be demonstrated and discussed with their assistance. The Hungarian teaching assistants create simulated role-play scenarios in the classroom or in the Medical Skills Laboratory (also known as Medi Skills Lab) while the international students take the medical histories of their simulated patients. Afterwards, the international students are expected to give instructions in Hungarian while performing a physical examination. The teaching assistants base the simulations on real cases they have encountered at the hospital. In the simulation tasks students are given prompts in English, which helps them ask relevant questions. During these simulations cross-cultural difficulties which might arise with patients of different ages, ethnic groups and social and religious backgrounds are also discussed. The actual hospital visits are also part of the class curriculum, in which international students practise taking medical histories with Hungarian patients under the supervision of the Hungarian teaching assistants. The clinical visits are beneficial for all participants, as the students have the opportunity to practise real-life interactions (Csongor et al. 2017). Conclusion Due to globalization, geopolitical and economic changes and worldwide migration, the patient population is comprised of a heterogeneous group of people speaking different languages and representing numerous cultures, ethnicities, religions and beliefs. Healthcare options and outcomes must be clear to all patients, regardless of their culture or experience. Cultural and language obstacles are the primary challenges in meeting the healthcare needs of this diverse patient population. Thus, medical professionals must develop intercultural competences that facilitates understanding of patients’ cultural norms, and accordingly adjust their behaviours to achieve the best healthcare for patients. Awareness of cultural differences and the ability to respond appropriately is crucial for the effective practice of medicine. Therefore, medical education in Hungary needs to reach adequate cultural awareness, knowledge, skills and attitude levels. Cultural curriculum development must extend beyond merely transmitting culture-specific knowledge and include attitude and skills components as well. 168 Sodobna pedagogika/Journal of Contemporary Educational Studies Németh, Csongor Responding to the university’s strategical goal of implementing international, intercultural and global dimensions into its teaching and research activities, the medical school at the University of Pécs has made several steps under the auspices of internationalisation and internationalisation at home. The aim of this paper was to present internationalisation and internationalisation at home processes, curricular changes and novel teaching methodologies which contribute to the quality of learning and teaching in a multicultural student environment. Several policies have been instigated to lure scholars and academic staff back from well-developed foreign countries, and curricular changes have also been implemented. Internationalisation and internationalisation at home are expected to have positive effects on academic education, cultural awareness, international understanding and world peace, as specified by UNESCO (2009, pp. 51–52). Students become good citizens, not only of their own countries, but of the world and therefore are able to work internationally across cultures. Many will find employment abroad, yet all will live in an increasingly multicultural society. 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Bioethics Forum, 19, št. 1–2, str. 17–23. This article was prepared in the scope of the Support to the implementation of EHEA reforms project. It has been funded with support from the European Commission and the Ministry of Education, Science and Sport. This paper reflects the views only of the authors, and the Commission cannot be held responsible for any use which may be made of the information contained therein.