Toward Optimizing Global Learning Opportunities for US Physical Therapy Students: A Description of Current Practices and Initial Recommendations

Purpose. To examine and describe the structure, curricular objectives, and outcome measurement practices of faculty developing and providing international opportunities in physical therapy education programs and to provide guidance and initial recommendations for faculty. Background. Physical therapy educational programs are adding international opportunities as a way to address the increasingly global nature of the profession. Guidelines to enhance practice, optimize the experience, and provide structure for managing risk are warranted. Methods. A researcher-developed survey was distributed to 216 physical therapy education programs and professional listservs. Respondents from 56 programs (26%) returned the survey. Data were analyzed descriptively. Results. Most respondents cited global understanding as critical to the physical therapy profession, and the reason for involving students in global learning opportunities. Knowledge of the host site, sustainability, and potential strength of partnership were cited as the most important factors when choosing an international community partner. Risk management efforts included supplemental insurance, availability of emergency contact information, safe transportation and housing plans, and plans for adverse occurrences. Conclusion. This study supplements previous literature in designing international student experiences. Activities addressing clear purposes and expected outcomes for all participants, including the community partner, and the university-community partnership before, during, and after the experience are essential.


Introduction
3][4] Development of these experiences aligns with the increasingly global nature of our profession. 5Globalization is influencing healthcare, and physical therapists are likely to encounter marked diversity in any setting in which they practice.Indeed, the 21 st century has seen the profession of PT taking a more global stance and positioning itself for enhanced international awareness and collaboration. 5,6Therefore, providing opportunities for PT students to experience diversity and increase their cultural competence is critical.One way to address these issues in academic programs is to offer international experiences as part of curricula or encourage participation in elective opportunities organized by PT faculty.][10][11][12][13][14][15][16] These international experiences may help to develop skills and attributes that enhance students' preparation for practice in this culturally diverse and global health arena.
Despite the potential benefits, the proliferation of programs raises ethical concerns [17][18][19][20][21] and increases the potential for occurrence of adverse incidents. 22,23Managing the risk of safety and ethical incidents can take many forms.In addition to more typical risk management practices undertaken by faculty and often mandated by university risk management or study abroad offices (such as following legal and procedural mandates, purchasing extra insurance coverage, and emergency preparedness activities), faculty can further reduce the risk of unethical and/or unsafe situations by developing experiences that are structured and well prepared for.This structure and preparation might include in depth consideration of the purpose and expected outcomes of the program, student and faculty preparation and participation, the quality of international partnerships, and the interaction with the people served.Therefore, thoughtful and diligent planning and preparation are critical to create experiences that meet stated objectives, while being meaningful, ethical, safe, and sustainable.

Review of Literature
The following review of the literature includes exploration of the evidence that exists related to faculty practice, challenges to ethical and safe program development, and outcome measurement for international opportunities for students.The literature informed the development of the methodology and the interpretation of the resultant data for this study.

Faculty Practice
Apart from anecdotal information suggesting that many PT programs are offering international options, little evidence is available regarding who is developing them, why and how they are being developed, how many there are, how many students are participating, or where they are occurring.One study 2 began to describe the demographics of faculty who lead international student opportunities.Aside from that study little has been published about the demographics and experience of faculty who plan and lead international student opportunities.There is no aggregate data available about how locations are chosen, length, locations, type and number of participants, costs, or funding for international offerings.Further, other than case specific descriptions, no studies have explored the programmatic reasons for offering international opportunities, the objectives of those opportunities, the reasons faculty get involved, or levels of administrative support.
Understanding the motivations for why PT faculty are involved in developing and participating in international student opportunities is important because the reasons may have a major influence on how experiences are conceptualized and brought to fruition.Faculty may not be aware of, or be guided by, existing literature that could support and inform international student opportunity practices and objectives.5][26][27][28] However, in the service-learning related literature, Hammond 26 suggests that three predominant categories of faculty motivators exist: personal, co-curricular, and curricular.Personal motivators include past involvement in service activities, affinity for service and an interest in helping those in need, endorsement of social change, and a desire to work with students outside the classroom.Faculty co-curricular motivators include beliefs that such activities will promote civic involvement, moral character development, and improved multicultural understanding in students.Curricular motivators include effective presentation of content material, encouragement of self-directed learning, professional training, and experiential application of content.Faculty have also reported servicelearning helps to develop global citizenship and an understanding of common good, justice, equity, and fairness in students. 266][27][28] Data on faculty outcomes have yet to be published.

Challenges and Preparation
In medicine, best practice guidelines for global health training experiences have been proposed which include ideas from the Working Group on Ethics Guideline for Global Health Training (WEIGHT). 29In their exploration of international clinical education for PT students, Pechak and Black 30 proposed guidelines for structuring, carrying out, and evaluating clinical education abroad.However, other than case specific studies where some aspects of participant preparation are described, there is no literature that explores how students and other participants should be prepared for PT international opportunities.
Inherent in the preparation for international opportunities there must be an appreciation for -and attention to -potential ethical and safety challenges.[20][21][29][30][31][32] It has been reported that this is most often due to inadequate preparation about the ethical and safety dilemmas participants might encounter.2][33][34][35][36] There are no published studies about mitigating challenges and risk related specifically to taking PT students abroad.

Outcome Measurement
8][39][40][41][42][43] Authors agree there is value in assessing and measuring student outcomes such as attitudes and critical thinking ability, 24,41,42 global citizenship, 43,44 cultural competence, 45- 49 clinical skills, [50][51][52] and professionalism. 53Also, it is generally agreed that opportunities for reflection can enhance student outcomes. 54,55However, there is no consensus about what should be measured, how outcomes ought to be measured, or what tools should be used.Studies have indicated outcomes related to various stakeholders (PT programs, faculty leaders, students, host sites, and those served in the host sites, etc.) should be considered, yet no agreed upon tools have been identified.Most programs that do measure outcomes have done so by utilizing homegrown tools or tools that have been developed by those in other disciplines.
Because the inclusion of international opportunities in PT curricula is a relatively new and rapidly growing educational endeavor, it is vitally important to begin to establish and utilize standard expectations and guidelines.Research providing rationale that supports, justifies, and legitimizes the time and cost required to undertake international opportunities is necessary.
Further, studies that provide information that can help faculty develop programs where the experience is optimized and risk is minimized are needed.The purpose of this study is to examine and describe the structure, curricular objectives, and outcome measurement practices of faculty developing and providing international opportunities in physical therapy education programs, and to provide guidance and initial recommendations for faculty.

Subjects
Faculty from 56 PT programs across the United States (US) who have developed, or are in the process of developing, international opportunities for students participated in the study.
Participants were recruited via direct emails to each of the 216 PT education programs listed on the Accredited PT Education Programs page of the American Physical Therapy Association (APTA) website.A consent document was provided on the first page of the survey and consent was assumed when participants completed the survey.This study was approved by the University of Rhode Island Institutional Review Board.

Instrument
From a review of the literature, it was discovered that an existing tool to measure the items focused on in this study was not available.A researcher-developed tool was created following a thorough review of the literature and incorporation of key themes from the literature.
Items were developed to gather a variety of data related to various key aspects of developing and leading international experiences that are beneficial and safe.Prior to dissemination, a panel of five experts with substantive experience in survey design and research reviewed the survey to assess clarity and face validity.Revisions and modifications were made in response to their feedback.
The survey was comprised of 50 open-ended, multiple choice, multiple response, ranking, and multiple item Likert response questions.The survey items were organized into six sections.Section 1 included 12 standard demographic queries: including sex, educational background, years of experience, area of expertise, and experience in planning and leading international student opportunities.Section 2 asked for specific information about international offerings.Respondents were asked to answer 15 opportunity specific questions.The questions were related to length of opportunity, number of opportunities offered to students annually, number of student participants annually, costs and funding for students and faculty, whether or not trips are interdisciplinary, and factors influencing choice of location.Each respondent could provide information for up to 5 different opportunities.Section 3 included 6 questions related to the programmatic reasons for offering international opportunities, the objectives of those opportunities, the reasons faculty get involved, and whether or not programs are supported by university administration.Information about participant selection and preparation was requested in section 4.This included 6 questions related to student participants, faculty/leader participants, and any other participants.Risk management efforts and faculty concerns were explored with 6 questions in section 5. Items related to emergencies, travel insurance, housing and transportation were included.In this section respondents were also asked to report how often they worry about a variety of things when planning and leading international opportunities.Lastly, information about outcome measurement was requested with 5 questions in section 6.This included outcomes related to students, faculty/leaders, host sights, and universitycommunity partnerships.
Procedures A letter of introduction, which included a link to the survey, was emailed to each of the 216 PT programs in the US.It was requested that the SurveyMonkey™ link be passed on to the most appropriate person.In addition, two professional listservs were utilized to seek participation also via the SurveyMonkey™ link.This sample was a purposeful convenience sample. 56cessing subjects via listservs is not a probabilistic sampling technique, but utilizing the listservs provided a mechanism to reach a geographically diverse subject pool with specific interests in an economical, timely, anonymous, and efficient manner.Lastly, snowball sampling was utilized; subjects were asked to share the survey link with other interested PT faculty who may not have been included in direct emails or the listservs.An informed consent statement was provided on the first page of the on-line survey.

Data Analysis
Descriptive statistics (frequency and percentage) were calculated for the study variables: mean and standard deviation were calculated as indicated using SPSS24. 57

Results
Because not all participants answered all questions, the number of respondents is reported for each item.Moreover, some programs had multiple sites, therefore the number of programs varies from other sample size numbers.

Faculty Demographics and Experience
The majority of the faculty respondents leading international opportunities are female, and have been in academia for nearly 15 years.Nearly 43% had earned PhDs in one of the following areas: education (3), rehabilitation science (2), doctor of health sciences (2), neuroscience (2), biomedical engineering (2), kinesiology, PT with public health concentration, anatomy and cell biology, interdisciplinary sciences, biomechanics, exercise physiology, educational psychology, experimental psychology, health/physiology, health services research, doctor of business administration, and pathokinesiology (1 of each).
When asked what the total number of international experiences they had planned or developed in total, the 54 participants who responded reported a range from 1-16, with a mean of 3.87 (sd = 3.48).The average number of trips each respondent has participated in overall, ranged from 0-25 trips with a mean of 6.65 (sd 6.22).Each respondent generally participated in 1 per year.Respondents reported that their programs offer an average of 2.38 international opportunities to students each year, and an average of about 12 students participate annually.
Table 1 provides a summary of demographic information.

Faculty and Program Objectives
The majority of faculty identified: personal; co-curricular; and support for the institutional mission and values as reasons for being involved in developing and leading international opportunities for students (Table 2).A wide variety of educational reasons for offering international opportunities for students were reported (Table 3), however, the most frequently reported reason was the importance of global understanding.When asked to rank (1 most important, 7 least important) program objectives and outcomes, the top 2 reasons for providing international experiences for students were "Provide exposure to a diverse population / setting" and "Provide a life-changing experience for students."

Costs, Funding, and Curricular Options
In addition to airfare, the average daily cost for both faculty and students was estimated at between $51 and $75 per day.Faculty respondents reported their expenses were paid in a variety of ways.Although multiple responses were allowed, 44% reported their expenses were covered with departmental funds, 31% reporting self-funding, 24% reported that some funding came from student fees, 11% reported getting money from a Dean's fund, and 9% getting some funding from their global studies office.Additionally, faculty reported combinations of grants, scholarships, personal funding, and/or donations from friends or churches.With respect to student funding sources, again, multiple responses were allowed and reportedly, students pay their own expenses (94%), secure internal grant funding (26%), receive departmental funds (21%), and receive external grant funding (13%).
In general, international opportunities that were identified as being credit-bearing (80%) also had a syllabus and were graded.Of credit-bearing courses, the majority were longer in duration (two weeks or more) and considered to be non-elective.About 70% of the experiences were reported as "not-required" regardless of their length or credit-bearing status.Some opportunities could be taken for credit or not, depending on student needs.For trips where faculty traveled with students, the majority of study participants reporting a faculty:student ratio of 1:5 (range 1:2 to 1:15) .

Locations and Partners
A wide variety of locations and reasons for choosing destination and host site were reported (Table 4).When asked what factors influence choice of destination (multiple responses allowed) faculty overwhelmingly reported that knowledge of host site, likelihood of sustainability, and potential strength of partnership were most important.Additional factors included: the language spoken (45%), the clinical opportunities available (35%), the types of clients served (33%), and the cost (30%).Whereas factors such as availability of a variety of local experiences for students (23%), diversity of the culture (18%), opportunity for servicelearning (15%), location (10%), and climate (8%) were reported less frequently.Further, when asked about any other factors, participants reported such things as; the opportunity for immersion in a different socio-cultural setting, faculty interest, the needs of the international partner, availability of translators, physical beauty, and access to fun activities on days off.
Participants were asked how important various factors were when considering and choosing a community/host partner.Of note, the presence of a local physical therapist was seen as "very important" or "important" by only 36% (n = 13) and 24% (n = 9) ranked this "unimportant" or "very unimportant." In terms of whether or not international opportunities were interprofessional, 65% reported that their opportunities were interdisciplinary and 35% reported that they were not.For those programs that reporting having interprofessional involvement, the majority were collaborating with students in occupational therapy (17), nursing (11), and medical (10)   programs.Several participants who do not currently offer interprofessional opportunities reported that they plan to make their opportunities interprofessional in the future.

Participant Selection and Preparation
Students were selected for participation in international programs in a variety of ways.
Multiple responses were allowed and of the 38 participants who responded to this item, 63.2% (n = 24) reported having an application process and 60.5% (n = 23) took professional behaviors into account.Some considered grade point average (n = 18; 31.6%) and some reported that any student who wants to go can (n = 11; 29.0%).Few require medical screening (n = 5; 13.2%) and only 1 program reported requiring previous travel experience or language proficiency.The programs that reported having faculty leaders (n = 28; 50%) provided the following information (multiple responses were allowed); 11 (31.4%) reported that anyone who is interested can lead a trip; 8 (22.9%) said leaders must have previous experience taking students abroad; 4 (14.3%) reported that leaders must have previous personal international travel experience; and 4 (14.3%) said that they choose a colleague who they felt would be good.Two programs (7.2%) reported using former students as leaders and one program reported having an application process for leaders.In addition, programs tended to allow other types of participants.
These included professional colleagues, former students, faculty friends and spouses, and students' spouses.Still, 13 of the programs reported that they do not allow any participants other than faculty and students.
When asked what sort of information was provided to all participants prior to a trip, the 36 respondents identified topics that fall into three main categories (Table 5).The majority (65%-75%) discussed these issues with all participants and did not differentiate between information shared with students and information shared with faculty.Items that were reported as not being addressed at all by one or more respondents include: leader roles and responsibilities, program objectives, learning objectives, information about local medical providers/hospitals, inquiring about and responding to traveler's concerns, communicationon site, home, with participants, immunization and Center for Disease Control recommendations, outline of explicit rules and expected behaviors, notions about culture, money / currency, illness, packing list, and clinical issues.Eight programs responded that they do not address means for dismissal with either students or faculty.
When asked more specifically about student preparation before the experience, two categories of preparation are evident from the multiple responses of 36 study participants.The first was information and activities to prepare the student for the experience and enrich the experience such as: discussion of global health issues (33, 83.3%), required readings (19, 52.8%), team building (18, 50.0%), and personal goal development (11, 30.6%).The second category was practical issues such as: fundraising (22, 61.1%), involvement in logistics planning (18, 50.0%), collection of items to bring and donate (17, 47.22%), contact with host site (8, 22.2%), and collection of money to bring and donate (4, 11.1%).

Risk Management
Preparing for international settings appeared to be multifaceted.Regarding insurance, the majority (74%) required travelers to get special travel medical insurance, and the majority (45.7%) do not require evacuation insurance.Of the respondents, 64% indicated that they do not register with the US Embassy.Table 6 indicates the various information and items that leaders carry with them.
The majority of respondents (80%) reported that they used private transportation or rental vehicles hired or provided specifically for the group, with 44% reporting use of public transportation.Fifty percent (50%) of respondents reported spending a majority of nights in housing provided by the community partner / host.Other options, though lesser utilized, included hotel, home stay arrangements, and hostels.
Participants were asked what they worry about when planning and participating in international opportunities.Although the way in which data were collected makes it difficult to make definitive statements about the results, some trends indicate that the majority of leaders worry most about minor or major illness or injury of group members and transportation accidents.Most respondents reported "never" or "seldom" worrying about group members drinking too much, getting lost, experiencing mental health issues, being arrested, being bitten by animals or harmful insects, having swimming accidents, experiencing violence, harassment, or sexual assault from other group members or local people, witnessing violence, being kidnapped, or dying.Further, most "never" or "seldom" worried about terrorist threats or natural disasters.

Outcome Assessment
Student.With regard to using formal or standardized outcome measures to assess students, 55% (n = 21) responded affirmatively.Examples given included: reflective writing, report of activities, oral presentation, evaluation of attitudes and behaviors, clinical evaluation by supervisor, goals, practical examination, written papers, facilitator and barrier identification, program improvement analysis, grading rubrics, standardized clinical assessment tools, publications, locally developed learning objectives, and group projects to assess student outcomes.
Host site.Nearly 80% of participants reported that they do not use any formal or standardized outcome measures to assess their host sites.The small percentage of those who do stated that they utilize: student evaluations of the site, "outcome analysis", "the host site staff fills out a survey that consists of Likert and open-ended questions rating our program and providing direction for future programming", "evaluations available from professional organization", assessment of clinicians involved with students, and a satisfaction survey.Two participants reported that they plan to initiate site assessment in the near future.
Partnership.When asked if they use any formal or standardized outcome measures to assess university-community partnerships, 92% said they do not.One respondent said they use "many" but did not elaborate and 2 stated they were working on tools to be used in the future.
Faculty.Fewer than a fourth of respondents indicated use of formal or standardized outcome measures to assess faculty leaders.Examples included: course evaluations, student evaluations, submission of a vita, and peer review.

Discussion
The purpose of this study was to examine current practices related to developing and providing international student opportunities, discuss strategies to manage risk and promote optimal experiences, and to propose initial recommendations.The results of this study add to what is known and lead to some initial guidelines that should be considered by PT faculty developing international programs.The guidelines based on the findings from this study support and reiterate those previously identified in the literature. 29,30though the data do not provide exact information about how many (or what percentage) of all 216 accredited programs are actually offering international opportunities, it can be assumed that the 56 respondents represent a relatively high number of those programs that areassuming that all are not.In and of itself, this number is important.Strikingly, 26% of the programs nationwide responded that they are undertaking international efforts.This response allows some important conclusions to be made.Further, recruitment mechanisms allowed the researchers to reach a geographically diverse subject pool with specific interests in an economical, timely, anonymous, and efficient manner.
Given that international experiences are increasingly popular and align well with student interest and the increasingly global nature of our profession, 5 it is important that they are of high quality.This includes addressing risk management issues and ethical concerns while creating opportunities where participants are well-prepared with a clear purpose, clear objectives, and use of outcome measures.

Faculty Demographics and Experience
This study adds to what is known about PT faculty who develop and lead international opportunities for students.As was found in previous research 2 , it appears that most faculty planning and leading international opportunities have quite a bit of seniority and experience in academia.This can be advantageous in several ways.Perhaps these faculty have a level of clout that allows them to initiate international programs and capitalize on existing professional international relationships.It is likely they have strong curricular knowledge and experience developing student learning activities and objectives.27][28]58 The vast majority reported that they are involved for reasons that are "personal" or "co-curricular."It would be interesting to explore how/if these efforts are weighted in promotion and tenure processes.RECOMMENDATION #1: Senior faculty with experience leading international opportunities with students should mentor faculty to become future leaders of international opportunities (Table 7).

Purposes and Objectives
Consistent with the literature, most respondents ranked items such as; enhancing global understanding, providing students with exposure to a diverse population/setting, and providing a life-changing experience for students as most important.This corroborates the "personal" and "co-curricular" reasons for faculty involvement and might create a conflict for those trying to develop and justify programs that meet professional, curricular, and/or accreditation 7 expectations.RECOMMENDATION #2: Faculty should consider making objectives explicit and structuring the experience to: a) enhance participants' global understanding; b) expose participants to diverse populations and settings; and c) provide a life-changing experience for participants.

International Offerings and Partnerships
International opportunities are expensive for students, faculty, and programs.Although this study provides some preliminary information, further research is needed to explore cost benefit ratios.Better outcome measures and data are necessary for that to happen.This will allow programs to make important curricular decisions when incorporating international opportunities.
Destinations and host sites are chosen for a wide variety of reasons, however, faculty overwhelmingly reported that knowledge of host site, host site mission, and the likelihood of a sustainable, strong partnership were felt to be among the most important factors.This underpins the thought and care with which partnerships must be undertaken.Logistical factors such as location, climate, and the presence of a local physical therapist were seen as less important.
The occurrence of interprofessional international opportunities is on the rise.Program developers should consider the value of interprofessional opportunities and carefully develop the related objectives and expected outcomes.Perhaps the data indicate that careful thought should be given to decisions related to which disciplines will participate and how learning objectivesrelevant for allwill/can be accomplished.
While most programs seem to be occurring in Mexico, Central, and South America, the data indicate that study participants have international programs all over the world.No dynamic, up-to-date professional database, clearinghouse, or directory currently exists.Such an entity might provide educators with this, and other important information, that could facilitate sharing of resources, collaboration, improved sustainability, and research opportunities.RECOMMENDATION #3: An entity such as the APTA's Section on Education, Section on Health, Policy, and Administration The Catalyst, Global Health Special Interest Group, or other should consider creating and maintaining a dynamic and up-to-date international opportunities resource website.

Participant Selection and Preparation
While there is no consensus in the data about how leaders are chosen, students are selected for participation in international programs in a variety of ways.An application process seems to be common, but professional behaviors seem to be considered more often than grade point average.
Reportedly, a wide variety of information is provided to participants from three main categories; information to optimize the experience, logistics information, and risk management information.Interestingly, several programs reported that they do not address means for dismissal with either students or faculty.The data from this study seems to indicate that faculty leaders are not provided with all of the same information that students are giveneven in areas that would be important to them.The depth with which each topic is covered was not explored in this study.Further research is warranted that would better describe the importance placed on each topic and the specific nature of the information shared.
Preparatory activities for students often include discussion and or course work relates to global health, required reading, group team building, personal goal development, fundraising and logistics planning.Nearly half of respondents collect donation materials to bring and distribute and many fewer collect monetary donations.This should be explored further since there are those who feel that sometimes more harm than good is done when people who mean well arrive at partner sights with unnecessary and unwanted donation items. 59,60sk Management This is the first study to collect data related to faculty concerns and risk management activities undertaken by PT faculty when organizing international student experiences.A general consensus of what should be done would be beneficial to program leaders.
Most programs require some sort of supplemental insurance.Notably, very few programs let the US embassy know they will be visiting a foreign country.Depending on the nature of the trip and presence of a faculty leader, student and faculty emergency contact information, copies of passports, first aid, and emergency funds are carried.The variability in responses to housing and transportation questions is likely due to the diversity of locations, availability, and the nature of the host sight.
This study provides preliminary information about what faculty leaders worry about which can be compared to the information reported by a company that provides insurance for university students travelling abroad. 61This company reports that most trip organizers, students, and parents tend to worry about big problems like death, kidnapping, natural disasters, civil/political unrest, and terrorism.Whereas the things that should be worried about, because they are much more common (sexual/physical assault or harassment from a group member or other, mental health issues, serious illness/injury, arrest/questioning by local police, slips and falls, swimming mishaps, transportation related safety, getting lost, minor injury, and animal and insect bites), are given less attention. 22,23,61

Outcome Measurement
Many of the respondents reported having syllabi for their international experiences, and three expected student outcomes stood out from the rest: 1) improved understanding of global health issues; 2) higher levels of cultural sensitivity and competence; and 3) higher levels of cross-cultural understanding.As a means to those ends, faculty generally require frequent and regular updates and feedback, daily debriefing and/or reflection, and journaling.
57,62 The data show that only a few programs are doing this well.For example, are they measuring using evidence based, accepted tools, measuring the outcomes of all stakeholders, and utilizing outcome data.Many other respondents reported that they are measuring outcomes, however, their responses indicate otherwise.No agreed upon tools were identified.This is perhaps due to the fact that goals and objectives differ from program to program.Having at least some agreed upon goals and objectives, and assessment tools would be helpful.Collaborative research across universities would allow for richer aggregated data to identify goals, objectives and outcome measurement tools that could be used universally.RECOMMENDATION #5: Determine objective and measurable outcomes agreed upon in advance by each stakeholder (host, student, faculty) and following the experience, complete an assessment examining a priori outcomes, whether cultural competence [63][64][65][66][67] , professionalism 65 , interprofessional practice 68,69 , or civic learning. 67

Limitations and Future Research
Although convenience samples are often used, they may not be representative of the whole population, and as such might be biased toward those who chose to participate and should be considered in that context.The instrument was developed by the researchers and was not validated beyond the panel of 5 experts.Moreover, the tool was lengthy and could have resulted in participant fatigue.Additionally, it may have been helpful to more clearly operationalize definitions (long-term and short term experiences, and clinical education for example).
In light of the fact that this is a preliminary study, it be used as a steppingstone to prompt future research that might include more rigorous exploration of subtopics.Although beyond the scope of this study, analysis of the affects of host location with further analysis of the data by country would be beneficial since objectives and safety issues would likely be different in developed versus developing locations.Studies exploring appropriate goals and objectives and learning activities would also be beneficial.Insight about creative and useful ways to measure outcomes for all stakeholders is needed.And additional research is warranted to explore the costbenefit ratio of international opportunities for students, faculty, universities, and hosts.

Conclusion
The purpose of this study was to begin to describe faculty practice related to the development, curricular objectives, and outcome measurement practices of faculty developing and providing international opportunities in physical therapy education programs, and to provide guidance and initial recommendations for faculty.Educators involved in taking or sending students abroad should consider the recommendations provided in Table 8.In order to remain salient, these guidelines will need to evolve with continued findings from research and reflection.
Although the results of this study are most applicable to PT education, they can also provide information that may be useful to other health disciplines initiating international student opportunities.
Further exploration of what worries leaders is warranted to better understand if what they actually worry about is what they should be worrying about.This is important since worry is likely an indicator of what is considered, attended to, discussed with the group prior to experiences, and planned for in ways that minimize risk.Of course, this information should be put into the context of the location being traveled to, since location specific risks can vary widely.Risk management efforts protect faculty, students, the host site, and the University.Faculty should consider what sorts of things leaders and participants (and/or their parents) worry about going wrong, and weigh those with what should be worried about and planned for.RECOMMENDATION #4: When preparing for an international opportunity the university's office of risk management should be consulted.