Strides in Development of Medical Education

Document Type : Review

Authors

1 PhD in Health Information Management, Office of VC for Global Strategies and International Affairs, Tehran University of Medical Sciences, Tehran, Iran

2 PhD Student in Information Science, College of Communication & Information, University of Tennessee at Knoxville, Tennessee, US

3 MA in International Relations, Office of VC for Global Strategies and International Affairs, Tehran University of Medical Sciences, Tehran, Iran

4 MD, Clinical PhD on Chinese Medicine & Acupuncture in Beijing University of Chinese Medicine, Department of Traditional Medicine, School of Persian Medicine, Tehran University of Medical Sciences, Tehran, Iran, Beijing University of Chinese Medicine (BUCM), Beijing, China

5 DDS, Diplomate of Iranian Board of Endodontics, PhD on Dental Biomaterial in Cardiff University, Cardiff, UK, Department of Endodontics, School of Dentistry, Tehran University of Medical Sciences, Tehran, Iran

Abstract

Background: Despite the numerous advantages of internationalization, universities and higher education institutions (HEIs) often encounter challenges when implementing internationalization activities. Part of the problem concerns the vague definition of internationalization and its performance indicators.
Objectives: The present research aims to identify indicators for internationalization in universities and (HEIs) by conducting a comprehensive literature review to help universities better understand and implement internationalization activities and processes.
Methods: This study is a systematic literature review, informed by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, in which six bibliographic databases, including Web of Science, Educational Resources Information Center (ERIC), ScienceDirect, and Wiley Online Library for English literature and Scientific Information Database (SID) and MagIran for the Persian literature were searched in 2023. Approved articles underwent synthesis, and findings were analyzed using qualitative content analysis.
Results: A total of 2086 articles were identified, out of which 37 were selected for content analysis. The content analysis and final synthesis revealed six overarching themes consisting of 12 subthemes, 38 groups, 11 subgroups, and 466 codes. The main themes included education (with three subthemes of internationalization at a distance, quality assurance and continuous improvement of internationalization, and internationalization of education, teaching, and learning outcomes), international aspects (with two subthemes of international public relations and communication, and international cooperation and networking), research (with two subthemes of internationalization of research, and commercialization of ideas and innovations), students (with two subthemes of student welfare/support services, and cultural/social services), management and human resources (with two subthemes of management, and human resources), and healthcare (with one subtheme of healthcare and treatment).
Conclusion: The results necessitate consideration of several indicators, rendering internationalization a multifaceted challenge that requires inter-sectoral cooperation at both internal and external university levels. The results hold significance for international relations managers and education policymakers in facilitating the planning and implementation of internationalization activities.

Keywords

Background

It has been more than three decades since the discussion of the internationalization of higher education at national levels started in many countries as an important aspect of responding to the challenges and needs caused by globalization (1). In many universities and Higher Education Institutions (HEI), the concept of internationalization has received much attention and is becoming one of the main concerns of universities around the world. The importance of internationalization is so great that many universities and HEIs have gone beyond and included it in their vision/mission statements, operational plans, national institutional frameworks, and the content of their curricula (2). Knight has defined the internationalization of higher education at national, sectoral, and institutional levels as “the process of integrating the international, intercultural, or global dimension into the goals, functions, and delivery of higher education” (3). The internationalization of higher education has experienced many changes in recent years and has changed from a concept that was only related to the transfer of students to a broader concept that includes academic programs (student exchange programs, foreign language training, internationalization of curriculum), scientific research (international joint research projects, international conferences, and conventions), extracurricular activities, and international relations (4-7). Internationalization is one of the ways to respond to the effects of globalization while fully respecting the national identity (8). Universities and HEIs have realized more and more that internationalization is a necessity and a mission for all departments of a university rather than a marginal activity.

In Asian countries, creating world-class universities and promoting them in global rankings are often on the agenda of the internationalization of universities, and governments such as China and South Korea have adopted strategic policies to achieve such goals (9).
Pre-defined and quantitative Key Performance Indicators (KPI) associated with governments' internationalization initiatives have also become commonplace with the rise of such policy measures (10). However, the problem is that achieving quantitative KPIs is often the end goal in some universities, and less emphasis is on improving the quality of internationalization activities. Most of the indicators in global ranking systems and academic journals are quantitative and of the same type as KPIs and are of the same problem (11).

Numerous studies have been conducted to investigate the internationalization of higher education, considering internationalization at organizational levels and internationalization of curricula and learning outcomes. The Organization for Economic Co-operation and Development (OECD) has provided a tool called “Internationalization Quality Review Process” to evaluate internationalization. This assessment includes internationalization policies, support structures, academic programs, grants and contracts, students, scientific cooperation and research, and human resource development programs and opportunities (12). Ellingboe's Six Dimensions of Internationalization (1998) is the result of two large research studies in American universities (13). Five of these dimensions, i.e., faculty participation in international activities, international curriculum, study abroad, international students and researchers, and leadership, are mentioned in almost all internationalization documents and thus represent key components at the international level (13). In Paige's (2005) internationalization model, key functional categories include university leadership for internationalization, internationalization strategic plan, institutionalization of education, infrastructure and staff, internationalized curriculum, international students and researchers, studying abroad, participation of professors in international activities, extracurricular activities in the university environment, and monitoring the internationalization process (14).

In Iran, several studies have been conducted to investigate the internationalization of higher education at the institutional level and the internationalization of curricula and learning outcomes (15-19). Additionally, by interviewing 16 academic experts, Zamanimanesh et al. (2016) designed a local model for the internationalization of Iran's medical sciences universities (17). The conceptual model of their research included infrastructure (which indirectly and imperceptibly affects internationalization) and superstructure factors (which directly and visibly give medical sciences universities an international image). The infrastructure factors also included global and regional conditions, cultural and economic conditions, and political and security conditions, while the superstructure factors included management and human resources, scientific cooperation, space and equipment, curricula, extracurricular activities, monitoring and evaluation, and academic culture (17).

In Iran, despite the fact that the upstream documents and related long-term plans, such as “The 20-Year Vision Document,” “The Comprehensive Scientific Map of the Country,” “The Major Objectives of Science and Technology System,” “The Sixth Five-Year Development Plan Law,” and “Transformation and Innovation Programs of Medical Education,” by the Ministry of Health, Treatment and Medical Education explicitly emphasize on the development of science and technology in the world and the expansion of international cooperation in all fields of science and technology, Iranian universities and HEIs are facing challenges in assuming the roles, priorities, and strategies of internationalization.

Objectives

The present study aimed to provide a comprehensive set of quality indicators that can be used for self-evaluation and peer evaluation of internationalization performance. The present study intended to provide a manageable set of internationalization evaluation indicators for universities and HEIs through a comprehensive review of existing literature. These indicators allow universities to analyze their current situation in relation to their internationalization activities, identify their weaknesses, and develop strategies and plans for internationalization improvement.

Methods

This study is a systematic literature review conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, in which available original English papers related to indicators, criteria, or standards of internationalization of universities and HEIs were searched. The Patient, Intervention, Comparison, Outcome (PICO) framework was applied to identify and define the research population (universities and HEIs), intervention (internationalization activities), comparison (N/A), and outcome (self-reported effectiveness). The six bibliographic databases included Web of Science, Educational Resources Information Center (ERIC), ScienceDirect, and Wiley Online Library for English literature and Scientific Information Database (SID) and MagIran for Persian literature. All retrieved articles (n=2086) were examined. The data collection tool was a research-made form consisting of various fields, such as author, title, journal name, year, publication date, uniform resource locator (URL) of the article on the web, abstract, link to the full text of the article, organizational affiliation of the first author, country, type of study, data collection method, participants, number of participants, and main findings, which were organized in the form of a table. The validity of the form was confirmed through review by the research team, which has expertise and experience in the field of qualitative research methods. Original research articles published in both Persian and English languages were searched in the target databases by applying a time span of 1 January 2017 to 16 July 2023.

Search Strategy

Keywords included Evaluation, Assessment, Accreditation, Quality, Standard, Criteria, Indicator, Internationalization, University, Higher Education, and their respective Persian equivalents. Boolean operators (AND, OR, NOT) were used appropriately to construct the search query.

Examples of English search queries included as follows:

  • ((Evaluation OR Assessment OR Accreditation) AND Quality AND Internationalization AND (University* OR (Higher AND Education AND Institution*))
  • (Internationalization AND University* AND (Standard OR Indicator*))
  • (Quality AND Internationalization AND (University* OR Higher Education) AND Iran)
  • (Evaluation AND Quality AND Internationalization)

Inclusion Criteria

  • Being related to the research purpose, i.e.,
    focusing on:
  • Internationalization standards/ indicators/ dimensions/ strategies/ policies in universities
    and HEIs
  • Pillars/ elements/ models/ frameworks/ patterns of internationalization
  • Development and implementation of internationalization
  • Internationalization of education and curricula
  • Internationalization of research
  • Original research articles
  • The time span of 1 January 2017-16 July 2023
  • Both English and Persian languages
  • All countries/geographic regions

Exclusion Criteria

  • Out of the study scope and focused on other issues of internationalization, including but not limited to:
    • Political theories/ colonialism and post-colonialism/ Westernization
    • Women's studies/gender studies
    • Intercultural competence/ sensitivity among students/ academic staff
    • Pedagogical aspects of English Language Teaching (ELT) and English as a Foreign Language (EFL)
  • Systematic reviews, conference papers, book chapters, notes, editorials, book reviews

Screening and Data Extraction: In order to analyze data, retrieved papers were reviewed in terms of their relevance to the research aim. The criteria for accepting the articles were to address at least one of the goals specified in this research. After reviewing the titles and abstracts of the articles, relevant items were extracted for full-text reading.

Quality Assessment

Quality assessment was undertaken focusing on the purpose of the review as explained earlier and on the following criteria: (a) The validity of the methods, (b) how far the specified outcomes were supported by the study findings, and (c) to what extent the content of the study described internationalization indicators/ activities in universities and HEI.

Data Synthesis: The full text of the selected articles was analyzed and described using the qualitative content analysis method (20). In this method, concepts are classified in the form of analysis units, meaning units, codes, categories, and themes. The analysis unit is the smallest and most specific concept identified in the content and can be visual or verbal. Examples of analysis units include phrases, sentences, paragraphs, and images. All 37 articles underwent thorough quality assessment, and none were found to lack quality.

Results

Overall, 2086 article titles, 1102 article abstracts, and 731 full-text articles were reviewed, of which 37 articles were accepted for final analysis (Figure 1). A summary of the reviewed studies is presented in Table 1.

Content analysis and final synthesis of findings included the identification and extraction of six themes, 12 sub-themes, 38 groups, 11 subgroups, and 466 codes. The main themes included: Education, international relations, research, student welfare services, management and human resources, and healthcare services and treatment. The sub-themes and sample codes in each of the six themes are described in Table 2. In some themes and groups, due to the large number of codes, only examples have been mentioned.

Discussion

The field of education holds significant importance in the internationalization of universities and HEIs, with the highest number of indicators. Following that, the field of management and human resources comes into play, followed by the field of international relations, which exerts a great influence on the university's internationalization efforts. The field of healthcare and treatment, being a secondary focus for some universities and HEIs worldwide, possesses the fewest number of indicators and thus holds less significance in terms of the internationalization of HEIs. While the attention and application of internationalization in universities and HEIs is increasing, there are many ambiguities about its meaning and application. There are several models for implementing internationalization in universities, and various measurement indicators for university internationalization have been proposed by various researchers, among which are the studies and indicators provided to serve universities in England (21), United States (22), Australia (23), Germany (24), Netherlands (25), Japan (26), Taiwan (27), and China (28).

In Iran, several studies have presented models of internationalization of higher education and highlighted significant indicators (2, 18, 29-31). There are various classifications available that help organize indicators into important groups based on the structure and functions of universities. In the literature, numerous dimensions and indicators of internationalization have been discussed. However, the most comprehensive collection of indicators was published in 2010 by the Indicators for Mapping and Profiling Internationalization (IMPI) report. This publication classified a comprehensive set of 489 indicators into nine distinct dimensions, including students, staff, administration, funding and finance, curricular and academic services, research, promotion and marketing, non-academic services, campus and community life, and others (26). In 2018, the United Nations Educational, Scientific and Cultural Organization (UNESCO) Bangkok proposed other dimensions, such as social participation and institutional networks. As all member states of the United Nations adopted the Sustainable Development Goals in 2015, the third mission of a university, social participation, was emphasized in the internationalization of higher education (32). In the present research, the common denominator of the reviewed studies showed that internationalization could be implemented in most of the five main dimensions of education, international relations, research, student welfare services, and management and human resources (33-35).

According to the results of this review, student/staff exchange, including virtual exchange or mobility, particularly during the coronavirus disease 2019 (COVID-19) pandemic and health emergencies
(2, 17, 30, 36-48), use of virtual and online platforms for teaching (15, 19, 38, 39, 47-53), use of English language in teaching (18, 36, 40, 41, 51, 53-55), internationalization of curricula (15, 19, 37, 38, 41, 47, 55, 56), and admission of foreign students (2, 33, 36, 37, 40, 47, 49-51) are frequent indicators in the internationalization of education, learning, and teaching.

During the COVID-19 pandemic, most of the articles in the field of internationalization of higher education have focused on using the capacities of virtual space and information and communication technologies (ICT) for internationalization, or have addressed educational challenges from the perspective of professors or students. The COVID-19 pandemic has disrupted many aspects of higher education, particularly the internationalization activities that involve the physical mobility of students and staff. To cope with this challenge, some universities have adopted virtual machine (VM) as an alternative way of providing international learning experiences to their students
(39, 45, 48). While VM can offer benefits, including increased access, flexibility, diversity, and sustainability, it also faces challenges, such as quality assurance, recognition, equity, and inclusion. According to a recent report by UNESCO-International Institute for Higher Education in Latin America and the Caribbean (IESALC), VM has become more prevalent and diverse during the pandemic, but it still needs to be further integrated into the curriculum and supported by adequate policies and resources (32).

In the international relations field, most of the reviewed studies have focused on the importance of indicators, such as the active engagement of faculty members in international associations and forums
(16, 18, 19, 30, 47, 57), academic development and joint and international capacity building projects
(15, 38, 41, 43, 58), development of international cooperation (40, 43, 46, 54), signing memorandums of understanding (MoU) and memorandums of agreement (MoA) (18, 43, 44), and establishing international campuses/ branches (15, 18, 33, 35, 51).

While membership in international scientific associations is an important indicator, it has been less noticed by universities, particularly smaller universities with more limited financial resources, but considering its impact on networking, it plays an important role in creating international relations and its development. In the field of research, the results demonstrate that indicators, such as joint research projects (2, 15, 18, 30, 35, 37, 40, 45, 46, 49, 52, 55, 57, 58), organizing international/ joint workshops, seminars and conferences (2, 15, 17, 30, 35, 45, 47, 49, 50, 52), obtaining international research grants/ funds (15, 19, 33, 40, 47, 55), joint research with international organizations (37, 46, 49, 57), and publication of articles in widely-recognized international journals (17, 33, 47, 53, 55), are among important indicators.

Joint research collaborations are a widely-defined indicator and is a portal for starting and implementing a variety of international activities, such as signing memorandums and research contracts, exchange of professors/ researchers, attracting research grants, cooperation with international research organizations, attracting postdoctoral researchers, and presenting research results in conferences and international events, and as a result, it is of great importance in the internationalization of research profile of universities.

In management and human resources, indicators, such as the inclusion of internationalization in the mission/ vision statement of the university (15, 18, 19, 35, 52, 58, 59), attracting guest/ visiting professors from international universities and institutions (33, 35, 40, 47, 50, 51, 55), developing the language skills of professors and staff (18, 36, 55), providing study opportunities for professors (15, 19, 30, 55) and developing a strategic plan for internationalization (15, 33, 58), are among the most frequent indicators. The importance of including internationalization in the mission/ vision statement of the university is so great that it was mentioned in almost all the reviewed studies.

In a study conducted in more than 100 universities in the United States, the researchers concluded that the importance of internationalization should be included in the statements, missions, and visions of the university, and a motivational and communication organizational structure should be provided to establish international communication (60). Another important indicator of this field is the attraction of international/ visiting professors, which seems to be the biggest weakness of Iranian universities. Due to legal restrictions and inadequate infrastructure, challenges in paying foreign professors, and financial transfer challenges, Iranian universities, in particular, are less willing to attract foreign professors/ employees (17).

Considering that government financial support is one of the most important factors affecting the attraction of international students and professors, it is necessary for universities to be financially supported by the government in order to be internationally competitive (61). In the student welfare services field, the most frequent indicators include developing intercultural communication skills (50), holding events inside/ outside the university for intercultural exchange (51), providing various services for international students (17), advising and guiding international students (15), and increasing flexibility in facing different cultures (17). Internationalization has changed global platforms for education and connects three economic, political, and cultural dimensions with scientific and academic issues. In the cultural dimension, internationalization is an important factor in deep cultural influence, changing social views and cultural influence (62).

The articles reviewed in this study mainly focus on the internationalization of teaching and research missions of universities while neglecting service missions, such as providing healthcare services to society. This indicates a research gap in this area, particularly for countries like Iran, where such services are vital. Future research should address the internationalization of the services that universities offer to the public and citizens, for example, in the field of health tourism. Moreover, the new roles of universities as entrepreneurial institutions and the impact of internationalization on them are also underexplored and deserve more attention in future studies.

Conclusion

As shown by the results of this study, internationalization in universities and HEIs is a multifaceted and interdepartmental issue requiring the interaction and cooperation of all departments of a university and the integration of internationalization in all current processes of a university, such as educational services, research affairs, international affairs, student affairs, cultural and welfare services, management and human resources, and even healthcare services and treatment. While many dimensions and indicators of internationalization have been frequently discussed in the literature, the issue of using indicators to implement accreditation systems and evaluate the quality of internationalization in universities and HEIs and its effectiveness on quality improvement activities and processes has been less researched. The indicators identified in this research can be used in the establishment of such quality accreditation systems for the internationalization of universities. The results of this research help policymakers in the field of internationalization of higher education in evaluating the quality of processes and benchmarking activities.

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