Collaborative Online International Learning (COIL): A Teaching and Learning Experience in Nursing

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The article provides a thorough overview of the implementation and outcomes of a COIL activity between the University of Girona and the University of Coventry.

The introduction could benefit from a more detailed explanation of the background of internationalization in education and specifically in nursing.

 The methods section is well-structured, but additional clarity needs on the specific methods they used during each stage.

Overall, the article makes an appreciated contribution to nursing education.

Comments for author File: Comments.pdf

Author Response

Dear reviewer,

Thank you very much for your comment. And thank you for your recommendations, addressed in turn below.

 General Comments:

Comment 1:The article provides a thorough overview of the implementation and outcomes of a COIL activity between the University of Girona and the University of Coventry.

Response 1: Thank you for your comment.

Comment 2: The introduction could benefit from a more detailed explanation of the background of internationalization in education and specifically in nursing.

Response 2: Thank you for your suggestion. We have now added more information about internationalization in nursing education. From line 60 to line 67. We have also added 2 new references (ref 6 and ref 7).

“In the other hand, the world's increasing globalization presents a challenge for nursing education, as it highlights the importance of training nursing educators to address the unique care needs of various populations, integrate international students into their programs, and develop curricula that better prepare nurses for a technologically advanced and globalized world with a focus on global health [6]. Offering nurses opportunities for international experiences and collaborations is a powerful method for inspiring them to become global citizens who can help enhance healthcare, and fosters connectivity between local and global communities [7].”

Comment 3:The methods section is well-structured, but additional clarity needs on the specific methods they used during each stage.

Respomse 3: Thank you for your comment. The self-reflection method used as described by Colomer et al. [20] has different components to achieve the full reflective cycle, so there are not different stages of the reflection, as is a global process. Moreover, all the stages of the COIL are explained in the introduction sections, between lines 99-132. We have now added more information about how the students performed this reflection in lines 155 and 167-168. However if you consider that more information is required do not hesitate to ask for it.

 “which consisted of four components exposed in the student’s reflective diary:”

“All the components reflected in the diary were developed autonomously in the personal reflective diary, having a time-line of one week to finish the assessment. “

Comment 4: Overall, the article makes an appreciated contribution to nursing education. Response 4: Thank you very much for your comment.

Comments Attached in the manuscript:

Comment 5: I think the introduction needs to be strengthen with more details about

"intemationalization at home". It must be clearer to the reader. (Intro)

Response 5: Thank you verymuch for your comment. We have now added more information about Internationalization at Home definition. (Lines 55-59).

“Internationalization at Home serve as a means to promote common values and closer understandings between different peoples and cultures, enhance cooperation between institutions in their internationalization efforts, while also improving the educational quality of through mutual learning, comparison and exchange of good practice [5].”

Comment 6: More info on what COIL is will help the readers (Line 54).

Response 5: Thanks for your suggestion. We have now added more information about COIL in lines 69-70. Moreover, if you consider that more information is needed, do not hesitate to let us know.

“COIL is a pedagogical approach using digital technology to provide experiential international learning without travel abroad. COIL is an online teaching methodology that enables students to develop globalized internationalization skills within diverse multicultural environments

Comment 7: I am not clear on how this actually work.

Response 7: Thanks for your suggestions. We have clarified all the previos points in the manuscript from line 99 to line 127 (in red).

• Does studuents from both universities work on simulation at the same time? Yes, they worked together in groups of students of both universities simultaneously.
• What do they have to do for the scenarios? The students were requiered to developed the thechniques (intramuscular puncture or preparing a sterile field for bladder catheterization) in the labs from their university meanwhile the performance of the technique was recorded in the CAE-Learning Space Platforme. This allowed students from both universities to review the other groups perfomances of the scenarios and assessed them by a standardized rubric (already incorporated to the plaform) while visualizating the recorded video.
• Did they have an specific tasks to complete? The second year students had to complete the performance of the techinique in the lab, and also review and asses anothers group scenario. The fourth year students provided support and guidance during the second stage. Finally the last stage of the COIL the students of both universities shared experiences and learnings adquired during the COIL. After all the activity, each student had to perpare a reflective diary about the COIL experience individually.
• Were the same for both universities? The COIL activity, stages and scenarios were the same for both universities.
• What the students have to do for theses scenario? What they assessed on? They assessed if the thecnique was performed correctly following the standarized rubric. .

The COIL activity proposed in this study consisted of five stages where students of both universities work together in groups simultaneously: 1) an ice breaking activity, 2) group-based clinical simulation activities, 3) co-evaluation and feedback, 4) experience sharing, and 5) self-reflection on individual learning (Figure 1). Some of these activities were conducted synchronously, involving students from both universities, while others were asynchronous. Additionally, nursing teachers participated in certain activities throughout the COIL program.

Prior to initiating the COIL activity, groups were created consisting of three second-year nursing students from the same university. These groups worked collaboratively throughout all the activities proposed within the COIL framework.

The first stage of the COIL activity was the ice breaking session. This synchronous session lasted approximately 60 minutes, during which students were encouraged to share cultural traditions from their respective countries. Teachers and researchers played a role as moderators in facilitating this discussion. Following the ice breaking session, the second stage involved conducting the clinical simulation activity in groups. In this stage, students were instructed to prepare and self-record their resolution of one of the two low-fidelity simulation scenarios provided specially designed for the project. The students had the option to choose between two scenarios to be performed in the lab: the intramuscular puncture scenario, in which they were required to perform the technique on a mannequin, or the sterile field preparation scenario, where they were tasked with preparing a sterile field for male bladder catheterization. Fourth-year nursing students provided support and guidance only during this stage. The clinical simulation scenarios performed in the lab were recorded and managed using the CAE-Learning-Space Clinical Simulation® [21], that was the platform used in the nursing program from the University of Girona.

The third stage of the COIL activity involved the co-evaluation of the scenario resolution. Second-year students were able to assess each other's performance reviewed a video of another group's scenario recorded on the CAE-Learning-Space Clinical Simulation® platform and evaluated the scenario using a standardized rubric incorporated in the same platform. The fourth stage aimed to foster the sharing of experiences among students from the different universities. A synchronous session was organized between the students from Girona and Coventry for this purpose. During this session, teachers and researchers assumed the role of observers. The final stage of the COIL activity involved writing reflective individual learning diaries, where students were encouraged to reflect on their personal experiences and insights gained throughout the COIL process.

Comment 8: Whay only female?

Response 8: Thanks for this consideration. Althogh we encourage to participate all the students, only female students agreed to participate. Moreover, the average of male students in the Nursing Degrees is very low.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Evaluation of the COIL initiative is not only informative for those considering a similar project but serves as thought provoking reading material for educators within the health professions. The overall benefits highlight the importance of intercultural exposure for undergraduate nursing students. Identification of challenges will be helpful for newcomers to COIL. In addition, the creativity in presenting the learning themes and categories tree in Figure 2 added to a positive reading experience.

 Abstract
Clarification of participants:
The abstract refers to “the undergraduate nursing students” (Lines 21-22), which implies involvement of all students registered within the respective programs at the two universities. I suggest omitting “the” in Line 21.

In section 1.2. of the introduction reference is made to mentorship by fourth-year students (Line 99) but the year group of the students who participated in the activities is not mentioned. This information follows in section 2.2. I suggest that the year groups be mentioned in the introductory section 1.1. of the manuscript.

-     In Line 24 the sample size is noted as 12. Please clarify whether this was the total number of participants at both universities, or one setting only.

-       In Line 125 the number of participants is noted as 15. Please correct.

The number and wording of the main categories identified during data analysis differ between the abstract (Lines 26-30); the results section (introductory paragraph and sub-headings), as well as Table 2 and the discussion section (Lines 398-401). Please ensure alignment to ensure accuracy of reporting and to avoid confusion.

 Objective (Lines 78-80) - I suggest phrasing the objective within the context of this research for example “…second-year nursing students from two universities who engaged in clinical simulations through a COIL activity.”

Description of the COIL activity
In Line 96 please provide a little more information about the simulation scenarios, for instance:
- Whether these were existing or specifically designed for the COIL project.
- Were the simulation sessions video recorded?

Line 100 - Please clarify the co-evaluation process.
- How did the students observe each other’s performance? Did the evaluation take place within the groups of three or were video recordings made available to the other participants? Did the fourth-year students participate in the evaluation?

Figure 1 - In the third column I suggest removing the hyphen in “feedback”

Method
Line 112 - …a qualitative descriptive (design)…?

Results
Correct the spelling of “awareness” in Figure 2

Discussion
Line 402 - Avoid generalizing qualitative results by rephrasing: “…COIL, the participants felt excited, …”

The organization of the content and flow are not always logical. The language in this section can also be improved.

Lines 403-404 – “…these attitudes to learn may be influential in the transition into higher education.” Are the students not already enrolled in an undergraduate program?

Lines 404-405 - “…changes to curriculum based on student motivation may improve student success, and retention.” It is unclear how student motivation could inform curricula.

Lines 418-419 – Please clarify in what ways the outcomes differed. Was it from their usual outcomes or between universities?

Line 440 – “Being this competence an essential one for future nurses.” – meaning unclear.

Line 444 – I suggest rephrasing for sake of clarity for example, “Moreover, in support of our results, Philips…”

Line 449 – Rather refer to “…teamwork…”

Lines 498-499 – Please check the language - “…activity carried has allowed learning outcomes…

Limitations
Line 496 – Please rephrase as follows: “…qualitative approach restricts the generalizability…”

Comments on the Quality of English Language

The manuscript can benefit from language/technical editing. There were for example many punctuation errors and inconsistencies.

Everything of the best with the project.

Author Response

Reviewer 2

Dear reviewer,

Thank you very much for your comment. And thank you for your recommendations, addressed in turn below.

Comment 1: Evaluation of the COIL initiative is not only informative for those considering a similar project but serves as thought provoking reading material for educators within the health professions. The overall benefits highlight the importance of intercultural exposure for undergraduate nursing students. Identification of challenges will be helpful for newcomers to COIL. In addition, the creativity in presenting the learning themes and categories tree in Figure 2 added to a positive reading experience.

Response 1: Thank you very much for your comment.

Comment 2: Abstract Clarification of participants:The abstract refers to “the undergraduate nursing students” (Lines 21-22), which implies involvement of all students registered within the respective programs at the two universities. I suggest omitting “the” in Line 21. Response 2: Thank you for your suggestion. We have now amended the spelling mistake. Line  21.

Comment 3: In section 1.2. of the introduction reference is made to mentorship by fourth-year students (Line 99) but the year group of the students who participated in the activities is not mentioned. This information follows in section 2.2. I suggest that the year groups be mentioned in the introductory section 1.1. of the manuscript.

Response 3: Thank you for your suggestion. We have now added in section 1.2. information about students who participated in the COIL. Lines 106-107.

“Prior to initiating the COIL activity, groups were created consisting of three second-year nursing students from the same university. “

Comment 4: In Line 24 the sample size is noted as 12. Please clarify whether this was the total number of participants at both universities, or one setting only.

Response 4: Thank you for your comment, we have now clarified this point in line 24.

Comment 5: In Line 125 the number of participants is noted as 15. Please correct. Thanks for your comment.

Response 5: We have now amended the error in line 151.

Comment 6: The number and wording of the main categories identified during data analysis differ between the abstract (Lines 26-30); the results section (introductory paragraph and sub-headings), as well as Table 2 and the discussion section (Lines 398-401). Please ensure alignment to ensure accuracy of reporting and to avoid confusion.

Response 6: Thank you for your suggestion. We have now corrected and homogenized the information in the different paragraphs (Abstract (from line 26 to 29) , Results (from line 189-192)  and Figure 2  (line 196).

“The analysis identified 5 6 themes related to the COIL activity: a) Initial attitude towards the COIL activity; b) Main learnings through the COIL activity; c) Positive aspects of the COIL activity; d) Weaknesses of the COIL activity and improvement proposals; and e) Overall evaluation of the COIL activity. “

Comment 7: Objective (Lines 78-80) - I suggest phrasing the objective within the context of this research for example “…second-year nursing students from two universities who engaged in clinical simulations through a COIL activity.”

Response 7: Thanks for your comment. We have now amended it (Lines 95-96)

“The objective of this paper is to assess the learning outcomes of second-year nursing students from two universities who engaged in clinical simulations through a COIL activity nursing students who engage in clinical simulations through a COIL activity.”

Comment 8: Description of the COIL activity: In Line 96 please provide a little more information about the simulation scenarios, for instance:
- Whether these were existing or specifically designed for the COIL project.
- Were the simulation sessions video recorded?

Response 8: Thank you for your suggestions. We have now added more information about the scenarios specifically designed for the COIL, and how the scenarios were recorded using the platform Learning-Space for Clinical Simulation. Lines: 120 to 127. We have also added  a new reference (ref 21).

“The clinical simulation scenarios performed in the lab were recorded and managed using the CAE-Learning-Space Clinical Simulation® [21], that was the platform used in the nursing program from the University of Girona.

“The third stage of the COIL activity involved the co-evaluation of the scenario resolution. Second-year students were able to assess each other's performance reviewed a video of another group's scenario recorded on the CAE-Learning-Space Clinical Simulation® platform and evaluated the scenario using a standardized rubric incorporated in the same platform”.

Comment 9: Line 100 - Please clarify the co-evaluation process. How did the students observe each other’s performance? Did the evaluation take place within the groups of three or were video recordings made available to the other participants? Did the fourth-year students participate in the evaluation?

Response 9: Thank you very much for your comments. We have added more information about the evaluation process (lines 123-128).

“The third stage of the COIL activity involved the co-evaluation of the scenario resolution. Second-year students were able to assess each other's performance reviewed a video of another group's scenario recorded on the CAE-Learning-Space Clinical Simulation® platform and evaluated the scenario using a standardized rubric incorporated in the same platform”.

Additionally we have clarified that the fourth-grade students only participated in the second stage of the COIL activity (Line 120).

“ Fourth-year nursing students provided support and guidance only during this stage. “

Comment 10: Figure 1 - In the third column I suggest removing the hyphen in “feedback”. Response 10: Thank you for your suggestion. We have now amended it.

Comment 11- Method: Line 112 - …a qualitative descriptive (design)…?.

Response 11: Thank you for your comment. We have not amended your suggestion in line 138.

“The study conducted was a qualitative descriptive design study “

Comment 12- Results: Correct the spelling of “awareness” in Figure 2.

Response 12: Thank you for your comment. We have not amended your suggestion in Figure 2.

Comment 13- Discussion: Line 402 - Avoid generalizing qualitative results by rephrasing: “…COIL, the participants felt excited, …”.

Response 13: Thank you for your comment. We have now amended it rephrasing in line 432.

“Before starting the COIL, some students feel excited, curious and motivated.”

 Comment 14: The organization of the content and flow are not always logical. The language in this section can also be improved.

Response 14: Lines 403-404 – “…these attitudes to learn may be influential in the transition into higher education.” Are the students not already enrolled in an undergraduate program?.

Comment 15- Lines 404-405 - “…changes to curriculum based on student motivation may improve student success, and retention.” It is unclear how student motivation could inform curricula.

Response 15: Thank you very much for your suggestion. To enhance clarity, we have revised and amended the way these two paragraphs are written. From line 432 to line 435. 

“This motivation is particularly significant for nursing students, as noted by Edgar [27] and Abdulghani [28], who emphasize that student motivation is a crucial factor in their commitment to their studies and their overall academic performance.

. taking steps to improve students' motivation can improve their commitment to studies.  and according to Edgar [24], these attitudes to learn may be influential in the transition into higher education. Therefore, changes to curriculum based on student motivation may improve student success, and retention [24,25]. “

Comment 16- Lines 418-419 – Please clarify in what ways the outcomes differed. Was it from their usual outcomes or between universities?.

Response 16: Thank you for your comment. The outcomes achieved by all the participants from the both universities are similar, we did not detect any significant differences between them.  Although each student could achieve a specific personal development, there were various similarities between the learning outcomes achieved, so the outcomes were presented globally. We have clarified this point in the text. From line 456 to line 457.

Through the COIL activity, the nursing students achieved several did different learning outcomes without observing significant differences between both universities. 

Comment 17- Line 440 – “Being this competence an essential one for future nurses.” – meaning unclear.

Response 17: Thank you very much for your comment. We have now clarified the meaning of this sentence (from line 478 to 481). We have also added a new reference (ref 40).

“Teamwork was another skill that participants developed learned with the activity. Being this competence an essential one for future nurses.  This is important because equipping nurses with the necessary knowledge and skills for effective teamwork through education and training is a crucial step [40].”

Comment 18- Line 444 – I suggest rephrasing for sake of clarity for example, “Moreover, in support of our results, Philips…”.

Response 18: Thank you for your comment. We have now amended it. Line 485

Comment 19- Line 449 – Rather refer to “…teamwork…”

Response 19: Thank you for your comment. We have now amended it. Line 490.

Comment 20- Lines 498-499 – Please check the language - “…activity carried has allowed learning outcomes…..

Response 20: Thank you for your suggestion. We have now rephrased the first paragraph in the conclusion section. Frome line 541 to line 547.

“The study revealed that the use of Clinical Simulation in a COIL activity facilitated the achievement of learning outcomes related to transversal nursing skills, such as critical thinking, self-confidence, cultural competence, teamwork, and English language proficiency, in addition to enhancing clinical skillsThe study has revealed that Clinical Simulation used in a COIL activity carried has allowed learning outcomes related to transversal nursing skills such as: critical thinking, self-confidence, cultural competence, teamwork and the improvement of the English language, in addition to the improvement of clinical skill. “

Comment 21- Limitations: Line 496 – Please rephrase as follows: “…qualitative approach restricts the generalizability…”. Response 21: Thank you for your comment. We have now amended it in line 537.

“Besides, the application of a qualitative approach restricts the generalizability transferability of the findings to a more extensive population”.

Comment 22- Comments on the Quality of English Language: The manuscript can benefit from language/technical editing. There were for example many punctuation errors and inconsistencies. Everything of the best with the project.

Response 22: Thank you for the recommendation. A new linguistic revision of the manuscript has been conducted, and some changes have been made.

Author Response File: Author Response.pdf