Higher Education (2022) 84:629–646

https://doi.org/10.1007/s10734-021-00792-7

Iranian faculty members’ metaphors

of the internationalization of medical sciences education

Iman Alizadeh1,2 · Parand Pourghane3

Accepted: 15 November 2021 / Published online: 28 February 2022

© The Author(s), under exclusive licence to Springer Nature B.V. 2022

Abstract
Faculty members’ beliefs can affect the trajectories of internationalization activities at a
university. This study aimed to use metaphor analysis to discover Iranian faculty members’
beliefs about the internationalization of education at a medical sciences university. To col-
lect data, a qualitative research design was adopted and interviews were conducted with
the faculty members. The analysis of the interviews resulted in the discovery of 19 meta-
phors which were condensed into five themes of clinical culture, a road map for change,
challenges, promotion, and links and relations. The faulty members particularly called for
considerations for context-specific clinical setting conduct, urged a reform in the education
system so as to include international and intercultural components in the medical education
curricula, preferred the scientific and cultural reasons to the political and economic ration-
ales for internationalization, described learning the local language and dialect as necessary
for international medical students as they need to communicate with local patients and hos-
pital staff, and viewed internationalization as an opportunity for the university to expand
its health tourism industry. The findings have practical implications for medical sciences
universities that aim to become an international educational institution.

Keywords Internationalization · Medical education · Metaphors · Faculty members

* Parand Pourghane
pourghanep@gmail.com
Iman Alizadeh
Iman_alizadeh96@gums.ac.ir
1
English Language Teaching Department, School of Medicine, Guilan University of Medical
Sciences, Rasht, Iran
2
Cardiovascular Diseases Research Center, School of Medicine, Heshmat Hospital, Guilan
University of Medical Sciences, Rasht, Iran
3
Nursing Department, East of Guilan School of Nursing and Midwifery, Guilan University
of Medical Sciences, Rasht, Iran

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Introduction

Faculty members play a pivotal role in the internationalization of higher education as long
as the delivery of education matters (Criswell & Zhu, 2015; Li & Tu, 2016). Educational
institutions cannot manage “a comprehensive internationalization process without coordi-
nation with, support of, and participation by the faculty” (Dewey & Duff, 2009, p. 503).
Moreover, faculty members have been described as the ones who initiate international pro-
grams (Finkelstein et al., 2009) and promote higher education institutes’ international com-
petition (Schwietz, 2006). Stressing the role of faculty members in the internationaliza-
tion of higher education, Stohl (2007) notes that to internationalize a university, its faculty
members have to be internationalized.
Research, however, has shown that a chief challenge in the internationalization of uni-
versities is the involvement of faculty members (Childress, 2009). Criswell and Zhu (2015)
argue that the internationalization of higher education may not be among the priorities of
faculty members, and they may not demonstrate any professional commitment to involve in
internationalization activities. In the same vein, Biddle (2002) maintains that “to the extent
that the idea of internationalization…has any reality, faculty must buy into it” (Biddle,
2002, p. 120). To secure faculty members’ commitment to and involvement in international
activities, they can be familiarized with such benefits of internationalization as engagement
in international research and partnerships (Knight, 2014), involvement in international aca-
demic and business organizations (Ponds, 2009), and scholarly collaboration (Childress,
2009), to name only a few. Therefore, faculty members can be involved in internationaliza-
tion activities at universities if their views and benefits are considered in the internationali-
zation policy making procedures.
On the other hand, the literature on faculty members’ perceptions of internationaliza-
tion attests to the shortcomings dissuading faculty members who might have otherwise
decided to participate in the internationalization activities of universities (Andreasen,
2003). They may view international initiatives as additional work with little or no ben-
efit (Lebeau, 2010). Lack of administrative support (Dewey & Duff, 2009), poor language
skills (Andreasen, 2003), unclear internationalization initiatives (Friesen, 2012), lack of
time (Saiya and Hayward, 2003), and policies dissuading untenured faculty members from
involvement in the internationalization of education (Andreasen, 2003; Stohl, 2007) are
among the factors discouraging faculty members from engagement in internationalization
activities. Research has shown that the obstacles in the way of faculty members’ involve-
ment in the internationalization of higher education are “very real and can and do act as
deterrents to international participation” (Andreasen, 2003, p. 68). Therefore, faculty mem-
bers may not opt to participate in the internationalization activities of universities because
of the above-mentioned problems and not having a voice in the development of internation-
alization policies.
Because of the faculty members’ role in the success or failure of internationalization
plans of universities, one of the principal preliminary measures in this regard could be the
discovery of their beliefs about internationalization, which was accomplished in the pre-
sent study by delving into their metaphors of internationalization. Metaphor analysis has
been extensively used in social sciences and educational research (Saban et al., 2007; Mar-
tinez et al., 2001). Arguing for the justifiability of using metaphors in educational research
to elicit the beliefs of individuals instead of using direct means such as questionnaires
or observation, Farjami (2012) argues, “When subjects are approached through indirect
means they are more forthcoming and are better taken aboard for providing trustworthy

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and credible information.” According to Farjami (2012), the metaphors people produce
“represent the way they perceive the world and reality.”
The literature on faculty members’ metaphors of internationalization of universities
shows that despite the significance of the issue, there has been no research in this area.
There are, however, studies which have described internationalization as a “white knight”
(Brandenburg & de Wit, 2011), a fad (Haas, 1996), important (Altbach & Lewis, 1996),
and “symbolic” (Bartell, 2003). The present study attempted to bridge the gap in this area
by discovering the beliefs of the faculty members of Guilan University of Medical Sci-
ences (GUMS) about the internationalization of medical education through delving into
their metaphors of internationalization. Discovering the faculty members’ metaphors will
help university officials, educational program developers, and educational policymakers
learn about the extent to which they can count on the the faculty members’ support for the
internationalization of education at the university.

Internationalization of medical education in Iran

Like many other world and regional countries, Iran has formulated coherent policies on
the development of higher education and the admission of international students over the
past few decades. The 20-Year National Vision of the Islamic Republic of Iran (2011),
for example, envisions Iran as “a developed country in the first place in the region in the
realms of economy, knowledge, and technology; with an Islamic and revolutionary identity,
an inspiration for the world; and with productive and influential interaction in international
relations.” To accomplish the goals set in the policies on internationalization, constructive
measures have been taken and “a great capacity has been created in the country for over-
seas students” (Shamsi Gooshki et al., 2018).
The Plan of International Development of Medical Education was also drafted in 2015
to outline the road map to the internationalization of medical education and help materi-
alize the international goals set in the 20-year vision of the country. The plan stipulates
the internationalization of medical education as one of the main strategies contributing to
the evolution of medical education and recent studies have subjected the internationali-
zation of medical universities to the employment of interactional, political, and academic
strategies at the international level (Zamanimanesh, et al., 2017). The plan aims to identify
the available potential in all medical sciences universities in the country, set international
standards of medical education, and develop plans for using the existing capacity in the
country. The plan has been rendered to all universities and colleges of medical sciences in
the country in the form of a common mission. Moreover, a national system called Educa-
tion Iran (http://​educa​tioni​ran.​ir/​en) has been developed by the Iranian Ministry of Health
and Medical Education for medical sciences universities to present their capacities and
programs. International students can apply to different Iranian medical sciences universi-
ties via the system. The students can also find all the necessary information they need to
study and live in Iran on the system.
To meet the international standards, the Iranian Ministry of Health and Medical Educa-
tion has also started the international accreditation of medical universities. Therefore, a
great capacity has been developed in the country for attracting international students in
medical fields as graduates from the medical fields play a vital role in the society by pro-
viding health services and saving the lives of the people (Shamsi Gooshki et al., 2018). In
the Iranian context, the medical education system integrates education with the delivery

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of medical services; that is, “in addition to having a human resource training mission, it
is also responsible for providing health services to the community” (Marandi, 2009). The
integration of education and provision of health services in the Iranian medical educa-
tion system has been well received by other world education institutions (Majdzadeh et al,
2010) and has the potential to attract international students as the integration provides stu-
dents with access to service delivery fields, which can, in turn, improve the students’ medi-
cal knowledge and skills (Shamsi Gooshki et al, 2018).

The context of the study

As internationalization of medical education is one of the main objectives of the Iranian

Ministry of Health, Treatment, and Medical Education, all universities affiliated with the
ministry, including GUMS, where the present study was conducted, are supposed to take
measures to internationalize their education. GUMS, which is located in the provincial cap-
ital city of Rasht, north of Iran, is affiliated with Iran’s Ministry of Health, Treatment, and
Medical Education. It is the institution in charge of health issues and education of health-
related fields in Guilan Province. The internationalization activities at GUMS started in
2015 with the provision of such infrastructure as launching the English website of the uni-
versity and identifying educational programs that the university could offer to international
students. As a result, a lot of information on GUMS and the educational programs it could
offer for international students were translated from Persian into English and were fed into
the Education Iran system. Several meetings were organized at the Deputy for Education of
the university to study and analyze the capacities of the university for internationalization,
which resulted in the development of the internationalization document of GUMS. English
learning programs have been launched at the university and incentives have been consid-
ered for the faculty members at the English teaching department of the university to teach
English to all faculty members willing to engage in the internationalization activities of the
university. The university also provides international students with accommodations.

Method

Research design

We used qualitative content analysis research methodology to accomplish the objectives of

the study. We also utilized the purposive sampling method to select the participants, and
the participant selection continued until we reached the data saturation point. We used semi
structured interviews to collect data on the faculty members’ metaphors of the internation-
alization of medical education.

Participants

The population of the study consisted of all faculty members of GUMS. The participants
of the study were 27 faculty members from schools of medicine, dentistry, health, nursing,
midwifery and paramedical sciences. To observe maximal variation in sampling, faculty

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members with various characteristics in terms of gender, major, education, and teaching
experience at the university were selected.

Data collection and analysis

This study is part of a research project approved by the Deputy for Research and Technol-
ogy of GUMS with the ethical approval code of IR.GUMS.REC.1398.192. To begin the
data collection phase and to perform the interviews, the researchers introduced themselves,
explained the purpose of the interviews to the faculty members, and obtained informed
consent from them. During the interviews, the faculty members were asked, “What do
you compare the internationalization of medical education at GUMS to?” or “What is the
internationalization of education at the university like?” The participants’ responses to the
interview questions were recorded after obtaining permission from them. The researchers
told the faculty members that they could withdraw from the study anytime. The partici-
pants were assured that their information would remain confidential.
To analyze the data, the conventional content analysis model of Graneheim and Lun-
dman (2004) was used. Conventional content analysis is a systematic analysis that uses
data coding and categorization of contextual data to determine the trend and pattern of
words and their relations, structures, and communicative discourse (Graneheim & Lun-
dman, 2004). To analyze the content of the participants’ metaphors, we transcribed the
interviews and then went through them to gain a general understanding of the ideas raised
during the interviews. Then, we set the entire interview as a unit of analysis and identi-
fied the meaning units which included words, phrases, sentences, and paragraphs. Next, we
condensed the meaning units (metaphors) bearing similarity. We compared and contrasted
the meaning units (metaphors) and clustered them into themes. The researchers ensured
trustworthiness and rigor in the data collection and analysis processes by taking into
account the credibility, transferability, dependability, and confirmability criteria proposed
by Lincoln and Guba (1985). The researchers ensured the credibility of the data by col-
lecting accurate data, increasing the interaction time with the faculty members during the
interviews (30–60 min), allocating adequate time to the data collection and analysis (over
four months), having variation in the sampling method (male and female faculty members
from different departments and different experience and age ranges), and asking confir-
mation questions from the faculty members. The researchers followed the data collection
and data analysis procedures meticulously in a step-by-step manner and observed the steps
of the qualitative data collection and content analysis to ensure dependability. Moreover,
the researchers’ colleagues who were competent at qualitative data collection and analy-
sis analyzed and rechecked the data. The researchers asked for the views and approval of
other faculty members at the school of allied medical sciences to secure the conformability
of the data. They also provided a detailed and rich description of the research procedures
and findings to help other researchers evaluate whether the study is transferable to other
contexts.

Findings

We analyzed, reviewed, and condensed the faculty members’ responses in the interviews
based on similarities and differences, which resulted in the extraction of 19 metaphors and
five themes. We labeled the themes based on their underlying meanings. The themes and
their underlying metaphors are given in Table 1.

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Table 1  Themes and metaphors N Themes Metaphors

of the internationalization of
medical education
1 Clinical culture Clinical culture challenge
Clinical culture attraction
Culture booster at clinical settings
2 Road map for change Educational reform
Element of change
Eyeglasses
New ambition
3 Challenges Funding challenge
Language challenge
4 Promotion Medical tourism window
Ladder
Flower and fruit garden
Science and culture promotor
Economic growth factor
5 Links and relations Ambassadors
Chain
Bridge
Railroad
Tree

Theme one: clinical culture

The faculty members raised concerns about the conduct and behavior of international stu-
dents in their encounters with patients and their relatives in clinical settings. The faculty
members particularly underscored the need for international students’ familiarity with
ways to communicate with and treat the opposite sex clients in medical or clinical settings.
“In our culture, unless necessary, it is not customary for medical staff or students
to touch an opposite-sex patient. This issue may not be considered in many other
cultures; therefore, international students should know this and act according to our
norms and codes of conduct. This can be a challenge and may take time for interna-
tional students to learn about and get accustomed to our norms and ethical considera-
tions,” one of the faculty members said.
In the hospitals and other clinical centers affiliated to GUMS, there are not any foreign
medical practitioners and it is not customary that a patient referring to a hospital for non-
emergency medical care be interviewed or examined by an international medical student or
practitioner. The presence of an international student receiving medical training in a hospi-
tal, which necessarily requires close encounters with patients, is a culturally and religiously
sensitive issue. In Muslim countries, a doctor’s gender is important for female patients par-
ticularly when the encounter necessitates an examination of body parts required by Islam
to be covered (Lafta, 2006; Matin & LeBaron, 2004; Uskul & Ahmad, 2003). Accord-
ing to Islamic religious maxims, patients who are in need of non-emergency medical care
should be treated first by a same-gender Muslim doctor, followed by a same-gender non-
Muslim, then an opposite-gender Muslim and, lastly, an opposite-gender non-Muslim doc-
tor (Aldeen, 2007). Patients may refrain from any communication with the international

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students or do not allow any kind of examination by the students. This is where internation-
alization of medical education is presented with a dilemma. One the one hand, the students
need to visit and have close encounters with patients as part of their education; on the other
hand, the exiting sociocultural norms deprive them of such training. Sociocultural issues
cannot be changed overnight and international medical students, who have to encounter
patients during their training, are required to be sensitive to such issues. Therefore, the fac-
ulty members believed that clinical conduct of the international students would be one of
the main challenges of the international non-Muslim students at the university.
The professors, on the other hand, believed that the cultural and social norms observed in
the Iranian context, including GUMS, can help the attraction of Islamic international students.
“Although respecting patients’ privacy is accepted in all cultures, in the Islamic
countries both health care providers and patients or clients follow the Islamic codes
of conduct with others especially with the opposite sex. As Iran is an Islamic coun-
try, this issue is specifically observed in the country. This can encourage students
from Islamic countries to continue their studies in Iranian universities. International
students will not encounter strange non-Islamic conduct from the locals in the soci-
ety and the food is all Halal and non-alcoholic; therefore, one of the major concerns
of Islamic students is removed,” another professor said.
In contrast to the difficulties international non-Muslim students can face in their
encounters with patients, Muslim international students can find the situation for continu-
ing their education in the Iranian context suitable. Iran is a Muslim country where Muslim
international students will not face difficulties adjusting themselves to religious and cul-
tural issues. The country shares a common culture and religion with Muslim countries.
In addition to challenges confronting all international students, Muslim students studying
abroad in non-Muslim countries may face such problems as lack of respect or familiar-
ity with their religious practices (Nasir & Al-amin, 2010), direct and indirect discrimina-
tion based on culture and dressing (Gillbborn, 1996), shortage of nutritional necessities
and prayer spaces, and ignorance of Islamic holidays (Ali & Bagheri, 2009), to name only
a few. In the Iranian Islamic context, however, the international Muslim students would
feel a close affinity with the community in terms of cultural, social and religious norms.
Although the international students might face differences in various other aspects of life,
the high degree of commonality in terms of cultural and religious customs outweighs the
differences and heralds an appropriate social and cultural milieu for the Muslim interna-
tional students to live in and study.
The faculty members’ foregrounding of the appreciation of context-specific clinical set-
ting conduct, on the one hand, implies that contravening local norms regulating, for exam-
ple, the relations between males and females, can deprive international medical sciences
students, who need to be present in clinical settings as part of their education, of commu-
nication with and examination of clients. The faculty members, on the other hand, believed
that similarities between the international students’ culture, customs and religion and the
norms of the target context can make the context an ideal destination for the international
medical sciences students to pursue their education abroad.

Theme two: a road map for change

The faculty members used such metaphors as educational reform, and element of change
to express their beliefs about the internationalization of the university, which supported

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the theme of a road map for change. Comparing internationalization of the university to
a road map is in line with the view that an internationalization plan helps institutions to
have direction, institutional commitment, and particular goals (Knight, 1994). A writ-
ten articulation of internationalization plans and goals is also vital for leaders aiming to
internationalize their institutions (Childress, 2009).
The faculty members emphasized the need for considering changes in the academic
issues of the university.
“ Internationalization does not happen overnight; the university should set short-
run and long term goals in this regard. I compare internationalization to an ele-
ment of change in the academic affairs of the university. For example, in the uni-
versity, we use non-original and translated references. If we want to step into the
international arena, we need to use original references enriched with international
and intercultural components,” one of the faculty members said.
The faculty members compared internationalization to a reform in the educational
programs of the university.
“I compare internationalization to reform; reform in the educational planning of
the university. The present educational plans are for domestic students, which may
have little attraction for international students. If the curriculum and the extra-
curricular programs are precisely developed for international students, I think the
probability of having students from other countries can be positively affected,”
one of the faculty members said.
According to Leask (2015), to internationalize education, universities need to incor-
porate international, intercultural, and global dimensions into the curriculum in a way
that the incorporation be related to international students’ professional practice. Interna-
tional education should be designed so that it can prepare all students to be intercultur-
ally proficient professionals and citizens (Beelen & Jones, 2015). As medical sciences
students need to function in health care sectors, the international medical education
needs to develop students’ ability to use advanced intercultural skills and practice med-
icine and other medical disciplines in a global context (Wu et al., 2020). The medi-
cal education which the Iranian medical education offers to non-international students
hardly contains any programs developing the students’ skills to function in intercultural
or international contexts. The only courses in the present medical education program
which are close to the tenets of international education are general English proficiency
and specialized English courses. To internationalize education, efficient international
collaboration and communication should be considered as the core components of med-
ical education curricula (Wu et al., 2020). Internationalization of universities has been
identified as a “inevitable fact” (Ma, 2002) and “a survival strategy” (Chen & Lo, 2013)
which should include the learning of “cultural competency and knowledge about health
issues worldwide” and can perform a pivotal role in “preparing future physicians to
practice medicine in a global context and laying the framework for international collab-
oration and understanding of differences among nations” (Wu, et al., 2020). Moreover,
international knowledge and skills have been indicated as necessary for students and
institutions to compete in the international education market (Ho et al., 2015). There-
fore, the faculty members’ found internationalization as an opportunity for the univer-
sity to reform its education so that graduates from the university can function in global
intercultural contexts.

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Theme three: challenges

The faculty members associated the internationalization of education at university with

such problematic concepts as learning English, local languages and dialects, and fund-
ing, which were categorized under the theme of challenges.
Most of the faculty members highlighted that professors’ poor English language pro-
ficiency can hinder progress in the area of internationalization of medical education.
“Currently, many university professors do not have a thorough command of Eng-
lish for conversation and teaching, so they do not welcome the internationalization
of the university,” one of the faculty members said.
On the other hand, the faculty members were concerned about the local languages
and dialects, which would affect the international students’ performance in clinical
settings. The faculty members believed that when an international student enrolls at
GUMS, he/she should become familiar with the dialects and the language spoken in
Guilan Province.
“One of the challenges of international students entering Iranian universities is
that they should learn local languages in addition to Persian. As communicating
with clients is a major part of the education of the students majoring in medical
fields, they need to spend a lot of time learning both Persian and the local lan-
guage,” a faculty member said.
In the present study, like many other studies on internationalization, a good com-
mand of English as the international language was described as a challenge for the
faculty members. In this regard, Salimi et al., (2015) describe professors’ weakness in
knowing international languages especially English as an obstacle in the way of inter-
nationalization. Firouzjaiyan and Khorsand (2018) also highlight lack of competence
in an international language as a barrier to internationalization, underscoring “Iranian
professors’ language weakness (not having competence at least in one international
language) in conducting and drafting international research projects” and “not teach-
ing courses using an international language” as the language-related obstacles in the
way of internationalization. A second problem which the faculty members referred to
in their metaphors was the international students’ problems with the local languages
or dialects. Knowing English as the international language has been described as one
of the requirements of internationalization and knowing the target context language
has always proved a boon for international students; however, knowing the local lan-
guage or dialect of the target context is a must for international medical sciences stu-
dents as they have to communicate with local patients and individuals as part of their
education. Not knowing the international or standard language of the target country
has been previously reported as a challenge in other studies. Özoğlu et al., (2015),
for example, investigated factors influencing international students’ choice to study in
Turkey and challenges they experience in the country, reporting that the students’ lack
of language proficiency was their most challenging problem in Turkey. Research has
also shown that lack of competence in local languages can harm students’ sociocul-
tural and psychological adaptation (Townsend & Poh, 2008).

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Theme four: promotion

The theme of promotion emerged from such metaphors of internationalization as medi-

cal tourism window, science and culture promotor, economic growth factor, ladder, and
flower and fruit garden. The faculty members linked internationalization to a window of
opportunity for the development of health and medical tourism in the university.
“I describe internationalization as the stimulator of the development of health
tourism in our university. I compare internationalization to health tourism stimu-
lator because our university is a medical university with which a lot of hospitals
and health clinics are affiliated. The internationalization of the university can help
the attraction of international tourists in the field of health and treatment," one of
the faculty members said, adding, “The outcome of the expansion of medical and
health tourism will be prestige and money for the university”.
The professors also pointed to the natural environment of Guilan Province and how
the internationalization of the university could be a window for presenting the scener-
ies, climate, and geography of the province. They said that the internationalization of
the university “can help the attraction of many foreigners to the province where they can
enjoy the beauties of the nature, study, and receive medical services”.
“Before applying to the university, foreign students normally learn about the uni-
versity in general, the country, and the climate of the place in which the university
is located. Internationalization of the university can help the presentation of Guilan
Province which has always been a tourist attraction spot with its pleasant climate and
environment. The beauties of the province can, in turn, help the attraction of interna-
tional students and clients to the university,” another faculty member said.
In the Iranian health system, medical sciences universities are responsible for the
provision and control of all health-related issues in the provinces in which they are
located. If the university internationalizes its hospitals and medical services centers, it
can attract foreigners, who plan to travel to Iran for both tourism and medical services.
Therefore, the faculty members believed that internationalization can expand the medi-
cal services the university can offer to foreign nationals, thereby bringing credit and
income for the medical institution and the province.
Other metaphors like growth factor, ladder, and flower and fruit garden which the
faculty members produced are in keeping with the economic rationale of internationali-
zation. To survive and develop in the competitive world of education, higher education
institutes need to attract money from international sources to meet their financial needs.
In this regard, international students can be a valuable source of income for education
institutions (Khalid et al., 2017). The faculty members in the present study believed that
international students bring “foreign currency” which can help the economy of the uni-
versity, which attests to the fact that international students are one of the largest sources
of income for the international education industry (Altbach & Knight, 2007).
In addition to highlighting the role of internationalization in the economy of the uni-
versity, they viewed internationalization as a factor in the scientific and cultural devel-
opment of the university. Faculty members said that internationalization will help the
university “exchange knowledge and information with other countries,” and will be
“an effective factor in improving the ranking of our university.” Moreover, they termed
internationalization as a kind of “culture exchange.”

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“By accepting students from other countries and establishing a connection with
them in some way, we will become familiar with the culture of other countries
and, in some cases, we will take lessons from them,” one of the faculty members
said.
An interesting point in the faculty members’ metaphors of internationalization was
that they viewed internationalization as a way for “transmitting” their “culture and tra-
ditions.” That is to say, they believed that they should not be the mere recipient of
others’ culture and norms; they rather viewed internationalization as an opportunity
to present and expand their own norms and culture, which corresponds with Knight
and Witt’s (1997) view that internationalization promotes national identity. Knight and
Witt (1997), in a study which was on the Asia–Pacific region countries, reported that
academic exchanges as a result of internationalization can be a key to the introduction
of national languages and cultures to the international audience.

Theme five: links and relations

The faculty members emphasized the role of internationalization in developing rela-

tions between universities, describing training international students as training ambas-
sadors for the university.
“Internationalization provides us with the means to train ambassadors…… In
fact, any foreign student, by transmitting our culture and traditions, can act as
one of our ambassadors. Training international students is like training scien-
tific ambassadors to introduce the university to the international community and
exchange information between countries,” One of the faculty members said.
By comparing internationalization of the university to training ambassadors, the
faculty members indicated that the international students, who would be admitted and
trained at the university as a result of the internationalization process, would have the
potential to have the representative role of the university from a student perspective.
The argument that internationalization of education is like training ambassadors is fur-
ther supported by the fact that they would talk with, answer questions by, and share
their experiences at GUMS with prospective students and their parents. They can be
even a role model for the prospective students. McFarlane (2015) notes that interna-
tional students studying at a university “can be so experienced that you have ambas-
sadors among you who can serve as catalysts for the community goals that you seek to
achieve.” Therefore, the faculty members in the present study believed that the inter-
nationalization of the university would result in the admission of international students
who can act in the role of ambassadors contributing to the establishment and expan-
sion of international relations and collaboration of the university.
In agreement with the traditional rationale of sociocultural expansions resulting
from the internationalization of universities, the faculty members’ metaphors denote
that the internationalization efforts at the target university should aim to create a situ-
ation where, according to Knight (2014), international and intercultural activities can
flourish. In this regard, research has also shown that internationalization “entails an
increase in the domain of social experience and cultural knowledge of students and
academics from different nations and cultures (Shamsi Gooshki et al., 2018).”

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Discussion

This study aimed to discover Iranian faculty members’ beliefs about the internationaliza-
tion of education in a medical sciences university using metaphor analysis. The analysis of
the faculty members’ metaphors resulted in the discovery 19 metaphors which were con-
densed into five themes (clinical culture, a roadmap for change, challenges, promotion, and
links and relations). An examination of the emerged themes showed that they partially cor-
respond with the traditional social, cultural, political, academic, and economic rationales of
internationalization (Knight & de Wit, 1997, 1999). The findings, however, revealed a bur-
geoning body of evidence for the emergence of such groundbreaking rationales as context-
specific clinical culture development, clinical setting conduct, and health tourism expan-
sion, which are among the novel contributions of the present study to the field. The faculty
members foregrounded both the challenges and attractions of internationalizing medical
education when zooming in on clinical settings. On the one hand, the faculty members
highlighted the necessity of international students’ familiarity with domestic accepted
norms of communication with and examination of clients in clinical settings. In the Ira-
nian culture, the relations between males and females follow specific norms, which include
issues like proximity, gestures, and eye contact. Previous research on international medical
sciences students’ problems in the Iranian context has also shown that they preferred to
do and cover their internship courses, which are at hospitals and other medical and health
settings, in their home country (Nakhoda, et al., 2020). The challenges arising from cul-
tural differences in the clinical setting have been also reported by nurses. Nurses describe
that unfamiliarity with the culture of patients makes providing care for them a challenge
(Amiri & Heydari, 2017). On the other hand, the faculty members brought to the limelight
the privileges of studying medical sciences in the Iranian context for international students
from Muslim countries. Amiri and Heydari (2017) quoted a nurse as saying that the Iranian
context “seems to be apt for students from Islamic countries which have similar culture and
norms. The international Islamic students which seek to continue their education abroad
and are concerned about Islamic cultural issues will probably find the country a proper
destination.” Accepted norms of conduct in clinical setting in Muslim and non-Muslim
countries differ. In a western culture, it might be normal for a male physician to examine a
female client without any worries or concerns about how close to be to the client. In Mus-
lim countries, however, special attention has been given to the issue of gender in physician
and patient encounters (Aldeen, 2007) and to the body parts to be examined by physician
(Lafta, 2006; Matin & LeBaron, 2004). Moreover, non-Muslim students, staff, and teachers
may have false assumptions about international Muslim students which can adversely influ-
ence the students’ integration in co-curricular activities (Nasir & Al-amin, 2010; Rocken-
bach et al., 2017) and their educational performance (Cole & Ahmadi, 2003). Therefore, as
Iran has the same religion and culture as other Islamic countries, the milieu of the country
seems to be suitable for social, cultural, religious and clinical practices of international
medical students.
Another significant finding of the study, which relates to the clinical and medical
aspect of the internationalization of medical education, was the economic contribution
that the internationalization of health and medical education can make to the university.
The faculty members believed that the internationalization of the university will present
the capacities and potential of the university in providing medical and health services,
which can be, in turn, influential in attracting patients from other countries. In this
regard, Iran’s Deputy Health Minister Harirchi (2019) said that the country earned $1.2

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Higher Education (2022) 84:629–646 641

billion from medical tourism in the year. The Iranian official further noted, “The num-
ber of foreign nationals traveling to Iran to receive medical care has increased tenfold
over the past decade to reach 300,000 annually.” Hashemzadeh (2019), head of Health
and Medical Education Ministry’s Health Tourism Bureau, said that between 500,000
and 550,000 tourists visited Iran from neighboring countries for medical purposes in
2019, adding, “Close to 72,000 of these tourists were hospitalized and the rest were out-
patients. Around 70% of health tourists visiting Iran seek services in five medical fields,
namely gynecology, ophthalmology, orthopedics, cardiology and cosmetic surgery.”
Therefore, it seems that health tourism has the potential to add a new dimension to the
economic rationale of internationalization, particularly in medical sciences universities.
Aside from the clinical attractions and challenges of the internationalization of the
medical university, the findings showed degrees of disagreement between the dominant
internationalization policies and the faculty members views on the internationalization
of the university. An institution might have such reasons for internationalization as com-
mercial advantage, knowledge and language acquisition, enhancing the curriculum with
international content, profit, prestige, economic and political integration, development, and
even personal choice (Altbach & Knight, 2007), which may not be welcomed by its fac-
ulty members. The faculty members’ metaphors showed that they supported the academic
rationale of internationalization which dictates the addition of an international dimension
to the teaching and research practices at the university. Unlike Knight and de Wit (2018),
who believe recent policies on internationalization are increasingly motivated by the eco-
nomic and political rationales and social/ cultural motivations for internationalization “are
not increasing in importance at the same rate,” the faculty members in the present study
attached high significance to the sociocultural dimension of internationalization by produc-
ing such metaphors as science and culture promotor, culture booster at clinical settings,
and local language/dialects challenge. According to Knight (2014), faculty members would
likely support an academic rationale, which is in line with the findings in the present study.
In this regard, it can be argued that top-down policies set by high ranking authorities and
the values and beliefs of those on the ground responsible for implementing these policies
were in tension in the present study. In the Iranian medical education system, the burden
of teaching university courses to the domestic and international students and the provision
of health services to the community is on the shoulder of clinical faculty members. They,
however, are not involved in the development of internationalization policies of universi-
ties. Likewise, Sanderson (2008) notes that the extant literature on internationalization has
been mainly on organization level internationalization, paying little attention to the role
of faculty members in the internationalization. What most internationalization policies of
universities seem to be lacking is consideration for faculty members’ (de)motivations for
engagement in internationalization. Research has shown that organizational characteristics
play a critical role in facilitating faculty members’ international engagement (Nyangau,
2020), indicating that faculty members would like to engage in internationalization process
if universities codify international activities within the academic reward structure (Beatty,
2013). Nyangau (2020), for example, reported “lack of recognition and rewards in the eval-
uative process for tenure and promotion, insufficient funding, structural constraints, and
lack of a framework for offering recognition and academic credit for international activi-
ties” as barriers to faculty engagement in internationalization. From the discussion above,
it can be concluded that the tension between institutional macro policies on internationali-
zation and faculty members’ views and beliefs will probably melt down if the institutional
policies on internationalization are informed by faculty members’ views and expectations.

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The existing differences between the faculty members’ views on internationalization

and the organizational policies of internationalization can also be traced in the faculty
members’ urgent call for reform in the educational activities of the university. The faculty
members believed that internationalization of medical education would promote the quality
of education at the university. They also believed that international education components
should be incorporated in the existing medical education system to internationalize the
education. One of the measures that faculty members in the present study called for, which
is also echoed in other studies, is offering part of the medical education program in English
(Zamanimanesh et al., 2017). Research has also indicated that such variables as “low qual-
ity of the course programs offered by educational departments,” “not using an international
language as a means of instruction,” “lack of variety in the extracurricular and curricu-
lar programs,” “no using new teaching methods,” and “not giving priority to intercultural
approach in curriculum planning” can adversely affect the internationalization of higher
education (Firouzjaiyan & Khorsand, 2018). Salimi et al., (2015) also named “lack of dis-
tance education,” “lack of online teaching,” “lack of the organization of online seminars,”
and “lack of joint educational programs with other countries” as the barriers to the inter-
nationalization of the higher education in the Iranian context. The current Iranian medical
education curricula are lacking in specific intercultural and international courses or com-
ponents. The medical education system in Iran integrates education with the provision of
medical services at clinics and hospitals affiliated to medical sciences universities. That is
to say, faculty members at Iranian medical sciences universities teach at medical colleges,
where they teach mainly basic sciences, and at hospitals, where they teach clinical sci-
ences and provide clinical and medical services. Despite all its benefits, the heavy burden
of teaching and offering medical services rob the faculty members of the opportunity to
revise the medical education curricula with the aim of embedding international elements
in the education system. Likewise, Wu et al., (2020) report that US medical educators have
little or no international professional experience and little time for curriculum review and
innovation, warning that internationalization of medical education will remain “an extracur-
ricular, optional activity” if no measure is taken to expand it (Wu et al., 2020). Therefore, to
approach the international standards of education, the university, as the faculty members in
the present study demanded, should undergo an educational and academic reform.
Still another challenge which the faculty members in the present study envisaged was the
issue of local languages or dialects, which has remained obscure largely in the literature on
internationalization. Studies have described lack of competence in an international language
as a barrier to internationalization (Zamanimanesh et al., 2017). What further concerned the
faculty members in the present study was the international students’ dire need for local lan-
guages and dialects to communicate with clients and hospital staff in medical settings. That
is to say, in addition to the local language problems they could have in their academic life at
the university and social life in the community, international medical sciences students have
to cope with the same problem in clinical settings with patients or their attendants and rela-
tives. The point is that research on internationalization has raised concerns about language and
communication barriers in academic and social settings (Andrade, 2006; Townsend & Poh,
2008); little attention, however, has been paid to the language problems international medi-
cal sciences students may face at clinical settings. Persian is the official language of Iran; in
the provinces, however, people normally prefer to use the local language or dialect and many
patients cannot communicate in accurate and fluent Persian. As international students major-
ing in medical sciences fields need to take up apprenticeship courses at the hospitals and other
health settings, they need to communicate with the locals, who speak the local language or
dialect. The point is that for non-medical international students learning the local language is

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Higher Education (2022) 84:629–646 643

not of necessity and learning Persian (Farsi), which is per se a challenge, suffices; for interna-
tional medical students, however, as they need to communicate with clients who speak only
in the local dialect or language, gaining the competence to communicate with the locals is a
prerequisite skill and an extra challenge. Similarly, Nakhoda et al., (2020) describe the Persian
language as one of the challenges of foreign students in Iran, quotinge a foreign student as say-
ing, “This place is great, but everything is in Farsi and we do not understand the language.”

Conclusion

This study used metaphor analysis to explore Iranian medical sciences faculty members’
beliefs about the internationalization of medical education. The evoked metaphors by the
faculty members were thematically categorized as clinical culture, a road map for change,
challenges, promotion, and links and relations. The faulty members particularly called for
considerations for context-specific clinical setting conduct, urged a reform in the educa-
tion system to include international and intercultural components in medical education
curricula, preferred the scientific and cultural reasons to political and economic rationales
for internationalization, described learning the local language and dialect as necessary for
international medical students as they need to communicate with local patients and hospi-
tal staff, and viewed internationalization as an opportunity for the university to expand its
health tourism industry. The study suggests that orientation courses on the sociocultural
norms of the target context and the local languages or dialects be organized for the interna-
tional medical students on admission, and the students be educated on the accepted codes
of conduct in clinical settings before they start apprenticeship courses in hospitals and
other health centers. Moreover, faculty members and hospital staff can ask for permission
from patients for international students to communicate with and examine them. As for the
differences between the organizational internationalization policies and the faculty mem-
bers’ reasons for internationalization, the study suggests the involvement of the faculty
members in the development of internationalization policies at universities, which can, in
turn, secure the faculty members’ motivation for and engagement in international activities.
Regarding the educational reform, it seems that, as most of the faculty members at medical
sciences universities are clinicians or basic scientists with little if any experience or exper-
tise in curriculum development, medical educationists, as a community, should take over
the helm of internationalization of medical education through injecting international and
intercultural components into medical education programs.
This study was conducted in the Iranian context; since cultural and social differences
can affect the formation of individuals’ perceptions and beliefs, it is suggested that similar
research be conducted in other universities and countries. The findings of these studies can
further deepen our insights into the extent to which faculty members, as influential drivers
of internationalization at universities, in different sociocultural contexts and educational
disciplines back up the internationalization of universities.

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