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An integrative literature review of study abroad programs for nursing students.

RESEARCH

ABSTRACT Nurse researchers need to explore study abroad programs and identify their impact on the development of cultural competence and global perspectives in nursing students. Despite the anecdotal professional and personal benefits that have been attributed to study abroad in other disciplines, current nursing literature regarding this topic is limited and has only emerged in nursing research within the last decade. There is a significant gap in the existing body of knowledge with respect to American nursing students who study abroad and the reported benefits of and impediments to their experiences. Much of the nursing research conducted with American nursing students has been quantitative as opposed to qualitative studies with European and Australian nursing students. Many samples are homogenous and therefore exclude diverse populations. Further research involving all methodological designs is warranted to better understand this type of engaged learning.

Key Words Active Learning--Study Abroad--Cultural Sensitivity--Undergraduate Nursing Education

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DESPITE THE MANY PROFESSIONAL AND PERSONAL BENEFITS THAT HAVE BEEN ATTRIBUTED TO STUDY ABROAD IN OTHER DISCIPLINES, CURRENT NURSING LITERATURE REGARDING THIS TOPIC IS LIMITED. An exhaustive review of the literature was conducted regarding this phenomenon since the topic first emerged in the nursing literature in the late 1990s. This review includes the historical development of study abroad programs for nursing and summarizes the existing literature, including anecdotal reports and research inquiries. The evident gaps or inconsistencies within the existing body of knowledge are discussed.

Findings from Anecdotal Reports In recent years, anecdotal reports have described the benefits of study abroad programs for nursing students (Colling & Wilson, 1998; Duffy, Farmer, Ravert, & Huittinen, 2003; Johanson, 2006; Leinonen, 2006; Tabi & Mukherjee, 2003). Reciprocal nursing exchange programs are gaining in popularity as both host and home country participants are recipients of these benefits. For instance, Duffy et al. evaluated an eight-week American-European exchange program for nursing students and faculty. Participants reported personal and professional growth, such as realizing the importance of remaining open to new cultural experiences.

Coiling and Wilson (1998) developed a short-term exchange program for nursing students from the United Kingdom and the United States that first involved a 24-week didactic course on topics germane to each country's health care system and nursing practice. Upon completion of the course, students studied abroad for two weeks. The authors stated that this experience allowed for the transmission of cultural ideas and practices. Participants described enlightenment and increased sensitivity that could be gained only through an immersion experience.

Johanson (2006) designed a five-week study abroad course in Mexico for American nursing students. Students perceived their benefits to be greater cultural sensitivity and the opportunity to dispel misconceptions. In addition, when faced with the poverty of the host country, students felt gratitude for their own socioeconomic situation. Tabi and Mukherjee (2003) summarized the benefits of a six-week study abroad program in Ghana, West Africa. The trans-cultural experience provided participating nursing students greater global awareness and understanding, which the authors stated was long overdue for the nursing profession. Leinonen (2006) examined an exchange program for American nurses employed by the Mayo Health System who visited clinical sites in Japan. She described this experience as facilitating global partnerships among nurses that resulted in the exchange of information, enhancement of nursing care through cultural awareness and respect, and opportunities for personal and professional growth. Likewise, Saenz and Holcomb (2009) explained the benefits of a nine-day immersion for 12 American undergraduate nursing students in Honduras. The American nursing students worked with Honduran nursing students to develop a community health fair, affording a first-hand perspective of poverty and its impact on health for a community.

Nash (2008) reported that study abroad programs for nursing students increase the comfort level of nurses working with diverse populations. She concluded that "cultural competence and global awareness clearly have been facilitated by ... enrollment in this interprofessional and international elective course" in Nicaragua (p. 25). Bentley and Ellison (2007) offered similar findings with American nursing students who participated in a one-week service-learning experience in Ecuador, concluding that "for most students to achieve greater cultural competence, an immersion experience was needed." (p. 210). Finally, Wright (2010) concluded that the American nursing students "who have participated in our study abroad program recognized they were looking at another culture through their own cultural lenses" (p. 286).

Findings from Research Studies DESTINATIONS / LENGTH OF STUDY ABROAD PROGRAMS Existing research on the phenomenon of study abroad programs for nursing students is varied and exciting. Destinations for nursing students have included developed countries and cities (Northern Ireland, England, Denmark, Scotland, Russia, Finland) and major cities (Brussels, London, Paris) (DeDee & Stewart, 2003; Grant & McKenna, 2003; Koskinen & Tossavainen, 2003, 2004; Zorn, 1996). Some study abroad programs targeted developing nations, including Thailand, Guatemala, and Tanzania (Caffrey, Neander, Markle, & Stewart, 2005; Inglis, Rolls, & Kristy, 1998; Sandin, Grahn, & Kronvall, 2004; Walsh & De Joseph, 2003). Other researchers have investigated a blend of developed/developing nations, including Jamaica, Northern Ireland, England, and Ghana in one study and Jamaica, Malta, Greenland, and Australia in another (Ruddock & Turner, 2007: St. Clair & McKenry, 1999).

To describe the long-term impact of study abroad experiences on American baccalaureate nursing graduates, Zorn (1996) developed and administered the International Education Survey (IES). The IES was reviewed by experts for content validity but had no prior reliability and validity estimates. It consists of 29 items on four scales related to a study abroad experience: professional nurse role, international perspective, personal development, and intellectual development. The items are rated on a Likert scale with scores ranging from 1 to 7. With 27 participants, all white females, the alpha coefficient was .97 overall. Participants had studied abroad between 1979 and 1993 in one of four countries: England, Denmark, Scotland, or Russia. The greatest impact reported was enhanced international perspective (M = 5.0) and personal development (M = 4.4), with older students reporting higher degrees of personal development. Items with the least impact were on the intellectual development scale (M = 3.5). Zorn noted that long-term impact was greater for students who had participated in a long-term program (12 to 16 weeks) versus a short-term program (3 to 4 weeks), but impact for both groups decreased with the passage of time. A significant positive correlation (p = < 0.5) was evident in all four subscales of the IES, but given the relatively small, homogenous sample, findings are not generalizable to more diverse groups of nursing students.

St. Clair and McKenry (1999) employed triangulated research methods to explore relationships among short-term international experiences of two to three weeks, cultural self-efficacy, and cultural competence, analyzed through participant observation, field note transcriptions, and reflective journal writings. The sample included 200 senior nursing students from a university in New England; 80 had participated in study abroad programs. All seniors were administered the five-point Cultural Self-Efficacy Scale (CSES) three times each year for two academic years. Students who planned to study abroad were administered the CSES before the experience and twice in the semester following their experience abroad. Scores on the CSES ranged from 1 to 5.

Statistically significant increases on CSES scores were noted for all students, regardless of group (M = 3.4, p = < .05). A statistical difference was found between students who had participated in an international clinical placement (M = 3.6) versus those who did not participate (M = 3.2, p = .04). St. Clair and McKenry (1999) reported that continued growth in cultural self-efficacy was observed for the cultural immersion group; for instance, when the two groups were compared just prior to graduation, the mean score for study abroad participants was 3.75, compared to 3.3 for the others (p = .007). St. Clair and McKenry contended that their sample overcame their "unknown" ethnocentrism compared to those who did not study abroad. One nursing student noted, "I feel as if I have been asleep my whole life. I didn't realize who I was, what I believed, or where I was going" (p. 232). The international exchange program afforded participants an opportunity to examine their own beliefs and values.

A noted strength of the St. Clair and McKenry (1999) study is its triangulated methodology, which included both quantitative and qualitative data. A weakness may be the lack of a control mechanism for the students' destinations. Students traveled to developed and developing countries (Northern Ireland, England, Ghana, and Jamaica) and may have had varied reactions to these diverse settings.

Preferably, the international exchange program should consist of long-term placement (12 to 16 weeks) in order for participants to gain the most benefits (DeDee & Stewart, 2003; Koskinen & Tossavainen, 2004; Zorn, 1996). However, long-term study abroad programs are rarely feasible for most nursing students due to financial and personal obligations and the constraints of nursing curricula.

Short-term intensive cultural immersion programs have provided a viable alternative in which educators fostered cultural competence with greater efficacy than with traditional methods such as lecture, discussion, case study, and role play. Even for students who participated in brief study abroad programs (2 to 4 weeks), a significant positive impact in their development of cultural awareness, cultural self-efficacy, and cultural competence was found when compared to peers who did not travel abroad (DeDee & Stewart, 2003; Koskinen & Tossavainen, 2004; St. Clair & McKenry, 1999). In fact, most research has explored immersion program outcomes for American nursing students involved in short-term trips of two to five weeks (Caffrey et al., 2005; St. Clair & McKenry; Walsh & DeJoseph, 2003). It would be interesting to examine experiences of students who are able to participate in a longer immersion such as the three to four months reported in some European student exchange programs (Koskinen & Tossavainen, 2003, 2004). To date, few published research studies have examined study abroad programs of two weeks or less, which would have the potential to make the experience available for many more students.

The existing research on study abroad programs is split between those to developed countries (DeDee & Stewart, 2003; Grant & McKenna, 2003; Koskinen & Tossavainen, 2003, 2004; St. Clair & McKenry, 1999; Zorn, 1996) and those to undeveloped destinations (Caffrey et al., 2005; Inglis et al., 1998; Walsh & DeJoseph, 2003). However, comparative studies between the two types of experiences have not been published. Findings from studies on travel to both types of countries are usually reported collectively rather than by type of destination.

CHARACTERISTICS OF STUDY ABROAD PARTICIPANTS To gain an accurate and representative idea of students' perceptions, insights, and benefits and impediments associated with immersion, it is important to examine samples of nursing students that are diverse with regard to gender, age, cultural background, and educational level. However, most existing studies are focused on homogenous samples of single, young, white females, usually in their final year of the nursing curriculum (Caffrey et al., 2005; DeDee & Stewart, 2003; Grant & McKenna, 2003; Inglis et al., 1998; Koskinen & Tossavainen, 2004; Sandin et al., 2004). Five of 11 existing studies examined groups of American nursing students (Caffrey et al.; DeDee & Stewart; St. Clair & McKenry, 1999; Walsh & DeJoseph, 2003; Zorn 1996), and most of these sampled students at the same level of the nursing program. Zorn recommended that study abroad programs be open to all students, regardless of age or program level, and stated that greater diversity of nursing students needed study.

Diversity of study abroad participants is relatively scarce in the literature. As previously stated, many studies to date have included homogenous samples of single, white females, yet some published studies do not explicitly report on the ethnic composition of their samples (Grant & McKenna, 2003; Inglis et al., 1998; Koskinen & Tossavainen, 2003, 2004; Ruddock & Turner, 2007; Sandin et al., 2004; St. Clair & McKenry, 1999). Edmonds (2010) sought to fill a gap in the existing literature. This qualitative study included a diverse sample of American nursing students and offers a rich, new perspective of nursing students who study abroad. The diverse sample in the Edmonds phenomenological study included 22 percent male participants, with 44 percent in either a pre-nursing or first-year nursing course; 61 percent were over 28 years of age, only 61 percent reported their ethnicity as white, and only 39 percent reported their marital status as single.

Research Methods Much of the qualitative literature on study abroad involved samples of nursing students who were not Americans. Inglis et al. (1998) conducted a small, phenomenological study with a sample of five female Australian nursing students who studied in Thailand for a four-week period; the students ranged in age from 19 to 24, and three had previously traveled abroad. The researchers hoped to understand the changes in conceptual understanding resulting from the immersion. They found that students had increased their knowledge through participation in this program and became aware of Thai cultural practices. Phase 2 of the study, which examined the students' perceptions of the study abroad experience, was not published. Several limitations of the Inglis et al. study were apparent. For example, the interviewer was not consistent throughout; the same case scenario was used for all students, providing opportunity for students to rehearse; and one participant could not be interviewed upon her return.

Grant and McKenna (2003) conducted a descriptive/exploratory qualitative study to examine the clinical experiences of Australian nursing students who spent four weeks in England and Northern Ireland during their final year in training. The nine participants were female and most were younger than 25. Data were collected through interviews and written journal entries. Three themes emerged: progression (the ability to adapt through recognizing and appreciating differences in the host country); differences (adjustment takes time and, as visitors, one must recognize differences in the environment and in oneself); and having a go (showing initiative and discovering what one wants to obtain from the experience). The study was limited by its small sample; three of nine students were interviewed, and six allowed their journals to be reviewed.

Sandin et al. (2004) described the experiences of eight Swedish nursing students who traveled to Tanzania for a three-week field experience. Students were interviewed for one to two hours in either individual or paired interviews. After data collection, content and contextual data analysis was performed collaboratively by all teachers of the course. Multiple themes were evident, including culture shock, experiencing different hospitality, feeling unprepared, different norms of behavior, different patterns of caring and nursing, perceptions of nursing education, and coping through reflection.

Koskinen and Tossavainen (2004) aimed to describe the process of learning intercultural competence in nursing through an international exchange program for Finnish nursing students who studied in Great Britain. Their sample consisted of one male and 11 female nursing students in their second or third year of training who ranged in age from 20 to 24 years. Three ethno-categories emerged as students began to develop cultural competence: transitioning from one culture to another, adjustment to the difference, and gaining intercultural sensitivity. The authors found that in order for students to successfully progress through these stages, they required significant guidance in the form of orientation and debriefing by faculty from both the home and host countries. Students' awareness of other cultures increased and matured as a result of experiencing a stressful adjustment to a different environment. The authors reported similar results in an earlier study of 15 British nursing students who spent three to four months in Finland (Koskinen & Tossavainen, 2003). They found that students who were able to become "insiders" by overcoming culture shock and increasing their knowledge and skills displayed greater progression toward intercultural competence.

Most of the current literature about American nursing students studying abroad is quantitative in nature. Similar to Zorn (1996), DeDee and Stewart (2003) examined the nursing international exchange program at the University of Wisconsin-Oshkosh. For this study, 38 participants completed the International Education Survey (IES) on the impact of their study abroad program on their professional nursing role, international perspectives, and personal and intellectual development. Study abroad significantly enhanced their international perspective (p = .006), professional development (p = .003), and personal development (p = .032), especially for younger participants. Some participants were recent graduates; others studied abroad up to five years before the survey. Those who graduated most recently reported the greatest impact for all subscales (p = < .04). Limitations to the findings include the relatively small and homogenous sample (participants were primarily young, single, white females) and the apparent lack of a control mechanism for the time elapsed since participation in the study abroad program. A noted strength of the study conducted by DeDee and Stewart was that it was conducted at an institution with more than 20 years of experience in conducting and researching nursing international exchange programs.

Caffrey and colleagues (2005) designed a quantitative study to compare the effects of integrating cultural content into a nursing curriculum on students' self-perceived cultural competence and the impact of an additional five-week clinical immersion. The control group of 25 received only the cultural content; the experimental group, seven students, also studied in Guatemala. The Caffrey Cultural Competence in Healthcare Scale (CCCHS), consisting of 28 Likert-scale items was administered to both groups in a pretest/posttest design. Pilot testing resulted in a favorable Cronbach's alpha of .94 on the pretest and .90 on the posttest; Cronbach's alpha for this study was higher, .93 on the pretest and .97 on the posttest. Scores for the control group improved moderately while the study abroad group reported higher levels of serf-perceived cultural competence. Again, the small, self-selected sample size may have been a limitation of the study.

Walsh and DeJoseph (2003) conducted an exploratory/descriptive qualitative study to examine experiences of 10 American nursing students and their faculty mentors who participated in a short-term immersion learning project in Central America, where they provided prenatal care. Students (including some recent graduates) had an average age of 28.4 years; five were Caucasian and three were Hispanic. They were interviewed individually, participated in focus groups, and submitted written responses. Three themes identified as contributing to the development of cultural competence were: I was already a nurse (describing the confidence of these students and readiness to practice as professionals); being other (the ability to recognize one's ethnocentrism and understanding the sense of being a minority); and expanding my worldview (an eye-opening experience, for the first time realizing how other people live). Even though some of these students had previously worked with or lived in diverse communities, the researchers concluded that study abroad had a greater impact on the development of cultural competence. They also reported that this two-week study abroad program increased participants' self-confidence, belief in their own abilities, personal growth, and professional identification as a nurse.

Edmonds (2010) conducted a phenomenological study with 18 American nursing students of varied demographic backgrounds who had completed a short-term (one week) study abroad program in either Dominica or England. Four themes were evident as a result of this study: recognizing, encountering, adapting, and mastering. Recognizing was a self-reflective process in which the participants recognized self as "other." Despite formal education on cultural topics, the study abroad opportunity afforded students a vital opportunity to recognize their own ethnocentrism. The theme of encountering included opportunities to go, do, and see. It was an active theme and evoked a sense of appreciation by the participants. The final themes from this qualitative inquiry included adapting to a foreign environment outside one's comfort zone and mastering a sense a self-efficacy, accomplishment, and serf-identity as a nurse.

It is important to note that a gap is evident in the existing nursing literature of qualitative studies with American nursing students. Thus, there is a true lack in understanding of the phenomenon of study abroad for this population, especially for students diverse in gender, age, cultural background, and academic level.

Implications for Nursing Education Themes evident throughout the literature suggest that study abroad provides an effective learning opportunity by which to foster and achieve a number of desirable requirements such as self-efficacy, the development of a global nursing perspective, and an understanding of the components of cultural competence. The study abroad experience offers other benefits to nursing students, contributing to the development of critical thinking and real-time problem-solving skills and the ability to navigate and communicate in unfamiliar environments.

Nurse educators are tasked with providing opportunities that promote cultural and serf-awareness in their students. Study abroad is one of the most effective ways to actively engage students in total cultural immersion. Students begin to see themselves as other, foreigner, or intruder. By encountering peoples of various cultural backgrounds beyond the level of a tourist, the student learns to avoid ethnocentrism (the feeling that one's culture is superior to others) and begins the journey toward cultural competence. Campinha-Bacote (2003) has emphasized the need for cultural competence in the delivery of health care services and offered the following definition: "The ongoing process in which the healthcare professional continuously strives to achieve the ability and availability to work effectively within the cultural context of the client (individual, family, community)" (p. 14).

Although time and again study abroad has been viewed as valuable for higher education and has been called "a useful strategy for bridging the theory-practice divide" for nursing students (Ruddock & Turner, 2007, p. 361), the present body of nursing knowledge regarding cultural competence as it relates to study abroad programs is not sufficient to soundly support this educational practice (St. Clair & McKenry, 1999; Walsh & De Joseph, 2003; Zorn, 1996). While positive anecdotal reports are available and encouraging, the body of nursing education knowledge is significantly strengthened through evidence-based research. Understanding the lived experience of nursing students who study abroad will provide valuable information about the personal and professional benefits of such programs and help educators make decisions based on evidence rather than speculation.

Of the available research involving nursing students, only five focus on American nursing students. Three used quantitative methodology (two of these used the same instrument), one was a qualitative study, and the other employed a triangulated approach. Studies with nursing students from other countries all used qualitative methodology. Clearly, there is a need for additional qualitative studies with American students. Not only is qualitative research an ideal method for providing rich data about a relatively underexplored phenomenon, it allows the diverse voices of individual participants to be heard.

Additional areas for future research include examining various issues, such as barriers to studying abroad. Financial barriers are especially difficult for students enrolled in highly structured academic programs as well as nontraditional students--those who are older, first-generation college students, and students with work and family obligations.

The National Association for Foreign Student Advisers (NAFSA), in a 2003 report, stated that "few seriously contest that study abroad is important. The problem has been getting political, higher education, and business leaders to pay serious attention to the matter--to give it more than lip service" (p. 16). In 2001-2002, 64.9 percent of American students who studied abroad were women, 82.9 percent were Caucasian, and most were between the ages of 18 and 23 (Dolby, 2004, p. 154; NAFSA, 2003). These statistics provide evidence for the need to research the experiences of students with diverse ethnic and socioeconomic backgrounds. A gap exists in the overall understanding of the experience obtained by American nursing students who study abroad, especially for students diverse in gender, age, cultural background, and academic level. This provides a fertile area for future nursing education research.

References

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Caffrey, R., Neander, W., Markle, D., & Stewart, B. (2005). Improving the cultural competence of nursing students: Results of integrating cultural content in the curriculum and an international immersion experience.Journal of Nursing Education, 44(5), 234-241.

Campinha-Bacote, J. (2003). The process of cultural competence in the delivery of healthcare services:A culturally competent model of care. Cincinatti, OH: Transcultural C.A.R.E. Associates.

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Saenz, K., & Holcomb, L. (2009). Essential tools for a study abroad nursing course. Nurse Educator, 34(4), 172-175.

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Michelle L. Edmonds, PhD, ARNP, is an associate professor at Jacksonville University School of Nursing, Jacksonville, Florida. For additional information, contact her at medmond@ju.edu.
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Title Annotation:STUDY ABROAD / NURSING EDUCATION RESEARCH
Author:Edmonds, Michelle L.
Publication:Nursing Education Perspectives
Geographic Code:1U100
Date:Jan 1, 2012
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