The Journal of Continuing Education in Nursing

Original Article 

Virtual Orientation of Volunteer Short-Term International Health Teams to Increase Self-Confidence and Cultural and Global Health Competence

Christopher Herring, DNP, RN, CRNA; Sydney K. Brown, PhD; Brett T. Morgan, DNP, RN, CRNA; Julie Thompson, PhD; Anna Kullmar, MBA; Jane Blood-Siegfried, PhD, RN, CPNP


International health team volunteers frequently arrive at service sites with considerable lack of confidence and knowledge gaps because of poor preparation. Preservice orientation has been shown to improve knowledge, confidence, and competence, but current practices fall short of meeting most needs. This health care improvement project was aimed to improve self-confidence and cultural and global health competence using a virtual preservice orientation format. The virtual innovation significantly narrowed the difference in confidence between new and experienced team members. Significant increases were observed in knowledge of global health and health equities for new and experienced team members. Following the orientation, a significant difference in global health skills for the entire team also was observed. Many Americans leave the United States annually attempting to help those in need. This effort is hindered by poor preparation and unreal expectations. Improving health team member confidence and competence is one way to address this concern. [J Contin Educ Nurs. 2019;50(1):35–40.]


International health team volunteers frequently arrive at service sites with considerable lack of confidence and knowledge gaps because of poor preparation. Preservice orientation has been shown to improve knowledge, confidence, and competence, but current practices fall short of meeting most needs. This health care improvement project was aimed to improve self-confidence and cultural and global health competence using a virtual preservice orientation format. The virtual innovation significantly narrowed the difference in confidence between new and experienced team members. Significant increases were observed in knowledge of global health and health equities for new and experienced team members. Following the orientation, a significant difference in global health skills for the entire team also was observed. Many Americans leave the United States annually attempting to help those in need. This effort is hindered by poor preparation and unreal expectations. Improving health team member confidence and competence is one way to address this concern. [J Contin Educ Nurs. 2019;50(1):35–40.]

Medical mission teams often are composed of multi-disciplinary health care providers who unite to deliver health services to underserved populations in unfamiliar settings. The extent to which teams function efficiently and safely depends on how prepared individual members are in regard to the environment. Many volunteers arrive at service sites with a considerable lack of confidence, as well as knowledge gaps that affect how they function (Boston & Horlbeck, 2015; Carey, Carter-Templeton, & Paltzer, 2015).

Lasker (2016) estimated 200,000 Americans serve on more than 6,000 international volunteer health teams per year, providing care in the developing world at a cost of nearly $750 million annually. Economic impact is only one way to measure the effects of international volunteer health teams. Ethical consideration of sustainability, capacity building, respect, and autonomy also should be weighed carefully. Although health care providers may be confident and competent to provide this care in their home environment, their preparedness is far from ensured in these resource-poor settings. One way to increase participant readiness and skill is with preservice training, yet many groups do not have an evidence-based approach toward this goal. Specific efforts in health care education have been shown to positively change knowledge and confidence via preparedness (Austin, Kakacek, & Carr, 2010; Birckhead et al., 2015; Cook et al., 2008).

Project Goals

Prior to this innovation, the target team had no formal member orientation process except the receipt of a series of e-mails that varied in content. They were never completely educated about the experience. Participants who joined the team late may have received confirmation of only payment and travel dates and times.

The purpose of this quality improvement project was to improve, confidence and cultural/global health competence for a group of health care volunteers on a short-term medical mission team traveling to Barahona, Dominican Republic, by using an evidence-based orientation. The four primary aims were:

  • To organize, simplify, and standardize the information a participant receives prior to service with the team.
  • To improve self-confidence of new team members prior to participation in the medical–surgical service trip by completing online preparatory education modules.
  • To improve all team members' cultural and global health competence by the completion of preservice education.
  • To have participants rate modules as complete and helpful.


Project Participants

The team orientation was offered to all individuals who expressed a desire to participate in the service trip. The group consisted of health care professionals from across the United States. Fifty-eight percent of the project participants had previously been members of a similar team, and 42% were first-time members of the group. The team provided surgical and medical care to populations of Haitians and Dominicans living in and around Barahona. Specialties within the group included general surgery, gynecologic surgery, otorhinolaryngology, and primary care. In 2018, during a 5-day period, the team performed 64 surgical procedures and cared for 675 individuals in clinic.


A preservice orientation for team members was built using themes extracted from stakeholder interviews with previous team members and guidelines from existing literature (Carey et al., 2015; Chapin & Doocy, 2010; Seager, 2012). Institutional approval was obtained for this project, and the project did not meet criteria for research oversight by the Duke University Institutional Review Board. The implementation of this quality improvement project began in August 2017 in preparation for the January 2018 mission trip.

The innovation was delivered virtually to accommodate the geographically dispersed team members and to enhance participant convenience prior to the service trip. The orientation innovation consists of an online Web portal linking to six education modules that inform participants of volunteer self-preparation, environment, work type and workflow orientation, resources and equipment availability, and cultural context of the population served. These modules are intended to streamline and formalize the preparation of team members (Table 1).

Educational Module Content

Table 1:

Educational Module Content

Depending on the participant's skill set, certain modules may be omitted or included. Experienced team members who had participated previously in the service trip may choose to omit modules 2 through 5. For the purpose of this study, all team members were asked to complete and assess all modules.

To improve the acceptance and adoption of this innovation, the implementation framework iPARIHS (integrated Promoting Action on Research Implementation in Health Services) was used (Harvey & Kitson, 2016). This model proposes that successful implementation depends on the relationship between four key constructs: innovation, recipients, context, and facilitation.

Evaluation of the Intervention

A pretest–posttest design was used to examine self-confidence and cultural and global health competence of the team members. The evaluation was completed by linked surveys to the education modules and supported by the Qualtrics® platform.

Before starting the orientation program, all members were asked to participate in a presurvey consisting of validated measures for self-confidence, cultural competence and global health competence, and basic demographic information. Participants also were asked whether they were new to the team and whether they had been on other similar trips in the past. Data collected during pretest–posttest surveys were linked to a participant-created five-digit alphanumeric code allowing the data to be paired. After completion of assigned modules, a posttest was administered to assess any change in the measured constructs.

The team members were asked to complete a survey after completion of the service trip to assess their satisfaction with and perception of the completeness and usefulness of the orientation modules. Open-ended qualitative questions were added to the end of the instrument to solicit information relevant to continuous improvement of the modules. This survey was in paper format and was completed on the return travel day.


Grundy (1993) developed the Confidence Scale (C-scale), a five-item instrument scored on a 5-point Likert scale with high construct validity pertaining to confidence. A score of 5 on an item represents high level of confidence and a score of 1 relates to low level of confidence. The scores of all five items are reported as a sum and can range from 5 to 25.

Cultural competence was measured using an instrument developed based on the cultural competence model (Doorenbos, Schim, Benkert, & Borse, 2005). The model describes four important elements that providers must understand to demonstrate levels of cultural competence (cultural awareness, cultural diversity, cultural sensitivity, and cultural competence behaviors). The Cultural Competence Assessment (CCA) is valid across disciplines and educational levels (Doorenbos et al., 2005). It has been used to evaluate the effectiveness of interventions designed to increase cultural competence. Two subscales in the CCA are the cultural awareness and sensitivity (CAS) subscale and the cultural competence behavior (CCB) subscale.

Global health core competencies are a set of guidelines adapted across multiple disciplines to develop curricula that address emerging health challenges (Wilson, Harper, et al., 2012). Six major competencies include global burden of disease; health implications of migration, travel, and displacement; social and environmental determinants of health; the globalization of health care; health care in low-resource settings; and health as a human right and development resource (Campbell, Sullivan, Sherman, & Magee, 2011). Global health competence was measured using the Global Health Competencies (GHC) Survey. The GHC instrument was developed to assess competency across different health professions in global health issues (Veras et al., 2012). As adapted for this study, three factors were measured within the GHC Survey:

  • Knowledge and interest in global health and health equity (3-level Likert scale, with 3 indicating a high level of confidence and 1 indicating a low level of confidence).
  • Global health skills self-assessment for working with patients with different linguistic, educational, socioeconomic, and cultural backgrounds (5-level Likert scale, with 5 indicating strongly agree and 1 indicating strongly disagree).
  • Learners' needs about global health (6-level Likert scale, with 6 indicating extremely important and 1 indicating not at all important).

The C-scale, CCA, and GHC were built into a single survey along with demographic items and a unique self-assigned participant identifier. The survey was administered pre- and postintervention to assess perceived change in these outcome measures.

A satisfaction survey was built using the National League for Nursing's Student Satisfaction and Self-Confidence in Learning Scale (SCLS) to assess the orientation process, participants' perception of innovation effectiveness, appropriateness, and completeness. The SCLS is a 13-item, 5-point Likert survey that has two subscales: the five-item satisfaction with learning subscale and the eight-item self-confidence in learning subscale (Franklin, Burns, & Lee, 2014). Participants are asked to rate the factors, with 5 indicating high agreement and 1 indicating low agreement to the item. Scores are calculated by summing the responses. Higher scores indicate higher degrees of satisfaction and self-confidence, respectively. The items on the satisfaction with learning subscale measure satisfaction with teaching methods, diversity of learning materials, facilitation, motivation, and overall suitability of the simulation. The subscale can range in score from 5 to 25. The self-confidence in learning subscale comprises eight items measuring self-confidence in content mastery, content necessity, skills development, available resources, and knowledge of how to obtain help to solve clinical problems. The subscale can range in scores from 8 to 40. Two open-ended qualitative questions were added to the end of the survey to solicit ongoing improvement data.


Paired t tests were used to compare the within group difference between the pre- and posttest mean scores for the whole group, new members, and experienced members for the constructs of confidence and competence in cultural and global health. Separate independent t tests were performed to show between group differences for the new and experienced groups in outcome constructs. Descriptive statistics were used to describe the basic features of the SCLS subscales, and qualitative data were coded for themes. SPSS® version 24 was used to analyze quantitative data, with alpha set to .05.


Forty-three individuals started the survey assessment. Thirty-six individuals participated in the education/orientation innovation and its pre- and postassessment. Because of cancellations for personal reasons, the final team included 33 individuals. Of those, 14 were new members and 19 were experienced members. The team comprised a variety of health care and nonhealth care professions. Participants ranged in age from 14 to 79 years (Table 2).

Participant Demographics

Table 2:

Participant Demographics

The difference in mean pre-education confidence scores between new and experienced groups was significantly lower for new members than for experienced members (p < .05). Posttest confidence scores for new team members increased by 2 points (from 16 to 18) and the experienced members had no change, with a mean score remaining at 21 of 25 possible points. Although the new participants' confidence score did not match the confidence levels of experienced participants, the difference between the two groups was no longer significant postintervention (Table 3).

Comparison of Outcome Measures Pre- and Postinnovation Between and Within Groups

Table 3:

Comparison of Outcome Measures Pre- and Postinnovation Between and Within Groups

Knowledge in global health and health equity was significantly improved postintervention for all participants, both new and experienced members (p < .05). Also within global health skills, a significant improvement occurred for the team as a whole postintervention but not for new or experienced groups individually (p < .05) (Table 3).

The mean satisfaction with instruction subscale score was 23 (SD ± 2) and the self-confidence with learning subscales mean score was 36 (SD ± 3). This measure was taken once at the completion of the trip, and results were pooled given that the innovation was new to all participants. The strongest finding within the satisfaction subscale was that the innovation facilitated the participants' learning of expectations for the service trip (81% strongly agreed and 16% agreed). Even the lowest satisfaction subscale element, relating to the participants' perception of overall suitability of the education to the way they learned, was positive (91% agreed or strongly agreed it was suitable). Within the self-confidence in learning subscale, 100% agreed they had the resources available to be well informed. Ninety-seven percent thought they had mastered content and had knowledge of how to obtain help, and 94% thought the learning facilitated appropriate skill development for the service trip.

Thirty of the 32 posttrip survey participants provided additional comments in the form of open-ended responses. Twenty-four indicated that all learning modules were helpful for their preparation and complete as offered. One participant who was new to the team but a veteran of several other medical service teams stated, “This was the best organized trip of multiple mission trips. The modules were helpful for a first-time participant.” Another participant stated, “The modules were great, but there is no way that you can provide all the information you would need to be prepared for this trip.” Four individuals requested more information about the politics and history of the local area. Two of the participants wanted a list of personal medical equipment they should bring.

Contextual Elements and Unexpected Consequences

All participants reported previous experience working and interacting with other racial/ethnic groups, as well as special populations of clients. New team members reported previous exposure to an average of 4.4 (SD ± 1) racial/ethnic groups and 4.6 (SD ± 2) special population groups. The experienced members reported exposure to 4.6 (SD ± 1) racial/ethnic groups and 5.1 (SD ± 1) special population groups. Mean cultural competence score was 4.0 for new participants and 4.3 for experienced members on a 5-point Likert scale, with 5 indicating high competence. None of these self-reported differences in cultural competence or diversity exposure between groups were significant (Table 3).

Missing Data

All individuals who self-identified as wanting to participate in the service trip were directed to the intervention website. As a condition of participation, they were asked to complete a pre- and postassessment surrounding the review of the educational orientation intervention. Three reminder e-mails were sent at intervals to encourage completion. Eighty-eight individual surveys were collected. Seventy-two of the surveys could be paired (pre and post for a single individual) for the analysis. The 36 pairs of surveys that were included had as a minimum completed the C-scale portion of the survey on both pre- and postsubmissions. If particular subscale items were omitted from an individual's pre- or postsurvey, they were not included in that portion of analysis. This equated to analysis of 35 pairs for the CAS, knowledge in global health and health equity, and learning needs in global health subscales. Thirty-four pairs completed the CCB and global health skills subscales as well.


This study demonstrated that a virtual educational program can significantly improve the knowledge and level of confidence in participants new to a medical mission group. Knowledge and self-confidence are considered central mediators of success for this type of a trip (Bandura, 1977). Improving the self-confidence of novice participants can positively influence their performance and improve their satisfaction while serving (Birckhead et al., 2015).

Sykes (2014) noted that cultural competence has been shown to play a role in quality of care provided to minority populations. Mission team participants must understand the cultural issues they will be facing. In this innovation, both new and experienced participants reported a high degree of overall cultural competence prior to the intervention that did not improve significantly. Health care travelers often avail themselves of additional cultural training, which would result in the higher initial scores found in both groups. The SCLS and qualitative questions showed that although participants were already fairly knowledgeable, they highly valued the content related to culture and would have liked even more content regarding this population.

Global health, which intends to improve health and equity in health, is an important part of health care training (Carey et al., 2015; Chapin & Doocy, 2010; Lasker, 2016; Seager, 2012; Wilson, Merry, & Franz, 2012; Wilson et al., 2012). To achieve competence in global health, one must understand not only an individual's culture but also disease burden, economics, inequalities, and government in the population of interest. Most providers have limited understanding of the specific local challenges when working in a foreign location and must consider the impact on the society as a whole. The global health content in the innovation encourages this big picture thinking. Significant improvement was shown for new and experienced participants in knowledge of global health and health equities, as well as whole team global health skills.

Prior to service on a short-term international health team, participants should be prepared for the tasks they will perform and the context in which they will perform those tasks. Lasker (2016) and Seager (2012) pointed out that the stakes of not preparing for this mission of service can actually do more harm than good for those who are serving and those being served. This innovation organized, standardized, and simplified the information that one such team received prior to their trip. The members of the team rated their satisfaction with the orientation very highly for their mastery of the content, its depth and breadth, the way it was presented, and their ability to apply the knowledge they received as appropriate and complete.


This innovation was built and studied in a specific context, responding to a specific need of a small group. The educational modules were deployed in a way to meet those needs. Although four other teams serve in the location, they have their own unique context that will require customization of this innovation. The use of virtual modules for a diverse group such as this can contribute to understanding and can be used for growth of similar projects for future use.


Experience, preparation, and orientation can have a significant influence on an individual's confidence and competence. When prior experience does not exist or is not specific or generalizable to the tasks that will be performed, then orientation training is necessary to bridge the gap. This virtual orientation for a volunteer, short-term, international health team demonstrated that significant improvement can be made in new participant self-confidence and in global health competence for the entire team. Using a virtual distance-learning model, the project had a high degree of participant participation and satisfaction. The orientation resides virtually on a web hosting service and can be accessed at


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Educational Module Content

1Trip DetailsHTML and PDFTrip logistical information: the who, what, when, where, and how much Supporting preparatory information including links to the Centers for Disease Control and Prevention, U.S. State Department, and the Dominican Republic Consulate
2Travel DayHTML and internally produced videoTeam-specific video, images, and text description of travel to and from site
3Setup DayHTML and internally produced videoTeam-specific video, images, and text describing the workflow, equipment, and resources available
4Clinic DayHTML and internally produced videoTeam-specific video, images, and text of typical conditions, tasks, workflow, and resources during the primary care clinic
5Hospital DayHTML and internally produced videoTeam-specific video, images, and text highlighting typical tasks and workflow, and resources of surgical day
6Culture and Global HealthHTML and links to externally produced video contentHTML text and images, as well as links to reliable information and videos about global health issues and culture of the population to be served.

Participant Demographics

VariableNew to Team, n (%)Experienced Members, n (%)
Participated in orientation14 (39)22 (61)
Participated in service trip14 (42)19 (58)
Male4 (12)4 (12)
Female10 (30)15 (45)
Age (years)
  < 203 (9)1 (3)
  20 to 609 (27)11 (33)
  > 602 (6)7 (21)
Advanced practice RN1 (3)3 (9)
Certified surgical scrub02 (6)
Dentist01 (3)
Nonmedical5 (15)2 (6)
Pharmacist03 (9)
Physician2 (6)5 (15)
RN5 (15)4 (12)

Comparison of Outcome Measures Pre- and Postinnovation Between and Within Groups

TestPre–PostNew MembersExperienced Members

Confidence scale (C-scale)Pretest**14162221
Cultural diversity exposure (ethnic groups)Pretest124.42224.64
Cultural diversity exposure (special populations)Pretest114.64225.14
Self-rating of cultural competencePretest143.93224.32
Cultural awareness and sensitivity (CAS) subscalePretest145.98216.18
Culturally competent behaviors (CCB) subscalePretest134.74215.20
Knowledge in global health and health equitiesPretest131.93*222.13*
Global health skillsPretest**122.86223.14
Learning needs in global healthPretest134.54224.63

Dr. Herring is Clinical Assistant Professor, Nurse Anesthesia Doctor of Nursing Practice Program, College of Nursing, University of Arizona, Tucson, Arizona; Dr. Brown is Dean, Gayle Bolt Price School of Graduate Studies, and Professor, School of Education, and Ms. Kullmar is Graduate Assistant, Center for Personal and Professional Development, Gardner-Webb University, Boiling Springs, North Carolina; and Dr. Morgan is Assistant Professor and Director, Nurse Anesthesia Doctor of Nursing Practice Program, Dr. Thompson is Research Associate/Statistical Consultant, School of Nursing, and Dr. Blood-Siegfried is Professor, School of Nursing, Duke University, Durham, North Carolina.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Christopher Herring, DNP, RN, CRNA, Clinical Assistant Professor, Nurse Anesthesia Doctor of Nursing Practice Program, College of Nursing, University of Arizona, 1305 N. Martin Ave., Room 305, Tucson, AZ 85721; e-mail:

Received: April 17, 2018
Accepted: August 17, 2018


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