Globalization of information, technology, and other areas of human activity and the changing trends in demography (Eshleman & Davidhizar, 2006; Lutterman-Aguilar & Gingerich, 2002) prompt nurse educators to reevaluate ways of preparing nursing students to meet the health care needs of populations they currently serve and will care for in the future. In a policy statement issued in 1975, the American Association of State Colleges and Universities declared that “no field of knowledge can be isolated from global problems and the pursuit of their solutions” (p. 2).
Nurse educators must assume the field of nursing knowledge was included in this statement. However, despite the encouragement of some nursing leaders that clinical experiences from different parts of the world should be “sampled and savored” (Styles, 1993, p. 507), few study abroad programs have been developed and made available to nursing students. Ryan, Carlton, and Ali (2000) concluded that study abroad or field opportunities need to be made available to nursing students, and faculty need field experience to facilitate student learning. Bosworth et al. (2006) and Tabi and Mukherjee (2003) agreed nursing faculty need to have opportunities to be immersed in another culture to be able to create strategies for a study abroad experience as a way to globalize nursing education programs.
During the 1990s, many European Union countries developed exchange programs that enabled their students to have clinical experiences in another European country. Study abroad opportunities also have been a fixture in the British nursing education system since 1995 (Greatrex-White, 2007; Koskinen & Tossavainen, 2003). However, most of these experiences have been arranged through the efforts of individual students rather than by faculty with a group of students. Nursing students, who made all of their own travel arrangements and wondered what type of living accommodations would be waiting for them, often became frustrated even before their study abroad experience began.
Inglis, Rolls, and Kristy (1998) reported that prior to their study, Australian university departments had begun establishing cooperative relationships with their counterparts in various Asian universities to position themselves as part of Asia. Nursing students eventually were provided with an opportunity to take a 4-week course in community primary health care at a university in Thailand and received elective credit from their own university’s nursing program. It is apparent that nurse educators in various parts of the world recognize the need to find ways to internationalize their educational programs.
Bosworth et al. (2006) cited two compelling reasons for the scarcity of study abroad opportunities available for nursing students. First, nursing faculty themselves may not have experience in the international health care arena or personal travel abroad experience. Second, faculty from a college or university that has and supports a study abroad program have concerns nursing students will not acquire the necessary preparation for the licensure examination, thus putting students and the nursing program in jeopardy.
Recently, Christoffersen (2008), a nursing faculty from the Boston area, recounted her first-time experience of going with five nursing students, another faculty, and five physical therapy students to Nicaragua for a 2-week study abroad course. Despite initial discouragement by relatives, friends, and other colleagues, she decided to go, reported on a successful trip, and is planning for another trip with students. Christoffersen (2008) stated she was assuming responsibility for a study abroad program that had already been developed by another member of the nursing faculty.
The literature supports valid reasons for a study abroad opportunity to be made available to nursing students. Students and accompanying faculty, who are able to look outside their own comfort zones, grow personally and professionally (Bosworth et al., 2006; Christoffersen, 2008; Glass, 2006). Students are challenged by new ideas and possibilities and begin thinking beyond what they already know as the usual (Greatrex-White, 2007; Tabi & Mukherjee, 2003). Students develop personal maturity, thus their attitudes are affected and they become more sensitive to cultural differences, which enhances their intercultural competence (Bennett & Holtz, 2008; Hadis, 2005; Inglis et al., 1998; Johanson, 2006; Koskinen & Tossavainen, 2003; Ruddock & Turner, 2007; St. Clair & McKenry, 1999). Besides personal growth, participating students develop their professional identification as nurses (Walsh & DeJoseph, 2003). Each of these reasons, individually or corporately, can affect students’ personal and professional lives in the future (Evanson & Zust, 2006).
Although the literature reports on several study abroad approaches, little discussion of the process or items to be considered to make such an experience possible is available. This article provides guidance and direction to other faculty who may be interested in initiating a study abroad experience for their students but who lack experience in either the international health care arena or foreign travel.
The development of a study abroad clinical program for nursing students raises several questions simultaneously. These questions include:
- Should this experience be available for groups of students or for students going individually or in pairs?
- What type of facility would provide the best learning opportunities?
- What courses would fit this experience the best?
- Should a new course be developed?
- Where should students be advised to go?
Some of these questions can be answered best by the faculty interested in developing a study abroad program for nursing students. If there is a faculty member with prior international health care experience, the faculty could visit potential sites. If there is no faculty member with international travel or health care experience, then a preliminary trip is essential to evaluate safety, supportive cooperating agencies, acceptable clinical experiences, and communication at all of the planned sites. By making visits to the potential sites, additional issues such as transportation, lodging, and necessary supplies can be evaluated. The information obtained will prove invaluable for faculty making decisions about the feasibility of the project and participating in it.
Having the support of a local cooperating agency or facility in the host country also is useful. Many government, private, and mission hospitals welcome American students at their facilities. Some of these hospitals may have attached clinics in nearby villages, making the site ideal for community, public health, or health promotion nursing experiences. If the chosen site has an educational facility such as a school of nursing, a faculty member from the host school of nursing may serve as the contact person for the American faculty and students. Thus, when questions of procedure, schedules for potential experiences, or cultural events or practices arise, the contact person at the destination site can provide clarification.
Timing of the influx of American nursing students and faculty also must be considered if the host facility is a school of nursing. It would be inappropriate to compete with the local school of nursing for clinical site placements. Because different clinical experiences are necessary for different courses, it is advisable to rely on the knowledge of the local host facility to determine the best sites for clinical experience.
The availability of clinical experiences also assists in determining the size of the student group. If there is a hospital with several surrounding clinics, more students can be accommodated than if there is only one village clinic. Likewise, if there are living accommodations in local hostels, more students can be part of the group than if lodging must be found in the homes of local residents.
Regardless of whether students are given the option of participating in a study abroad clinical experience individually, in pairs, or in groups, the same issues need to be considered. Discussions need to be clear with host institutions about their role in assessing or grading students’ progress toward clinical objectives when the students’ own faculty members are not present. To this end, a memorandum of understanding or an agreement of cooperation with the host agency or facility usually is required. This document delineates the responsibilities of each party and will cover areas of faculty role, student responsibilities, and health and accident insurance. It also may cover the authority under which students may observe or provide patient care in that country. When the host institution’s understanding of their role differs from the students’ understanding, friction occurs, and the host institution may withdraw from the program, making that site unavailable to students in the future.
In addition, each organization or facility has its own set of policies, procedures, and regulations. These must be considered during the planning of any study abroad experience. The host organization has the right to expect their American guests to be compliant with their standards of dress, duty hours, or religious meetings (as would be the case at mission hospitals).
The faculty and the nursing school administration need to be involved in the development of a study abroad experience through their curriculum committee, faculty council, or both. If a current course is to be used for this experience, planners must address how objectives of the course can be met or whether a new course needs to be developed to facilitate the experience. Consideration also must be given to necessary preparation for the licensure examination in light of the study abroad experience. Most states have guidelines for student-to-faculty ratio, and these requirements must be factored into the planning as well.
Depending on the size of the group and number of courses being offered, faculty also may divide course responsibilities. With one faculty member for each clinical course, each functions as the clinical instructor for that course. Faculty supervise students’ clinical learning in much the same way they would in their home environment. Typically, they select appropriate clinical experiences, check medications, and review charting in either arena. The difference in the experience would be in the concentrated nature of the clinical time (i.e., 8-hour days, 5 days a week for the duration of the experience) in a study abroad course.
When planning a study abroad clinical experience for nursing students, the issues of cultural activities, excursions, and recreation are additional areas needing consideration as these give students insight into the lifestyles of patients who are seen in the clinics and hospital. Excursions and recreation time also are necessary to alleviate student and faculty fatigue. As Ruddock and Turner (2007) discovered, when students had time away from the host culture, they were able to “relax and make sense of what was going on around them” (p. 367).
Well in advance of the study abroad experience, students should be provided with an information packet about the site, time schedule, fees, regulations, and other items of interest. This information packet must clearly state policies and rules to be followed as well as explain the grading criteria for the course or courses offered. Well-informed and interested students then may fill out and sign an application form, which becomes a contract. Student applications should go to an appropriate committee for review. After being accepted, students would register for the course or courses and begin preparing for their study abroad experience.
Meetings prior to an experience should keep students informed about assignment preparation, transportation arrangements, and other issues or concerns that arise. Several books and other readings can be recommended to acquaint students with the country and customs they will encounter. Obtaining passports and necessary visas should be completed as soon as possible if students do not already have them. Students and faculty must have passports that are valid for at least 6 months after their trip ends.
The first consideration is for the safety of students and accompanying faculty. The history of the country as well as current political situations should be reviewed during planning and then again closer to the departure date. Current information on the stability of a country’s government, how local populations react to foreigners, crime rates, and major health concerns can be found by reading newspapers, by accessing the country’s Web site, and by accessing the U.S. State Department’s Web site ( http://www.cia.gov/library or http://www.travel.state.gov).
The health of the students must be prepared for along with basic physical safety. Students should have the immunizations regularly required by their school of nursing. Beyond that, students can be given information about the nearest travel clinic and receive any additional immunizations plus prescriptions for antimalarial medications as necessary. Students should carry their own preferred over-the-counter medications for headaches, minor discomforts, and gastrointestinal upsets. If students have specific allergies, they need to consult their primary care provider and carry any prescription medications they may need.
A first aid kit and other medicines for common ailments may be carried for the whole group of students, but other physical aspects also must be evaluated. For instance, are there health risks for the students such as potential exposure to malaria, HIV/AIDS, tuberculosis, or other communicable diseases such as hookworm? What is the rate of motor vehicle accidents? Is adequate health care available, or would evacuation be necessary?
As these questions are answered, the information provides guidance regarding the amount and type of health insurance coverage students and faculty need. Because of the high HIV/AIDS rate in some countries, it may be advisable to carry an HIV postexposure prophylactic kit for the group. Parts of the kit may be temperature sensitive, which must be planned for when making travel and transportation arrangements.
Students should be provided with instruction about the potable water of the area and the safest ways and places to eat should they want to eat in the community. The World Health Organization Web site has country-specific health information available ( http://www.who.int) as does the Centers for Disease Control and Prevention Web site ( http://www.cdc.gov).
Because the study abroad experience is a school-sponsored activity, all students may need to travel together accompanied by a faculty member. Arriving together in the host country means arrangements can be made for only one pick up from the airport. Students will also leave together, which decreases ground transportation concerns. In some countries, ground transportation can be quite challenging. Several areas need to be evaluated during planning including the distance and length of travel time from the airport to the clinical site, types of available ground transportation, and whether selected ground transportation accommodates all of the luggage. If the distance to the site is lengthy, then students may need hotel accommodations for their first night in the host country.
Luggage also can become an issue because Americans tend to travel with more luggage than many people from other countries. If the last flight is on a small aircraft, luggage for some may need to be collected 1 or 2 days after arrival. Planning early and being consistent in the information given to students facilitates a smoother operation.
Another important area of concern during planning is the means of communication on several levels. One concern regards possible language barriers with local residents. Is English one of the languages of the host country? Will students be able to communicate with clinical and hospital staff and with patients, or will interpreters be needed? Do enough of the students speak the local language?
The second communication issue is how students can contact and communicate with their families during their time abroad. What is the availability of telephone or Internet services for students and instructors? The sooner students are able to contact their families to let them know they arrived safely, the quicker the level of anxiety will decrease in the students. A satellite phone may be the answer in some situations; however, students may buy a local cell phone or use phone cards for overseas calls.
A third communication issue is that the home or sponsoring school of nursing also may need the ability to communicate with students and faculty who are on a study abroad clinical experience, especially for emergencies. This provision often can be made through the host facility’s Internet access, by phone, or by local fax numbers.
Another consideration is supplies or items that may be taken for granted. Plans must be made for daily living, such as hand soap, towels, toilet paper, drinking water, and laundry. In many areas of the world, there are no laundromats, and clothes are washed by hand. Sometimes students will need to wash their own clothes, and sometimes villagers can be hired to do the laundry. If the host organization does not have cafeteria facilities, meal preparation and clean up also need to be planned. Again, it may be possible to hire people from the village for this activity.
Students who are not experienced international travelers often need assistance with luggage to keep within the airlines’ weight limits, best bag identification methods to use, and currency exchange. A suggested packing list that includes the type of clothing necessary and appropriate for their trip will help students. Several companies that specialize in travel clothing can be accessed online (e.g., http://www.travelsmith.com and http://www.llbean.com). In many places around the world, automated teller machines, or ATMs, are available, making standing in line for hours to cash traveler’s checks or to convert U.S. dollars unnecessary. Because students usually want to take home souvenirs from the local area, they also need information about bargaining and its appropriateness.
When providing a study abroad clinical experience for students, plans must be made for nonclinical cultural experiences and souvenir shopping. Expenses for these cultural experiences and excursions must be considered in the planning so that all students are able to participate in them. This down time is also necessary for reflection, relaxation, and reevaluating coping skills.
Although nursing students may be encouraged to make friends in the host country, only group activities might be considered. Students sometimes need to be reminded that personal and social boundaries are in place for their safety.
When the ideas of providing a study abroad clinical experience for senior nursing students first began to germinate, the possibility was discussed with the dean at the school of nursing, and then a trip was planned to several potential sites. Because the author had lived in Africa for several years, several sites in Africa were explored. At one site, the hospital management was discouraging and not able to envision what nursing students from the United States could do, especially since the nursing school at the time was in the process of multiple faculty changes. At the second site, the nursing school director was enthusiastic about American nursing students being on her campus and stated her school had already hosted several European nursing students individually or in pairs but not in larger groups. She saw great possibilities for the American students and for her own school. A third site was in a country with several internal political problems that had the possibility of affecting the safety of students and faculty. A fourth site that would have provided wonderful experiences for nursing students was located in a remote part of the country and would require a 12 to 14 hour bus ride from the airport.
The findings were reported to the dean, and proposed courses and a time frame for the study abroad clinical experience were presented. It became apparent that both the curriculum committee and faculty council would need to be involved in the decision making process. The curriculum committee reviewed the Public Health Nursing course and the Practice Elective course, both proposed for this experience, to assure that objectives could be met satisfactorily and then gave approval. The faculty council then approved the recommendations from the curriculum committee and determined the criteria and selection process for students.
The site chosen for the study abroad clinical experience was in Botswana, and the village chosen had both a hospital and a school of nursing on the same compound, as well as several clinics in the village operated by the rural health administration. The hospital and school of nursing administrators were supportive of having American students at their facilities. We were also careful to select our time for this experience (mid-June through mid-July) when many of the host agency’s students would be out of school or on affiliation (i.e., not on campus), so we would not be competing for clinical experiences with the local nursing students. In addition, we would be able to use their student housing and cafeteria facilities, thus making our stay an economically viable venture.
Six years ago, after thorough planning, a study abroad option was introduced to senior nursing students at Loma Linda University School of Nursing and is still continuing. The option encourages senior nursing students to apply for an intensive study abroad cross-cultural experience for the clinical portion of their Public Health Nursing course or for their Practice Elective course, which is primarily a clinical experience. Students are required to fulfill a minimum of 120 hours of clinical experience for either course (equivalent to 3 weeks of full-time experience). To date, almost 100 students have chosen to participate in this alternative clinical experience during their senior year.
At the beginning of the academic year, information packets are provided to interested students. The packet describes Botswana, the village of Kanye, and the local hospital and school of nursing, and it includes time schedules, fees (students pay their own airfare, but other expenses, such as room and board, are covered by tuition), regulations, and other items of interest. Policies and rules that must be followed are clearly stated and are especially important because the host facility is a church-sponsored mission hospital. Interested students then fill out and sign an application form, which becomes a contract and those applications are taken to the academic review committee for student selection. This process helps to minimize potential faculty bias for or against any particular student.
Our state board of registered nurses and the school of nursing requires a ratio of 1 faculty member for every 10 to 12 students during the senior year. Therefore, if there are more than 12 students who have been approved to participate in the study abroad experience, 2 faculty members accompany the students.
We have a general agreement of cooperation with the host school of nursing. Under this agreement, the host school of nursing takes responsibility to present to their country’s midwifery and nursing council the necessary documentation in the form of curriculum vitas for our faculty members and academic standing of our students. These documents plus the picture page of each person’s passport are collected and either faxed or posted to the host school of nursing. Our students then are allowed the same types of clinical experience as their students because they are under the auspices of the host school. The host school requested that our students wear white uniforms as their students do; however, a compromise was reached which allows our students to wear their own light blue uniforms and identification badges.
Because these nursing students are going to Botswana, they are encouraged to read The No. 1 Ladies’ Detective Agency. This book and series by Alexander McCall Smith gives a flavor of the culture and the importance of cattle, land, and “bush tea” in the lives of the people.
The participating students are required to present themselves to the travel clinic, part of the university’s student health center, to receive any additional immunizations and a prescription for antimalarial prophylaxes. Any other medications for this group as a whole or a first aid kit are not carried as the students stay on a compound that contains a hospital. The host school of nursing to which they will be affiliated has a family practice physician as part of their nurse practitioner faculty, who is readily available if any medical needs arise.
Bottled water is readily available at either of the two local grocery stores in the village, and a pot of boiled water was always available to make “bush tea” so the students feel free to participate in that part of the local culture. Meals for the students are provided in the campus cafeteria; however, they also are given recommendations about food choices when eating off campus. Most of the students choose to eat in the village several times during their month’s stay in Kanye.
Because Botswana has postexposure prophylactic medicine readily available for post HIV exposure, we do not carry a postexposure kit with us for our student group. We have had two incidences of HIV exposure, and the postexposure prophylactic medicine was available within the hour. Subsequent testing of the students on return to the United States and for the year following indicated that their HIV status had not changed.
Thus far, two thirds of the students who have chosen this study abroad experience do it to fulfill the clinical requirement for their Public Health Nursing course. Because the students complete the theory portion of their course on campus during spring term, they need 120 clinical hours for the Public Health Nursing clinical portion. The students are held to the same clinical evaluation tool during this study abroad experience as they would be in their own home-based clinical setting.
One of the main differences in the experience is in the way data are collected for their community project. Much of the information needed during the community assessment portion of the project is not available through the Internet, nor does the local health authority have a Web site to make such information available. Therefore, the students do many personal interviews with key informants of the village. The whole trip is planned to last for 1 month, thus accommodating jet lag and recreation time.
Students registered for the Practice Elective course are guided by their faculty in writing their own learning objectives prior to leaving the United States. Most participate in hospital-based experiences, and because they are fulfilling their own objectives, they select, with the guidance of their clinical instructor, the place and schedule of that clinical experience. For example, if students are interested in maternal-child health nursing, they will select the labor-delivery and pediatric wards for clinical placement.
Students for both courses have clinical assignments that are related to and that meet the objectives for their courses. Courses in health promotion and maternal-child health also would be appropriate for a study abroad clinical experience.
Over time, we have learned that the rural health administration clinics can accommodate 12 students for Public Health Nursing, and the hospital can accommodate 10 to 12 students for their Practice Elective course. To date, we have taken groups as large as 21 students, but generally, we have set 20 students as our cutoff number.
We use a travel agent who often does work for the university and can bill the university directly. The air-fare cost is applied to the students’ accounts, thus eliminating the need for students to come up with cash. The travel agent usually is able to acquire group airfare rates, and when that is not possible, students still all travel together, making the experience more comfortable for those who may have little international travel experience.
The village of Kanye, Botswana is a 1.5-hour drive from the airport, so multiple trips are costly and time consuming. We instruct our students to take only one checked piece of luggage and one carry-on, with an extra folded up bag to accommodate souvenirs when returning home. Luggage for the group must be easily identifiable, especially as it may become separated from the group. Students and faculty are supplied with the same color identifier, which makes luggage pick up 1 or 2 days later much easier.
The official language of Botswana is English, which is taught from the third grade onward, so anyone who has had some schooling is able to communicate in at least simple English. Many of the older generation were unable to attend school, and in these cases, an interpreter is needed. Clinic and staff nurses usually have been happy to assist the students in this area. The majority of our students who have gone to Botswana also have been eager to learn words and phrases in the local language, and the Botswanans have been just as eager to help them learn.
Several students have gone together and purchased a local cell phone and phone cards. This has been successful as many students have children or parents at home, and to hear the voices of loved ones is reassuring. Even though an international outgoing call is expensive, there is no cost to an incoming call on the local cell phone.
Our school of nursing has the telephone and fax number of the local school of nursing where we stay. We also can be reached by e-mail available on campus and at the local Internet cafe. Our nursing school also has the e-mail address of at least one family member of each student who is in the group, thus enabling the school immediate contact with family members should the need arise.
When our students arrive in Botswana, faculty meet them at the airport and provide each student with bottled water, a packet of tissues (toilet paper is not provided in most public restrooms), and approximately $20 in local currency. Students are advised to take hand sanitizing lotion with them in their carry-on luggage and keep it in their pockets as handwashing facilities are sometimes nonexistent.
During the 6 years of taking students overseas on these specially designed courses, we have learned how important it is to frequently repeat the purpose of the trip and learning experience. Our students become aware of the limited supplies in their clinical areas and often suggest that we all should have planned to bring supplies for the clinics. They need to be reminded that managing and providing supplies for the clinics is not our mission or purpose; however, because our cooperating agency is a local school of nursing, we generally bring nursing books and journals for its library.
We usually take in local cultural events during these study abroad experiences. For example, in Botswana, local concerns, such as marriages and petty crimes, are managed by the village chief or his deputy. These issues are attended to at the weekly Kgotla, a type of outdoor council meeting. The nursing students often are able to observe these proceedings, and the chief has been available for students’ questions at the end of Kgotla.
For another cultural experience in southern Botswana, we arrange for students to have a lesson in pot making with a local potter. Pottery is a major craft in this region, and we schedule this activity on a local holiday when clinics are closed. Students and instructors are all able to make something from local clay, and the items then are fired in the traditional method. Pot making is followed by a picnic and walk to a small dam, one of three water sources for the village. This day also gives students an opportunity to see more of village life and observe how domestic animals are managed in and near the village.
Students and their families at home are always interested in the variety of local crafts from an area. Time and transportation are made available so that students, in small groups of four to five, can visit several local handicraft workshops and souvenir vendors. Not only do the students and their families enjoy the handicrafts and souvenirs, but these students also make a positive contribution to the local economy through their purchases.
Two of Botswana’s neighbors share one of the wonders of the world, Victoria Falls. Most students have either heard of the falls or read about Dr. David Livingston, the first European to see the falls, and are eager to visit the falls. Victoria Falls are difficult to get to from southern Botswana, and students experience some of the transportation difficulties that are common outside the United States.
Botswana is in the heart of the southern African area and as such has and is surrounded by a number of game parks. Each year the students are able to spend one long weekend at a nearby game park. This mini-safari has been a relaxing time, much enjoyed by students and faculty alike.
Students who have participated in our study abroad program recognized they were looking at another culture through their own cultural lenses. They also discovered they could apply principles of basic safety, health care, and the nursing process in different circumstances. Students discovered an increase of their own strengths and skills, and the knowledge that humans, no matter where they live, do have basic similarities. For many, their world view changed, and for some, their plans for the future also changed to include the potential of working in a country other than the United States. One student described this well when she said, “In these clinics, if there were no nurses, there would be no health care.”
The students will not forget their study abroad experience, and it will provide a constant reminder as they continue both their personal and professional development. Several of the former students have asked if they could be considered as clinical instructors and go with the next group of students. A couple of student participants also have changed their career plans and have gone to serve in a majority country for a year or more before continuing with their careers at home.
Another outgrowth of this continued study abroad experience to the same village and school of nursing has been an invitation from that school to Loma Linda University School of Nursing to provide a curriculum consultant for the development of a baccalaureate of nursing completion program in Botswana. The faculty chosen to respond to this request was one who had curriculum experience and had accompanied every group of students to this site since the inception of this study abroad experience.
Nursing educators still wonder about the long-term impact that a study abroad program has on nursing students because little longitudinal research has been conducted. However, Hadis (2005) has reported that in other disciplines, college students “acquire global-mindedness, grow intellectually, and develop personally” (p. 57) during such a program. He also stated that when no such gains are found, it is usually because the sample size was too small. One might assume that nursing students have commonalities with the general college student population; however, the long-term effect of such a study abroad program on the professional or career development of nursing students needs to be explored further.
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