Community-based service-learning has been used as a strategy to advance professional skills and community accountability in various health care educational programs, including nursing, medicine, pharmacy, dental hygiene, physician assistant, and dentistry programs in the United States and Canada (Dharamsi et al., 2010; Hunt, 2007). In recent years, academic service-learning (ASL) has been implemented in various nursing curricula as a sustainable way to facilitate students’ interpersonal, academic, and leadership skills and to increase awareness of diverse cultural issues (Hamner, Wilder, & Byrd, 2007). ASL is an active learning strategy for baccalaureate nursing students, fulfilling each component of scholarship: liberal education, professional values (including caring, altruism, autonomy, human dignity, integrity, and social justice), core competencies, core knowledge, and role development (American Association of Colleges of Nursing, 2008).
ASL involves active teaching and learning, by which students serve a community-based need through hands-on activities. According to the National Service-Learning Clearinghouse (NSLC, 2011), this experiential learning integrates meaningful community service with instruction and reflection to enrich the learning experience, teach civic responsibility, and strengthen communities. It brings educational goals and community service into equal partnership (Hood, 2009). Evidence-based practice proposes that ASL supplements traditional pedagogical methods to promote motivation and community service exposure (NSLC, 2011). ASL is one of the most popular types of community immersions. It is a combination of classroom concepts, student reflection, and hands-on experiential learning. It is designed to be a rewarding experience for students, faculty, and the served community. Students involved in ASL become aware of responsibilities within the community while learning about their health profession (Loewenson & Hunt, 2011).
Looking ahead, ASL will continue to play an imperative role in nursing education (Loewenson & Hunt, 2011) in the age of the global economy. Globalization has created the need for leaders to become competent in cross-cultural awareness and practice. Global leaders need to develop communication competencies that will enable them to articulate and implement their vision in a diverse workplace (Northhouse, 2010). ASL can play a crucial role in the development of global leaders.
The idea for the current ASL project emerged from a Teaching Learning Collaborative Conference in which the authors participated. This conference provided inspiration to create an ASL project involving an oral health component for the Volunteer Morocco Organization (VMO). The VMO had a well-established interdisciplinary team in Morocco that included health professionals and supervisors facilitating transportation, governmental regulatory compliance, and health profession student supervision. The authors sent health professions students on a volunteer ASL trip to serve underserved rural, urban, and isolated communities in Morocco. Organization members who spoke the Moroccan languages and had cultural familiarity accompanied the students throughout the project. This has been the third year of the Volunteer Morocco program.
This article describes lessons learned from the experiences of health professions students throughout their ASL project in Morocco.
Sample and Setting
Nine health professions students (one dental hygiene and eight nursing students) from a private college and a private university in the northeastern United States volunteered to participate in this project. The participants were recruited by e-mail invitation. Their ages ranged from 20 to 25 years. Six were White, two were Hispanic, and one self-identified as Caucasian/Asian. Eight of the students were female and one was male. The majority were of middle socioeconomic class, able to fully fund their trip to Morocco. Participants were informed of their right to withdraw at any time, and all nine signed an informed consent.
Data Collection and Analysis
After obtaining institutional review board approval, the authors used semi-structured, open-ended individual interviews to gather data. Each interview lasted approximately 1 hour. Participants were interviewed until no new data emerged, which was considered the saturation point. Interviews were recorded and transcribed verbatim to establish descriptive validity and to generate inductive and deductive codes constituting major themes of data analysis.
The NVIVO 8© software was used to determine the frequency of applied codes. The authors compared codes and themes to establish interpretive validity. Codes and themes were originally determined independently by the authors and applied to the data afterwards. Qualitative content analysis was used to identify relevant themes. The authors compared the applied codes to establish intrarater reliability, with 95% agreement. Theoretical validity was established by comparing themes emerging from interview data. To protect participant confidentiality, the authors used study codes and numbers on data documents instead of recording identifying information. Moreover, a separate document linking study codes to participants’ identifying information was secured in a separate location that was accessible only to the primary investigators.
The authors led peer training of nursing and dental hygiene students in basic oral care and education. The students assumed the role of experts in their health profession during cross-training. The dental hygiene student trained the nursing students on proper dental care, and the nursing students trained the dental hygiene student on nursing psychomotor skills, such as wound cleaning and dressing and checking blood glucose level. The students applied this training in Moroccan oral health clinics. Oral health aids acquired by the authors from oral care companies (brushes, floss, toothpaste, and fluoride varnish) were donated, and care was being provided to underserved health clinics, hospitals, and orphanages. In interviews, the authors asked participants to reflect on their trip upon their return home; the results of that qualitative study have been published elsewhere (Puri, Kaddoura, & Dominick, 2013). The current article focuses on lessons learned from the Morocco trip.
The volunteers spent 2 weeks in rural villages (Riad Imsouane, Ighil, and Fem lahsen Palm Trees Village) and cities (Marrakesh and Essaouira). The Moroccan people speak Arabic, French, Berber, and Spanish, necessitating the use of translators. Participants (a) assisted licensed providers in organizing health and oral clinics and provided services such as blood pressure monitoring, blood glucose reading, assisting with logistics and planning, and helping villagers with farming, tilling, and tree planting; (b) provided fluoride treatments and oral and dental education in schools; (c) volunteered at the city hospital (Hassan II); and (d) took care of children in the orphanage. The students immersed themselves in the Moroccan culture by enjoying the Jamelfena square, which is famous for its music, folklore, story tellers, snake charmers, and acrobats, and they mountain biked, hiked, planted trees, organized a regional 5 K race, and spent time shopping at markets.
In general, participants perceived that the Volunteer Morocco ASL improved the self-sustainability of underprivileged communities and their members in Morocco by improving health care access, education, and farming technologies. Lessons for ASL are summarized below.
Lesson 1: ASL Programs Need Support by Higher Administration and Large Donors to Improve Care for Underserved Populations
On the basis of the student experiences, the authors learned that ASL needs to be supported by higher administration via academic credit and scholarship. The authors recommend developing concentrated ASL programs with course modules for academic credit. Consistent with Boland’s (2010) emphasis, the authors suggest incorporating ASL in community health or leadership capstone courses. It is important for university program directors, deans, and provost offices to promote well-targeted ASL programs. To provide credibility and viability, financial scholarships to support students and faculty should be established. In addition, donations should be sought for medical supplies and pharmaceutical items.
Although a small organization with a local model dependent on small donations and volunteers can make a positive local difference, addressing large public health issues requires large-scale, year-round support from big donors—for example, foundations and institutions such as the World Health Organization (WHO). This model would enable an expansion of the benefits contributed locally by the Volunteer Morocco project to tackle problems in communities nationwide.
Lesson 2: Constructing a Wide-Ranging Interprofessional ASL Program to Promote Multidisciplinary Teamwork and Global Leadership Skills
Participants perceived ASL as a learning experience that contributed to their heightened ability to value collaboration among health professionals, negotiate with others, appreciate cultural differences, leverage experience, and apply critical thinking on a daily basis. Opportunities to work in interdisciplinary teams enhanced partnership, communication skills, and collaboration with other health care professionals. Students interacting with professionals from various disciplines reported greater appreciation of other disciplines as partnerships were established with physicians, nurses, dentists, pharmacists, teachers, and other teams in Morocco. Interprofessional pretrip training was a foundation for later interprofessional practice and collaboration.
The authors recommend that ASL trip planning includes a multidisciplinary team from pharmacy, physician assistant, physical therapy, dental hygiene, nursing, and nurse practitioner programs. This provides an opportunity for cross-training for dental hygiene students in basic care. The ASL program demonstrated that such programs can positively enhance the leadership skills needed in a globalized world economy. Students grew as emergent global leaders as they applied leadership skills in their specialized training workshops prior to and during their trip. For example, the dental hygiene student led the dental hygiene workshop with support from the team leader, who was not a trained hygienist. The authors recommend that nursing, dental hygiene, and other academic health professions programs establish a global leadership initiative. Part of the initiative can foster mentorship to ensure that students develop the skills they need to become global leaders (Northhouse, 2010).
Lesson 3: Training Students on Cultural Nuances to Promote Cultural Competency
Participants expressed culture shock due to differences in language and customs. Getting through the language barrier was difficult for the participants. The participants tried to learn simple words, such as “thank you” and “hello,” in different languages. When translators were unavailable, students communicated with clients through gestures, whenever possible. On the basis of the students’ intercultural experiences, the authors recommend that training involve simulations using participant stories to prepare cultural scenarios and develop seminars.
Lesson 4: Integrating Ethics-Based Educational Modules in Nursing and Dental Hygiene Curricula
Participants faced eye-opening ethical issues in patient care. For example, corruption involving payoffs to hospital guards and even doctors were reported. One student described the ethics of limited resources:
I served one day in the neonatal intensive care unit (NICU). There were 40 babies and each one lined up diagonally; usually it is one baby per isolate. But they had four babies in each isolate; so they didn’t have ventilators for them. They had probably one cardiac machine that was monitoring the baby’s heart rate and everything. Thus, they have an average of 5 to 6 deaths per day in the NICU. That was a great ethical issue; it was hard to observe infants dying due to lack of care.
When student experiences were considered, the authors recognized the need to integrate ethics-based educational modules in the nursing and dental hygiene curricula taken prior to ASL trips.
Implications and Conclusion
ASL is an essential component of health professions education. Participants perceived that international ASL provided them with lessons in access to care, practice, interdisciplinary teamwork, communication, ethical awareness, leadership, and cultural sensitivity. With the growing stress on ASL, the lessons learned from this article will assist those who are interested in adopting ASL.
It is vital that nursing and other health professions administrators and educators think judiciously about the courses in which ASL is most appropriate and those in which it can most efficiently facilitate students’ service-learning and professional development. International ASL motivated students to return to Morocco or serve in other countries.
Lessons learned from participant experiences include the need for sustainable support at the administrative level, promotion of multidisciplinary teams using cross-training, global leadership initiatives with mentoring, the development of cultural sensitivity training via simulations using participant stories, and the integration of ethics-based educational modules in the nursing and dental hygiene curricula. Such initiatives and ASL programs will provide students with the tools, experiences, and perspectives to graduate and make a difference locally, nationally, and globally.
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