A popular trend in nursing education over the past decade has been to offer international learning experiences to students in prelicensure nursing programs. Research has shown the importance of offering global educational opportunities to nursing students as they facilitate meeting goals such as development of cultural competency, global citizenship, and personal and professional growth (Dalmida et al., 2016; Tippen, 2016). However, two main drawbacks to offering such programs are the time and resource intensiveness in the development and sustainability of the program (Visovsky, McGhee, Jordan, Dominic, & Morrison-Beedy, 2016). Although nursing education recognizes the importance of offering international educational experiences, the challenge to meet the needs of the students, host communities, program, and administration continue to exist. This article describes innovative strategies to capitalize on the rich educational opportunities by applying required credit hours to the international clinical placements and by creating similar experiences across programs that align with traditional clinical rotations.
Applying Clinical Credit
In 2009, our university's nursing program embarked on their first international short-term clinical experience. The 1-week program was focused on delivering free primary care to impoverished communities in Kingston, Jamaica, by partnering with a local charity. All team members—which comprised U.S. physicians, nurse practitioners, nurses, and nursing students— volunteered to serve the community. The following year, a second location in rural Guatemala was vetted to offer students more opportunity to participate in international clinical experiences. A typical team consists of 20 students and three faculty members, in addition to interprofessional team members serving as preceptors when appropriate. The teams set up free-standing clinics that assess and treat patients, provide education, administer medications, and make referrals to local providers. The same communities are served each time the team travels, with the difference being the students who participate.
Faculty participating in the initial programs observed that the global clinical experiences were similar in richness with those clinical rotations held stateside related to patient care and interactions with health care team members. As the challenge of finding rich clinical rotations for nursing students persisted in the United States, the faculty determined that these programs offered similar opportunities for learning. The initial step included reviewing courses with clinical components, which have specified credit hours allocated to clinical practice for similarities. The faculty predetermined the number of clinical hours that can be met in the global setting for each specified course. For example, a typical 1-week international placement would award 45 hours of clinical practice, using the ratio of 9-hour days for 5 days. Only direct patient care hours are applied for clinical credit. This excludes cultural experiences, reflection journals, and debriefings that enhance professional and personal development in a different capacity.
Select courses are able to achieve the total number of required clinical hours, replacing the need for stateside clinical experiences entirely. Meanwhile, other courses may fulfill a portion of the required clinical hours, which reduces the number of hours needed in a stateside clinical group. In such instances at the beginning of the semester, students receive a clinical schedule that rotates them in the stateside clinical group for a reduced number of required hours, therefore capitalizing on the number of students in one clinical group at any given time. To maximize the hours applied to the international clinical placement, clinical specialties are combined to one international clinical placement, depending on course offerings for the semester. An example is the combination of pediatric and adult care nursing clinical hours applied to one international placement. The faculty leading the clinical placement create a schedule that rotates students though a variety of clinical areas, optimizing the student's learning in the dual specialties. Students are awarded course-specific clinical credit based on the number of hours spent in each defined specialty area. Students are evaluated on their performance specific to the identified course objectives. Faculty with the expertise in the specific specialty work directly with the students in that area to evaluate their clinical performance along with other interprofessional team members. The nursing specialty courses used are pediatrics, maternity, adult medical–surgical, and public health.
Furthermore, the faculty embedded the experiences into all facets of the baccalaureate curriculum, linking to course and clinical objectives, assignments, and evaluations in order to apply clinical credit to such placements. Two written assignments used in these placements are care plans and reflective journals. The care plan analyzes the difference between local resources to U.S. resources, including access to health care. The second assignment is reflective journaling with guided questions to prompt students to make connections linked to cultural variations. To ensure that students are achieving the course objectives, two types of evaluation methods are used: formative and summative. Students are evaluated using a daily formative evaluation culminating in a summative evaluation on completion of all course-related clinical hours. Formative evaluations are derived from the clinical evaluation tools for the course linked to the clinical credit being applied and includes the principles of communication, safety, leadership, and clinical judgement. Objectives related to the specialty of the course are also evaluated. Examples for the pediatric rotation include completing comprehensive physical and developmental assessments and anthropometric measurements and interpretations. Students in the adult nursing rotation complete focused assessments, triage, and perform point-of-care testing and other interventions such as dressing changes. In the women's health rotation, students perform pre- and postnatal assessments, lactation education, and assist with internal examinations related to a variety of symptoms. All students prepare and administer medications, as well as provide education for medications and other discharge instructions. The formative evaluations are completed daily for each student by the supervising faculty in collaboration with the other health care team members. Feedback is provided to students to tailor goals and identify areas of improvement.
Summative evaluations are used to ensure that students have met the clinical objectives for the linked course by the end of the immersion period. Data from the formative evaluations, clinical assignments, and journaling are compiled for the summative evaluation and delivered by the lead faculty. Summative evaluations are part of the final clinical evaluation for the course linked to the experience, and clinical credit is applied as pass or fail. Clinical experience is one component of the final course grade.
Creating Similar Experiences Across Countries
Creating experiences that are connected to the program's student learning outcomes, as well as aligned across international placements, is important for consistency. The underpinnings that are maintained to ensure consistency between the experiences include (a) participants in the international clinical placements adhere to the same standards and scope of practice of an RN in the state of the prelicensure program, (b) the provision of care is based on current evidence-based practice that may be adapted for cultural variations, (c) the faculty-to-student ratio is the same according to the accrediting body standards, and (d) students are assessed using the same clinical evaluation tool as the stateside clinical rotation applying the clinical credit.
Furthermore, ensuring that all international clinical placements are aligned requires a conscious, thoughtful, and ongoing discussion among participating faculty. Procedures for program orientation, clinic set up, daily debriefing, assignments, and posttravel debriefing were designed collaboratively to ensure that the experiences were able to meet the course and clinical objectives. Standardized application and acceptance procedures along with consistency of faculty coordinators further helped to ensure fidelity of the two experiences. A unique feature is the requirement for students to participate in two pretravel orientations. The first session provides an overview of the country while emphasizing important cultural aspects. The second orientation is a clinical simulation that allows students to become familiar with the medical equipment, procedures, and processes that are anticipated in the daily clinics during the clinical placement during which a patient scenario is provided. This scenario requires every individual to walk through the patient experience, beginning with triage and ending with educational teaching. The simulation orientation allows students to function better during the 1-week placement and ensure consistency in clinical experiences.
An additional step in offering successful international clinical placement is to design clear program learning outcomes (Browne & Fetherston, 2018). Because these experiences serve as a method to assist students in developing global citizenship, a set of global program outcomes were developed (Dalmida et al, 2016). The international clinical placements should meet the needs of both the students and the communities; therefore, the evaluation focuses on the ability of the students to meet the needs of the community, as well as their own. The baccalaureate outcomes are centered on cultural sensitivity, professionalism, collaboration, communication, and improvement of the health of the communities. The faculty evaluate student success of these outcomes through interactions with patients and team members, debriefings, and reflective journal entries.
Finally, an important element to all clinical placements is to learn and practice collaboratively in an interprofessional setting (American Association of Colleges of Nursing, 2008). Our program purposely designed a collaborative practice environment by using an interprofessional health care team to deliver direct care, as well as mentor students about the evaluation and management of the individual patient and health promotion for the community. The interprofessional team is an authentic representation of health care delivery systems, providing an opportunity for nursing students to participate in the team-based care through communication and collaboration in practice. The team members consist of physicians, nurse practitioners, nurses, and other health care professional programs, including physician assistants, physical therapy, and occupational therapy. The caveat of the interprofessional team that is required for sustainability of the program is for the providers to enjoy teaching the student as much as providing clinical care to the impoverished communities. Learning is enhanced with nightly debriefing meetings with the entire team to stimulate thoughtful reflection and professional growth.
Implications for Nursing Faculty
The challenge for finding clinical experiences for nursing students persist in the United States. The described innovative strategies of the international clinical placements have been successful in meeting student, program, and community needs. Although the cost of the program is prohibitive for some students, as it costs an additional $1,500 in addition to the tuition, student and faculty feedback have been overwhelmingly positive with their experiences and no differences were noted in their clinical evaluations with the stateside students. By integrating the available experiences into the curriculum, maximizing credit hours applied, and creating meaningful assignments the international experiences fulfill clinical placements and develop the students' personal and professional goals. Furthermore, to ensure consistency with standards and procedures across programs and accrediting bodies, establishing policies and procedures, communicating amongst faculty leads, and recognizing cultural and geographic differences are warranted to implement sustainable international clinical placements.
- American Association of Colleges of Nursing. (2008). The essentials of baccalaureateeducation for professional nursing practice. Retrieved from https://www.aacnnursing.org/Education-Resources/Tool-Kits/Baccalaureate-Essentials-Tool-Kit
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