Due to an increase in globalization, migration, international travel, and exposure through the Internet, even if one never leaves his or her home country or city, all providers must possess a global perspective on health and nursing. As global issues become more relevant at a local level, the American Association of Colleges of Nursing (2008, 2011) explicitly recognizes the importance of training nurses at the baccalaureate and master's degree levels who possess the competencies to work in multicultural settings. Global health competencies can include social justice, human rights, cultural competency, communication, collaborative partnerships, assessment and management skills, environmental factors, global burden of disease, epidemiology, ethics, professionalism, social determinants of health, health systems delivery, travel and migration, key players, global health research, health promotion and prevention, and professionalism (Clark, Raffray, Hendricks, & Gagnon, 2016).
Concurrently, students express strong interest in having global experiences. Many nursing students have traveled, studied, or worked abroad prior to coming into nursing school and express a keen desire to have an international experience integrated into their nursing education (Kulbok, Mitchell, Glick, & Greiner, 2012). Students' motivation is multifactorial and ranges from a beneficent desire to make a difference to a desire to engage deeply out of a sense of social justice (Burgess, Reimer-Kirkham, & Astle, 2014). These programs can have a profound impact on students both personally and professionally, including helping them to develop an enhanced awareness of or sensitivity to cultural differences and skills necessary to cope with them in one's nursing practice (Kelleher, 2013). Short-term immersion programs can help build the students' sense of competency in the provision of multicultural care. They can also expand students' awareness of and knowledge about interactions with those from a different culture (Smith-Miller, Leak, Harlan, Dieckmann, & Sherwood, 2010). Experiences in developing countries help students understand the effects of extreme poverty, call into question their own ethnocentrism, and force them to recognize disparities in the distribution of health care resources, all of which contribute to increased cultural competence or cultural humility (Maltby & Abrams, 2009). Global experiences in lower resource settings also help students recognize the resourcefulness of nurses who must meet their patients' needs with limited resources. They also express a more profound understanding of the impact of health disparities and emerge with a commitment to advancing social justice within their nursing practice (Dohrn et al., 2018).
International educational experiences can take several forms, including exchanges, in which faculty and students visit between institutions or countries, and service-learning, in which students provide clinical care typically in resource-limited settings. A major critique of exchange programs is that the exchange is often not reciprocal in nature; students or faculty from one institution travel to the other institution either to learn or to teach but rarely as an equal exchange (Kulbok et al., 2012). The goal of service-learning is to put theory into practice while meeting an identified need in the host community. The service-learning model is critiqued as these programs often lack the long-term relationships necessary to engage the community in identifying their needs to develop future empowerment, sustainability, or the continued learning of the students (Ryan-Krause, 2016). Additionally, they raise the ethical issues of the provision of care by students who could be considered to be gaining experience at the expense of people with few alternative choices for care; student actions must be in line with the scope of practice in their home country, as well as in line with the level of demonstrable competence they have achieved (Amerson, 2019; Levi, 2009).
The Partnership: Two Colleges of Nursing in the United States and India
In 2017, the University of Illinois at Chicago (UIC) College of Nursing's Global Health Leadership Office and Bel-Air College of Nursing instituted a cultural exchange that introduced reciprocity into an already existing relationship. In 2004, UIC College of Nursing and Bel-Air Hospital in Maharashtra, India began a partnership. Bel-Air Hospital, founded in 1912 to serve patients with tuberculosis, is an Indian Red Cross Society–affiliated hospital that specializes in providing care to HIV-positive individuals. Originally, UIC College of Nursing and the hospital partnered to develop the Bel-Air College of Nursing, which opened its doors in 2006. Subsequently, they collaborated to expand the educational offerings to include a master's degree in medical–surgical nursing with a subspecialty in HIV/AIDS care. UIC nursing faculty have traveled to India to support the development of the curriculum for both programs and the faculty's and graduate students' research activities. Faculty, administration, and students from Bel-Air College of Nursing College of Nursing visited UIC on several occasions. These trips provide opportunities for interactions with counterparts, as well as global learning experiences that increase the UIC faculty and students' global engagement (Global Health Leadership Office, n.d.a)
In August 2017, the first group of students from UIC visited Bel-Air Hospital and College of Nursing as part of a study abroad program that sought to make the exchange between the two institutions wholly reciprocal. The opportunity was made available to graduate-level students, both pre- and postlicensure, in good academic standing; two credit hours were offered. Three prelicensure and one postlicensure student signed up for the 2-week trip and were accompanied by a faculty member with substantial global health experience, primarily in humanitarian response and development programming. In addition to clinical observations at Bel-Air Hospital every morning, the UIC students were embedded with the nursing students from Bel-Air College. The students were housed in the undergraduate nursing dorm and ate all meals in the dining hall. The students and their Indian counterparts attended several class sessions taught by faculty from both institutions. They worked in small groups with the undergraduate nursing students to prepare and present on topics of global importance, such as substance abuse, nursing research, and essential medications. The students attended a rural community-based health brigade with the graduate students. They also went on field trips, celebrated Indian Independence Day, played volleyball, and watched television with the students. In addition, faculty led daily debriefing sessions in which assigned readings were reviewed and the experiences were processed.
Institutional and Program Mission and Goals
The GENE model suggests starting by ensuring that a global experience program aligns with the institution's mission, vision, and goals. UIC College of Nursing's vision explicitly states its commitment to global health: “Our vision is to be a preeminent leader in advancing global health and nursing” (UIC College of Nursing, n.d.). This vision is put into practice by integrating global health into the curricula through specific course offerings and into course objectives. Additionally, the Global Health Leadership Office “promotes an international approach…in the US and abroad…providing opportunities for nurses of all countries to improve the quality of nursing and healthcare” (Global Health Leadership Office, n.d.b). As noted above, a strategic objective of the GHLO is to achieve its vision by providing global opportunities for all students. The relationship between these institutions, including the student exchanges, clearly fits into the college's vision and strategic objectives.
Global Health Core Content
The GENE model identifies four areas of learning that are key to developing global engagement: global learning, international service-learning and social consciousness, global cultural competence development, and country-specific knowledge. Learning in these areas occur throughout the experience.
Global Learning. Riner (2011) defined global learning as including the knowledge, attitudes, and skills to work effectively in international settings, including an appreciation for other cultures and an ability to interact with people from another culture. The structure of this immersion experience fostered global learning. By learning, working, socializing, and living with the Bel-Air students, the UIC students definitively gained a greater appreciation for another culture and an ability to effectively engage with students from that culture. This sense is highlighted in an article the nursing students wrote for the Bel-Air College of Nursing's graduation book:
The students were very attentive and made us feel at home with them. We felt included in activities, like watching Dance Plus 3 in the BCON [Bel-Air College of Nursing] Hostel or when students taught us translation of words from Marathi to English. We were always welcomed guests in their home. The students speak of Bel-Air as a family and there wasn't a day when we didn't feel like sisters in this family. We were always made comfortable and safe when we were escorted to the wards or dinner. Each person here is so very generous making sure that we never went without masala tea and food.
The experience also helped them to see the differences in patient care or hospital management between the two settings as differences without needing to judge one as inferior to the other. One student commented:
We were introduced to their medications and supply cabinet, medical charting system, and ward space. I instantly thought, “What would a medical record system do to this type of hospital?” I also thought the open ward concept was really interesting. Patients were within close proximity to one another, which minimized patient privacy. However, in this setting it seems to work for the patients. They are overhearing other patients' prognosis and plans of care, which allow them to encourage one another.
International Service-Learning and Social Consciousness. Although service-learning is a key component of Riner's framework, as noted above, this program was an exchange program. When the Bel-Air College of Nursing administration invited the students to India, it was with the express purpose of a cultural exchange and not as a service-learning opportunity. The administration of Bel-Air was eager to demonstrate that non–U.S.–based facilities had much to offer students from the United States, especially in terms of effective approaches in low-resource settings. Despite clearly explaining the nature of the program as an exchange and not a service-learning program, students occasionally expressed frustration that they were not giving back. In collaboration with the Bel-Air administration, the UIC faculty continually reinforced the value of the exchange program. The very structure of the experience was designed to raise social consciousness and indeed achieved that goal. According to Riner (2011), social consciousness refers to awareness of social injustices and an ability to conceive of actions to address them. A nursing student commented:
We live with stigma every day, but seeing women shunned for contracting a disease from their husbands was just painful. We also saw many men seeking a hospital that would not make them feel guilty about their life choices. [The] hospital was definitely a safe space for these patients and you saw it in their demeanor during rounds. It was definitely a humbling experience that taught me to think outside of the “American savior” mentality. I went into this cultural exchange with many biases due to things I saw on television, newspapers, and social media. I definitely went in with the mentality of “I am going to do something for this hospital or help in some way.” However, in the end they taught me so much that will forever have an impact on my future practice.
Global Cultural Competence Development. Riner (2011) described global cultural competence as the process by which people develop greater understanding of others' beliefs, values, attitudes, and behaviors that may differ from what is familiar. By living and working together closely, both the Indian and American students were able to gain a deeper level of cultural competence. Currently, there is a focus on cultural humility, which is described as a lifelong process of self-reflection that builds knowledge and awareness of self and power dynamics that will foster the building of trusting and authentic relationships with others (Tervalon & Murray-Garcia, 1998). The UIC students demonstrably achieved some level of cultural humility. This growing cultural humility was expressed as recognition of the privilege the students have due to where they live. A nursing student stated:
I was definitely taken back by how welcoming everyone was. I know part of it was a cultural difference; we were their guests and they were going to do everything possible to make us feel welcomed. The other part of it was the students and staff were genuinely pure of heart and sweet. The students would not let us carry our own bags or walk by ourselves. It was overwhelming having the students standing outside waiting for our arrival. And after a while it became a little much for me; it felt overbearing and uncomfortable. Later on that night, I struggled to sleep—everything was unfamiliar to me. The beds, the showers, the lack of Internet service. I learned how dependent I am with my phone/social media/Internet in general. The students in Bel-Air were not allowed to have cell phones. I thought that was a little extreme on the part of the administration. I certainly felt sorry for them, but quickly noticed they were indifferent about it. I felt it was torture while they distracted themselves with crafts, dancing, and simple fun. I felt my privilege.
Another student said:
Before I left for India, I always imagined India as a mysterious and beautiful place filled with ancient art and religious images. Unfortunately, the trip from Mumbai to Bel-Air did not align with my preconceived ideas. The mysteriously beautiful India in my mind was replaced by the mournful view of hundreds of families living on the street, with tents made from wooden sticks and billboard canvas as their home. It is hard to imagine how individuals could possibly maintain basic hygiene when their water supply and sewage system are side-by-side and wide open in the air. There are so many things that we take for granted, like clean water, indoor plumbing, and stable electricity. This trip really puts into perspective how fortunate I am, not because of my own efforts, but simply because of the geographic location in which I was born.
Country-Specific Knowledge. The immersion experience helped steep the students in specific knowledge about India. The American students gained knowledge related to comprehensive HIV care in India through their clinical experience. In addition, readings about the health care system, Ministry of Health protocols, drug pricing and manufacturing, HIV care, HPV vaccination, and tuberculosis focused on India were assigned and discussed. Additionally, the Indian faculty prepared lectures covering some of these topics, as well as care for epileptic patients and pregnant woman in the Indian context. A nursing student commented:
This hospital was surrounded by nature everywhere. Beautiful trees, flowers, and animals painted the backdrop for the wards and the college. Later, we learned the layout was intentional. The students explained having birds chirping right outside a patient's window and flowers blooming along a walkway helps patients recover sooner. It was another a-ha moment for me. Something as simple as sunshine and flowers can motivate patients to get up and walk outside, which will ultimately lead to a quicker recovery. It was ingenious and refreshing to see.
Another student commented:
During clinical observation, my expectation of learning about India's nursing holistic approach was partially met. The traditional Indian medicine, Ayurveda medicine, was widely integrated in patients' pharmacologic and physiologic therapies. In the wards where we observed, almost every patient received an herbal supplement called Liv.52. The staff nurse told me that Liv.52 was prescribed for patients receiving antiretroviral therapy and anti-[tuberculosis] therapy because this herbal supplement has shown to be helpful in improving or maintaining patient's liver function.… Personally, I don't think I will ever feel comfortable giving my patients any herbal supplement without knowing the side effects or efficacy of it. In the future, I would like to see more Ayurveda practitioners acting as researchers to investigate the science behind this ancient practice so more and more patients can benefit from Ayurveda medicine.
Another student commented:
The first expectation that was exceeded was seeing the facilities during orientation of the campus. I did not expect the x-ray facility and lab facility to be so advanced. Perhaps this says more about my prejudices and less about their facilities. Like we discussed in our final debrief before departing back [to the United States], I am used to the stories of poverty of India and lack of resources. These facilities did not match that story and thus I gained a more nuanced perspective on the resources and facilities available in the Indian health system as well as clearer picture of what a middle resource country looks like.
The GENE model acknowledges that the individual characteristics of a learner have an effect on how that learner engages with, processes, and gains from learning opportunities. The UIC students notably self-selected to avail themselves of this inaugural exchange program in India. These students were interested in a global health experience, were willing and able to travel during one of their brief breaks between semesters, and could afford the costs associated with the travel. In expressing their interest in participating in the exchange program, students cited several motivations, including interest in the following: global health issues; learning more about India, its health care delivery system, and how its culture influences that system; learning more about HIV care; observing how to provide primary care to a marginalized population; and being exposed to new approaches to care giving.
Other learner characteristics included preferred methods of learning and modes of engaging with new materials. Although the students' motivations were shared with the Global Health Leadership Office as part of the application process, they were not originally shared with the faculty. Additionally, due to logistical challenges, the faculty and students did not meet prior to arriving at the airport. Thus, although recognizing that learning characteristics are distinct, specific learning characteristics were not identified prior to the trip. For example, it was not possible to be familiar with preferred methods of learning, modes of engaging with new materials, emotional or physical barriers, or the baseline of knowledge related to India or global health prior to the departure. Furthermore, although the individual characteristics of the learner are important to the experience that each student has, as well as to the collective experience of a group, it is not always possible to tailor the learning to each individual's learning characteristics, even in a small group. As the program was relatively short and with little free time or flexibility in the schedule, it was difficult to individualize the experience to meet the specific learner characteristics. Additionally, as Bel-Air considered us guests, the locus of control was with the hosts making substantial negotiation of the experience challenging. With better knowledge of the context and the experience offered by Bel-Air and with more effective planning prior to the trip focused on identifying individual learning characteristics, the faculty can better prepare students and negotiate learning to meet individual needs more effectively. Yet, the nature of a short immersion experience will necessarily limit customization.
The GENE model highlights the effort that the faculty must make to ensure that the program is effective throughout the planning and implementation process with a focus on pre-experience planning, on-site supervision, and post-experience debriefing and evaluation.
Pre-Experience Planning. Of all aspects of this exchange, the pre-experience planning was the weakest, according to student feedback and the faculty experience. There were several factors that contributed to a deficit in this component. The faculty identified to guide the student experience to India was out of the country with limited capacity to communicate for the 2 months prior to departure. A thorough orientation to the experience did not take place due to some scheduling challenges, as well as the absence of the faculty member. Although there was a meeting in which visa applications were filled out, there was a lack of review of both practical and academic considerations for the course.
Chronic communication challenges between UIC and Bel-Air was another factor in poor pre-experience planning. E-mails often are not received or go unanswered, and the time difference and erratic Internet in Bel-Air hinder real-time meetings between the institutions. It was originally communicated that the students would spend mornings at the hospital in clinical observation and then in the afternoon, the UIC faculty would hold debriefing and educational sessions. In consultation with the Global Health Leadership Office, the faculty selected readings and developed assignments, including reflection papers, a case presentation, and a synthesis paper. Just days before the departure, the Indian team sent a comprehensive schedule including field trips, group learning activities, and joint lectures by the Indian and U.S. staff. Although the agenda was welcomed, the late date and the subsequent communication challenges made it difficult to set expectations for the UIC faculty and students. For example, the Indian faculty requested lectures by the American faculty in topics in which she was not well versed and did not respond when changes were suggested.
As suggested above, when the faculty and the students met in the airport departure lounge, it was the first time they had met as a complete group. The faculty had not met all the students participating in the exchange program prior. Despite efforts to meet virtually and to exchange information via e-mail, the faculty was not aware of the individual learning characteristics of each participant. The sharing of this knowledge prior to departure could strengthen future experiences, even if major accommodations cannot be made due to the short and compact experience.
On-Site Supervision. As noted above, although on-site in India, the schedule was full of learning and social activities. The students were actively engaged with Bel-Air faculty and graduate students during the clinical and supplemental learning experiences. Students were exposed to various professionals, including nurses, physicians, social workers, alternative therapy practitioners, and educators, as they navigated the learning experience. The UIC faculty visited the students at the hospital daily and was present for all other activities in which the students were engaged. One minor complaint from the students was that there was too much programming. Due to the immersive nature of the program and the limited time, programming could start at dawn with volleyball and end close to midnight following group work and socializing.
Additionally, on a daily basis, the UIC faculty led a debriefing session exclusively for the UIC cohort. These meetings provided opportunities to discuss the readings in the context of their daily experiences, to process challenging situations they witnessed or ethical quandaries they encountered, and to check in to ensure that expectations were being met and managed. According to a nursing student:
We talked about [a patient who had died] in our afternoon session, and I expressed that his suffering was the hardest part to watch. We became curious about how death and dying is discussed and managed among the nursing students at Bel-Air. After [UIC Faculty] stopped to ask [an Indian faculty member] about how death and dying is managed here, she reported back that the response was somewhat circular and that there wasn't a clear answer on how death and dying is addressed with the students, but that it was repeatedly mentioned that families can talk with the social workers…to help with grief management.… This experience has also brought up for me the different ways that cultures emotionally understand and process suffering, dying, death, and grieving. I think when I get home that I will attempt to find information about how Maharashtrian and/or Indian culture understands and processes these things. Maybe it will help me better understand this experience.
Post-Experience Debriefing and Evaluation. Upon returning home, the UIC cohort almost immediately started the new semester providing little time to debrief, process, or evaluate the experience as a group. The group met once approximately 2 weeks after their return in order to check in, answer lingering questions, and reminisce about the experience. While in India, students noted the cultural differences they encountered on a daily—or hourly—basis. Upon return, these cultural differences were further highlighted. In the brief period immediately following their return and before becoming fully immersed in their semester, the students expressed a desire to integrate certain aspects of their experience, including the slower pace of life and the focus on family and the collective, into their lives and developing nursing practices. A nursing student said:
It is this idea of families that are seeking care that will stay with me forever and guide my work going forward. The [United States] is such an individualistic society, we often eat alone or go to the hospital alone, but in India there was not a single day that I ate by myself or went anywhere without another person. While it was hard to adjust to, the experience of never being alone drove the point home to me that we truly are better off when surrounded by people and can do more when we are all working toward a common goal. As a nurse and hopefully one day a nurse practitioner, I will never again think of the work that I do as being work done alone. I will also be much more willing to lend my colleague a helping hand or find ways to assist people without asking.
An important aspect of the GENE framework is the opportunity to reflect on the experience as an immediate precursor to transforming one's perspective. As noted above, the students were assigned reflection papers to be written before, during, and after the experience; a total of four reflection papers were assigned. Through these assignments, the students offered their changing perspectives contemporaneously. These reflection papers demonstrate their learning and their appreciation for the immersion experience and cultural exchange. A nursing student wrote:
The trip to India exceeded my expectations and was immensely rewarding. The firsthand knowledge about HIV and TB [tuberculosis] intervention and treatment will inform my career for the rest of my life. There were many experiences that made my trip special, and I believe the most important was the clinical observation.… Throughout my 7 days of clinical observation, the high level of medical and nursing care provided at Bel-Air Hospital remains my biggest surprise. I am humbled by the amount of knowledge it requires to deliver adequate nursing care to patients with HIV and TB comorbidi-ties. I hope one day I can be as knowledgeable as the nurses here and deliver good care to my patients who may suffer from such conditions.… I believe it is important for both colleges to continue this communication and cultural exchange because it encourages communication between the West and East. Students and faculty from both colleges can benefit this experience.
Additionally, students were assigned a synthesis paper in which they were to choose a patient or an experience in India, reflect on it, and engage with the literature on the topic in order to draw conclusions about what they might have done differently or will do differently in the future. A main objective of the assignment was to foster reflective practice and to assist in the transformative process. This assignment was due approximately 2.5 months after the return, which would have provided ample time in which to complete the assignment but also an opportunity to integrate the experience further into their UIC-based practice or educational experience. In response to the students' request, this assignment was regretfully cancelled. Some manner of synthesis or reflection should be integrated into the experience that moves beyond personal reflection of the experience to foster the lasting change in perspective that global health experiences purport to implement.
In the future, to measure the influence of the experience on the student, it would be beneficial to include an opportunity to explore how effectively the experience contribute to the development of their own global health competencies, as elaborated above. These reflection and synthesis papers should provide space and time to help students reflect on their motivation for embarking on this global health experience and determine how the lived experience measured up to the motivation. They can also use these opportunities both during and in the months following the experience to reflect on how the experience impacted their cultural humility or to what extent they view themselves as global citizens.
The literature is replete with descriptions of global health learning experiences yet is limited in offering tools by which colleges of nursing can evaluate the experiences. All too often, there is heavy reliance on student evaluations and faculty impressions to provide evaluations of these indelible experiences that nursing students have come to value and demand. Riner's GENE model provides a user-friendly framework for a comprehensive evaluation. This article offers a unique opportunity to apply the framework to an inaugural experience.
Although Riner's GENE model provided a useful tool by which to evaluate the program, the framework was not comprehensive enough to evaluate the entire experience. The model lacks a component by which the quality and the characteristics of the faculty are evaluated. The past experience of the faculty in global health and in leading global educational experiences will affect the overall implementation of the program. In this case, the faculty member had extensive global health experience as a practitioner but had never led a group of students on a cultural exchange program. The skills necessary to run a humanitarian response or to teach in a U.S.-based classroom are distinct from those required to guide student learning in a different country. In addition to having a distinct skill set, faculty should be required to undergo standardized orientation in how to manage such a student experience in order to maximize the learning for the students.
The original description of the framework (Riner, 2011) is also limited in that perspective transformation is not elaborated upon; there are no measures or standards by which transformation is evaluated. Transformation of perspective implies a long-term change. A mechanism by which to measure any change in attitude beyond the trip itself was not built into this experience. The synthesis paper might have provided a slightly longer term perspective, yet that paper was cancelled. An effective evaluation of an experience ought to examine long-term transformation in some manner.
Despite its limitations, Riner's GENE model provided a method by which it is possible to conclude that overall, the cultural exchange that Bel-Air College of Nursing College of Nursing hosted for the UIC students was a successful inaugural effort. By demonstrating to UIC students how to offer high-quality, specialized health services in a low-resource setting, as well as a different model of nursing education more focused on the collective, effectively cemented the reciprocal nature of the relationship. The immersive exchange helped the students understand that differences in approach are differences that are to be valued as such, as opposed to judging lower resource settings as “less than” merely because of the material resources available.
Although there is always a cachet in being the first experience, with improved planning and more effective communication between these institutions' faculty and staff the experience will be improved. For future trips, the schedule must be developed with more input from both parties to maximize the limited time and provide the most appropriate learning experiences. At a minimum, a predeparture orientation will be integrated into future experiences to better communicate and manage expectations. Embedding this experience in a more fully developed course will also be explored. Finally, a postreturn reflection assignment will be developed that will maximize the ability to measure the transformation of perspectives, as well as the development of the core global health competencies. Additionally, we will consider using reflective writing as a means to evaluate the efficacy of the program to better understand the full impact of the program of the nursing students (Curtin, Martins, Scwartz-Barcott, DiMaria, & Soler Ogando, 2013). Finally, a thorough evaluation of the program would include input from our Indian counterparts. Future evaluations will include input from students and faculty from both colleges of nursing.