Nurses are being called on to participate in and lead global health care initiatives, and nursing curricula needs to prepare graduates for this competency (Dohrn et al., 2018). Providing international service-learning opportunities for nursing students can be a way to improve their ability to provide culturally competent health care and expand their global vision of health (Johns & Thompson, 2010). Immersive service-learning experiences can facilitate a deep understanding of social justice concepts and the social determinants of health (Brown, 2017; Phillips, Bloom, Gainey, & Chiocca, 2017). Two schools of nursing are situated in “sister cities” in the United States and Mexico, in which there have been multiple opportunities for cultural sharing. Nursing faculty from both schools of nursing developed relationships in 2011. Seeing similarities in both schools' community health nursing courses provided an opportunity to develop a student exchange and service-learning opportunity. The purpose of the article is to share how processes and structures were created for a sustainable international undergraduate nursing student exchange and service-learning program that is now in its fourth year of existence. The exchange is between two baccalaureate schools of nursing: one in the Pacific northwestern United States and the other in Guanajuato, Mexico. Developing and maintaining relationships with academic institutions and community partners are key components of a sustainable student exchange program and a rich part of student learning (The Forum on Education Abroad, 2011; Main, Garrett-Wright, & Kerby, 2013). A mutual, reciprocal student exchange program is considered a best practice for ethical and equitable international learning experiences (Fallieros de Mello et al., 2018; Mkandawire-Valhmu & Doering, 2012). Based on recommended best practices in international learning exchanges (Kulbok, Mitchell, Glick, & Greiner, 2012), experiences from both schools and strategies and barriers identified to overcome and sustain a nursing student exchange are presented.
Ashland, Oregon, and Guanajuato, Mexico, are sister cities, a relationship that began in 1969. Each city has “Amigo” clubs that support the sister-city relationship and ongoing community and academic partnerships. The Oregon Health & Science University (OHSU) School of Nursing campus in Ashland is located on the campus of Southern Oregon University (SOU). SOU and the University of Guanajuato (UGTO), Mexico have established relationships and exchanged opportunities. A pilot project was initiated to develop the infrastructure for a continuing exchange between OHSU and UGTO. The initial goals of the project were to (a) implement an annual nursing student exchange of approximately 3 weeks in length; (b) select eight students from each school, accompanied by a faculty member, to participate in the exchange; and (c) during the exchange, provide opportunities for students to participate in community assessments in the host community they are visiting. Interinstitutional agreements were developed between both universities prior to student travel. An application process for selection of students was developed. Planning included development of an itinerary for sending and receiving students, including projects with local community partners for students to engage in during their stay in the host community. Host and visiting faculty coordinated development of the on-site program of study before and during each exchange period. Opportunities were provided for visiting students to report results back to the identified host community and to their home university. Visiting students learned about the host health care system through discussions, presentations, and tours of facilities.
Successful international learning experiences include several layers of preparation, such as planning for the overall structure of the exchange and agreements between participating schools, followed by planning for each specific travel and learning experience. McKinnon and Fealy (2011) recommend asking “Why, where, when, and who?” in developing an international learning experience, including a purpose for the exchange to guide planning and implementation. For us, the driving purposes of answering the questions of “Why?” and “Where?” to develop this exchange program were the similarity of our respective community health programs, as well as the faculty and student interest in global health experiences.
To answer “When?” identifying the best time to have the exchange needs to consider timing within the course for the students visiting, as well as optimal timing for the receiving program, taking into consideration holidays, school academic calendars, and general seasons of the year. Creating a calendar of learning and social activities is a role assumed by course faculty, staff, and host student clubs, as well as with community partners who often host welcomes, campus and hospital tours, or additional trainings for students. Identifying community sites for assessments achievable within the time frame is another aspect of planning. The calendar culminates in ending activities, such as a report to the community.
Consider the selection of students and faculty in answering “Who?”. An informational session is held with course faculty, support staff, and ideally with students who have previously attended. A formal application is made with a personal statement, and candidates are reviewed and selected who are not at risk academically, clinically, or professionally, and who will gain the most from the experience. Although previous international experience and language fluency is not required, the ideal cohort is a mix of students with a range of travel experience and language fluency as to give those students who have not had exposure to different cultures this type of experience to enhance their competence.
Determining selection of faculty to accompany students is based on their interest and experience in global health. Ideally, faculty may be able to visit the exchange campus and community before bringing a cohort of students. Instructor fluency, which can increase with repeat visits, can also be useful in communicating with host faculty, students, and community partners about project goals and student learning needs.
Our recommendation is to add a next question of “How?”. To answer this question, it is important to consider how the experience will align with the overall program of study and whether it enhances or replaces curricular learning activities. A key early step is to have a good understanding of necessary institutional requirements and agreements and an understanding of international student travel requirements (Lotas, 2011). These may differ for each institution and may take additional time to finalize agreements in two languages. It is important to check with your international travel and academic offices about necessary agreements and memoranda of understanding. A knowledgeable staff support person is critical to understand the administrative and international rules, forms, and health requirements for both traveling and visiting students. International travel requirements can be found at the U.S. Department of State Bureau of Diplomatic Security ( https://www.osac.gov/Pages/Home.aspx). The Centers for Disease Control and Prevention (2018) and the U.S. Department of State Bureau of Consular Affairs ( https://travel.state.gov/content/travel.html) provide useful travel health notices and advisories. The Association of International Educators ( http://www.nafsa.org/) provides information on country specific travel requirements and e-learning tutorials about international travel.
Other aspects to consider in answering “How?” are to develop a budget to determine anticipated costs for traveling students, determine where students will be living and with whom, and develop a calendar of learning and social activities for the visit. Visiting students and faculty are housed with students and faculty, respectively, from each of the partnering universities. Community members have also volunteered to host student groups. This allows for more opportunities for immersion into the culture. Each visiting students pays $50 USD per week for housing and each host provides one meal.
Six to 8 months before anticipated travel, plan to select dates and confirm with host institution, develop and launch application, hold informational session for students, confirm institutional approval, and determine budget and program costs. Four to 5 months prior to travel, select students, provide financial aid information, and send and receive required institutional documents. Three to 4 months prior to departure, confirm medical and expatriation insurance, purchase travel, and confirm lodging. Upon arrival, obtain media release approvals and create student IDs.
Preimmersion Preparation. Preimmersion preparation can maximize learning during the experience (Brown, 2017) and includes regular meetings with the faculty and staff once the student group is selected (Johns & Thompson, 2010). An informational packet of key information is created for students approximately 1 to 2 months prior to travel and includes itinerary, schedules, contact information, and local travel guides and maps (Wright, 2010). Some student groups take a basic course in learning the language prior to travel and invite speakers who are familiar with the visiting culture to share their knowledge and experience with students prior to travel. Students work with their faculty and cohort before travel to learn about the population health issues in the area they will be visiting.
Use of Technology. Video and web technology can be useful for faculty planning, preimmersion learning activities to connect students from both countries, and during immersive experiences to maintain participation in enrolled classes and contact with the peer home-county cohort (Stephens & Hennefer, 2013). Test connections between sites before actual meetings to troubleshoot potential obstacles. Prior to travel, videoconference introductions across student groups can facilitate connections (Ziemba et al., 2016).
Learning objectives for the exchange focus around awareness of community as client, social determinants of health, impact of policy on community health, public health ethics including social justice, and nursing in an international context. Health Policy and Poverty as a Social Determinant of Health and Cultural Humility in All Interactions are the themes that predominate this experience.
During their stay in the host country, visiting students are assigned to visit a partner community agency of the host school, where they conduct a brief community health assessment. Pairing students on a project to include those having a higher level of fluency with those who do not can help bridge the language gap. The assessment is identified by the community partners, and a handoff from previous assessments by nursing students may be available. Topics explored to date include youth dental health, school and child nutrition, adolescent drug use, adolescent health issues, parental education for child sick days, continuity of care for migrant workers, and barriers to client use of a Wellness Center. Preparing for this assessment involves ensuring that the questions asked are culturally appropriate and the assessment is truly addressing the issues identified by the community. As the relationship has grown between the two schools of nursing, visiting exchange students have increasingly worked side by side with students from the host school, thus deepening their learning about health care systems and differences in nursing scope of practice. Reports of the community assessment occur at a presentation at the end of the visit in the host language and, when students return home, to their class cohort.
Reflection has been used in multiple programs as a teaching method to debrief the experience and meet learning outcomes (Browne & Fetherston, 2018; Kohlbry, 2016). Reflective journaling allows students to examine interactions, identify gaps in knowledge, challenge biases, process difficult situations, and improve nursing practice through self-awareness (Kennison, 2012). Students journal on a learning management blog site with focused prompts to address learning outcomes (Johanson, 2016). Experiences are also debriefed as a group in clinical seminar.
Outcomes and Evaluation
To date, since the exchange was formed in 2015, four cohorts of U.S. students have traveled to Mexico (32 students) and four cohorts (29 students) of UGTO students have traveled from Mexico. Ongoing evaluation is critical to ensure students are meeting learning outcomes and activities are sustaining the partnership and the program. The exchange has evolved over time based on student, faculty, and community partner feedback, and this comparative evaluation each year has benefited the partnership and the program (Johanson, 2016).
We have evaluated the length and timing of the exchange. In the setting of dates, we are mindful of local holidays and events that may affect student learning. We adjusted the timing of the UGTO students' visit from winter to fall based on student feedback about weather. This resulted in greater opportunity to align with local cultural events, as well as pairing with OHSU students for learning activities.
Although home stay is mutually beneficial, it is challenging due to the expectations of each group. The expense of $50 USD per week for housing is more affordable for U.S. students than those from Mexico, so efforts to explore subsidized funding for students is important. Food culture and eating times vary, which has resulted in contrasting expectations. These cultural differences have been mitigated by sending a FAQ document to traveling groups in order to reduce misunderstandings.
Evaluation of the student experience for the study abroad was based on survey results, narrative reflections, debriefings, and the outcomes of their completed community assessments. Through these evaluation strategies, we were able to find the following themes: (a) Expanded Learning About Health Care Systems and Policy; (b) The Role of the Nurse in Each Country; and (c) Enhanced Cultural and Ethical Awareness. The opportunity to learn about other health care systems and policies surrounding global health issues were topics expressed. Students discovered how much both countries have in common regarding the desire to provide optimal health care. Students' written reflections included accounts of how the trip was “life changing” and reshaped their views of the health care systems. Global health disparities and social determinants of health took on a new reality among student groups. The strengths of the communities were outlined, and highlighting these was included as a project outcome. Students visiting from Mexico emphasized the fact that people in the United States talked more about their health and were more aware of healthy choices, compared with people in their local community, although they were aware that this did not always translate into healthier behaviors. As one UGTO student commented, “Life in the United States is fast-paced and people are always on the go. People told us that they didn't have time to exercise or consider the nutritional value of meals. Everything is closer in a Latino country—there's more walking, and we're always sitting around a table eating food prepared by us.” Many of the U.S. students commented that health care policies in Mexico made access to care superior to that in the United States. One student who traveled to Mexico wrote about her comparison of the U.S. and Mexican health systems:
From this entire experience I learned just how much this culture displays collectivism rather than individualism. It is about meeting goals together, and the needs of the society come before the needs of the individual.
The Role of the Nurse in Each Country was a theme that was emphasized by the exchange groups. The students from Mexico commented on how the U.S. nurses had a broader scope. One UGTO student commented:
U.S. nurses are more independent, they have more of a relationship with their patients, and nursing is treated more like a profession than a job in the United States.
The U.S. students were inspired by the fact that in Mexico the nurses were able to give excellent care with fewer resources than students experienced in the United States. As one OHSU student noted:
I was impressed by how a small community of health care providers can make such a large difference in the community even when barriers—such as lack of government funding—are so prevalent.
Every student from each of the countries stated that the experience was valuable and enhanced their cultural awareness and how this translated into nursing practice. One OHSU student noted, “Understanding different cultures makes you a more capable and thoughtful nurse. I have a deep love for international service, and going abroad showed me new opportunities.” Another stated, “A nurse in an unfamiliar community must tolerate feeling vulnerable at times. Studying abroad really lent me that capacity.” Students were given an opportunity to explore their views of equity and social justice. Ethical challenges were addressed with concern for protecting patient welfare in each geographic locale, promoting fair and equitable care globally, and maintaining trust in the benefits of international service-learning program and the nursing profession. Through the exchange, many now recognize their responsibility toward global health ethics and what it means to be culturally sensitive.
Our evaluation is just beginning to assess long-term impact to evaluate how this experience has informed new graduate practice. We recently contacted graduates from both schools who were in our first two cohorts of travelers and now have been in clinical practice for 2 to 3 years. Graduates retained an expanded perspective about health systems and cultural awareness. One OHSU graduate shared:
The exchange with Guanajuato really put my own nursing into perspective. Whereas I had taken U.S. health care practices for granted, I discovered that a ‘one-size-fits-all’ approach doesn't necessarily translate across cultures.
Spending time in Guanajuato gave me the opportunity to see what community health in another country was like. It was a great experience to be able to immerse ourselves in the community and culture. It helped me realize the importance of cultural competence and community health and education no matter where you are.
UGTO graduates shared similar long-term learnings. One UGTO graduate said:
It is not just about comparing health systems, but learning and taking the best from each. Thanks to this experience abroad I was able to return with a more open mind and clearer objectives as a health professional since I realized how important it is to share knowledge and provide adequate information to those who need it.
This exchange gave me knowledge about different ways of practicing nursing, as well as the differences that exist between the health systems of Mexico and the United States, and thus be able to analyze what changes can be raised so that both nations can have a better and more efficient health system.
Recommendations for Developing a Similar Program
The following key lessons should be considered for faculty and programs considering establishing global travel experience or international student exchange:
- Adequate planning and adequate time for planning are cornerstones for success and cannot be underestimated. Consider mapping out strategies under the headings “Why,” “Where,” “Who,” “When,” and “How” to consider the purpose of developing such a program, where to travel to, which students and faculty may go, the timing of the year and the program to travel, and what are the processes and specific details that need to be achieved for success.
- Develop knowledge about international institutional agreements and travel requirements.
- Develop preimmersion preparatory activities, as well as plan immersive learning and social activities.
- Develop processes for capturing short-term and long-term evaluation of the impact on students, graduates, and communities. Have evaluation processes loop back to program revision.
This article adds to current body of knowledge of global health care experiences in providing an understanding of the processes involved in planning an exchange and how to develop an ethical exchange program that continues ongoing projects across student cohorts. Development of a reciprocal nursing student exchange program is possible with committed partners and staff support. A two-way exchange promotes important concepts of internationalization and shared learning across borders. Students greatly value the opportunity for international learning. An understanding of the process of developing international agreements and national and university requirements for student travel are challenges the project team encountered and are vital to planning a successful exchange. Administrative and faculty buy-in for the exchange at each of the universities is essential. A clear purpose of the immersion experience and the goals of the program are valuable for success. The staff responsibilities of supporting the infrastructure and logistics, as well as the faculty role of creating curriculum, collaborating with host faculty, and encouraging student engagement, are necessary to sustain the program. The cultural relationships that have developed between faculty, students, and the administrative support team for the partnering institutions have been invaluable.
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