Nurse educators must prepare nurses to provide competent and culturally sensitive patient care in our increasingly diverse health care environment (American Association of Colleges of Nursing, 2009). In response to this need, some nursing programs are offering the opportunity for students to study global health and participate in international service-learning projects (Ford, Neilan, & Moscou, 2017). These experiences allow students to develop clinical skills and cultural competencies that they may not otherwise have an opportunity to participate in during traditional clinical practice hours in the United States. In addition to preparing nurses to provide culturally competent care, nursing faculty are challenged to be creative in developing alternative clinical experiences for nurse practitioner (NP) students to supplement current practice. The traditional one-to-one preceptor method is becoming more challenging with the increased number of students competing for a decreasing number of clinical practice sites. International experiences can benefit advanced practice students in obtaining clinical practice hours toward their degree while also enriching cultural competencies. The purpose of this project was to determine whether an international service-learning nurse-led clinic was a beneficial experience for NP students in improving diagnostic and cultural confidence, skills acquisition, and cultural competence during a clinical practicum.
The United States continues to become more culturally diverse, with a growing population of racial and ethnic minorities. Immigration in the past 50 years has increased the nation's foreign-born population from 9.9 million in 1965 to 45 million in 2015 (Pew Research Center, 2015). This increasingly diverse population has important implications for nurse educators training future health care providers, particularly NP students. The demand for primary care providers in the United States is expected to increase, with an anticipated shortage of 20,400 primary care providers (Health Resources and Services Administration, 2013). NPs are expected to help fill the gap of primary care providers in the United States, particularly in medically underserved areas. These providers need to be competent in both the skills and cultural awareness necessary to meet the growing health care needs of the diverse population.
Service-learning is a teaching method that enables students to engage in real-world, community-focused projects that contribute in significant ways to their learning (Seifer, 1998). The service provided is not only a learning experience for the student but is also beneficial to the population that it serves.
Gap in the Literature
Literature describing international service-learning with graduate nursing students is limited. Whelan, Ulrich, Ginty, and Walsh (2018) described experiences with NP and Doctor of Nursing Practice (DNP) students on biannual mission trips to Jamaica. Student essays revealed themes of Cultural Awareness, Compassion, Vulnerability, Confidence, and Appreciation. The only other article describing NP students in a global health mission was with family nurse practitioner (FNP) students providing health care to residents of Honduras. Self-reported evaluations from the students and faculty found the program to be effective in developing clinical practice competencies and confidence, but there was no objective assessment of skills acquisition (Smit, Delpier, & Tremethick, 2012).
Studies with undergraduate nursing students in international service-learning show significant improvement in self-efficacy, self-confidence, skills, and self-awareness in working with diverse cultures and in developing cultural competence (Amerson, 2010; Long, 2014). A systematic review by Jeffrey, Dumont, Kim, and Kuo (2011) found that medical students who participated in international service-learning projects reported greater self-confidence in history-taking and performing physical examinations versus students who did not take part in a global health elective. Most of the studies used self-reported measures to assess the impact of the experience. None of the articles used evidence from clinical observations or assessments.
This project was guided by Kolb's experiential learning theory (1984) that suggested that students are more likely to learn by actively participating in the learning experience, as opposed to traditional transmission of information. Kolb believed that “learning is the process whereby knowledge is created through the transformation of experience” (Kolb, 1984, p. 38). His model represents four learning cycle modes: (a) experiencing, (b) reflecting, (c) thinking, and (d) acting to generate knowledge and facilitate learning.
Cultural care theory also influenced this project (Leininger & McFarland, 2006). This established nursing theory implies that nurses can only be culturally competent when they truly understand the care expressions, patterns, and practices of individuals in their care (Leininger & McFarland, 2006). This framework is relevant for enhancing cultural competence in NP students.
Setting and Sample
The setting for this project was in the country of Guatemala in Central America. Primary care clinics were held in two different rural villages: El Quimal La Joya and Alotenango. Both El Quimal La Joya and Alotenango are underserved and indigenous communities. Guatemala is a predominantly poor country with limited government-funded health programs. Access to care largely depends on socioeconomic status and location, with rural populations having the most difficulty in accessing basic health care.
Students from a midwestern public and research-intensive university who were enrolled in one of the NP tracks of the DNP program and completed at least one semester of NP-specific didactic theory were eligible to enroll in an elective Global Health Immersion course. This course was offered during the winter 2019 intersession. The international service-learning trip to Guatemala was a required component of the course. All students signed written consent to participate and decisions to join or decline participation in the study had no impact on final grades for the course.
Two NP faculty from the DNP program, who were also the researchers in this project, supervised the 10 NP students on the international service-learning project. The NP faculty consisted of a certified FNP and a certified Pediatric NP. A primary care clinic led by the NP students and the NP faculty was offered in both Guatemalan towns. Students in the FNP, Adult Gerontology, Pediatric, and Psychiatric Mental Health NP tracks saw patients with various acute and chronic health complaints with the support of translators. The most common conditions that students encountered were cough, neck pain, anxiety, gastrointestinal complaints, headaches, viral syndromes, diabetes, and hypertension. While the Women's Health NP students primarily cared for women with obstetrical and gynecological needs, the students also saw women with general health concerns in the primary care clinic. The DNP faculty circulated among the students to provide consultation, answer questions, and give feedback. Students were required to present their assessment, diagnosis, and treatment plan to the DNP faculty to sign off on prior to the patient's discharge from the clinic. All patients requiring follow up or specialty care were referred to local clinics supported by a network of nonprofit organizations. A Guatemalan family physician was onsite during every day of the primary care clinic to provide collaboration if needed.
Practice and cultural competencies were evaluated by the DNP faculty on each NP student on the final day of clinic using an analytic grading rubric. This rubric was created by the DNP faculty based on independent practice and cultural competencies established by the National Organization of Nurse Practitioner Faculty NP Core Competencies (National Organization of Nurse Practitioner Faculties, 2017). Students were observed by faculty as they cared for a patient in the primary care clinic. Prior to their evaluation, students were required to present their assessment, diagnosis, and treatment plan to the DNP faculty. Students were graded in five areas including (a) health assessment and screening; (b) diagnosis; (c) disease management, prevention, and health promotion; (d) interaction with patients; and (e) providing culturally competent care. The items on the practice competency rubric were measured from 1 (beginning) to 4 (exemplary). A student earned a score of 4 if they were able to perform the competency without need for supervision and if they consistently paid attention to patient cues and asked culturally competent questions.
The learning experience was evaluated by 10 students (100% of the sample) using a self-administered, Web-based, anonymous survey consisting of Likert-scale responses. The items were measured from 1 (strongly disagree) to 5 (strongly agree). Questions measured perception of learning and the value of the clinical experience. Data from the survey results and the practice competencies rubric were entered into a data collection sheet by the first author. Data were analyzed using SPSS® version 25 statistical software.
Participants consisted of 10 DNP students in the Adult Gerontology NP (n = 1), FNP (n = 4), Pediatric NP (n = 1), Psychiatric Mental Health NP (n = 3), and Women's Health NP (n = 1) programs. The majority of the participants were female (90%) and non-Hispanic (90%) or White (80%). The mean age was 33.8 years and the mean length of nursing experience was 8.7 years. Five students (50%) were enrolled in the final semester of their clinical practicum hours and the other five (50%) students were enrolled in the final clinical didactic course. The students enrolled in the didactic course had not yet started their clinical practicum hours with a preceptor prior to the international experience.
Scores from the practice competencies rubric were high overall, particularly in the area of providing culturally sensitive care (M = 3.8; SD = 0.632). The majority of students (70%) scored at a level of accomplished or exemplary in the areas of health assessment, screening, and diagnosis by the end of the week. A larger number of students scored at a level of accomplished or exemplary in the area of disease management, prevention and health promotion (80%), and patient interaction (90%). No students were rated at beginning for any of the categories. Students with previous clinical practicum hours (n = 5) scored slightly higher in their diagnosis and management competencies than students who had not yet started their clinical practicum (M = 3.3; SD = 0.693 versus M = 2.8; SD = 0.837).
All participants completed a postexperience survey. Results demonstrated that after the experience students were more confident in their history taking (M = 4.8; SD = 0.422) and performing a clinical assessment (M = 4.8; SD = 0.422). Students reported that completing clinical practice hours in the nurse-led clinic increased their confidence in their diagnostic abilities (M = 4.8; SD = 0.422) and capability to recommend a treatment plan (M = 4.89; SD = 0.333), as well as their confidence in caring for culturally diverse populations (M = 4.89; SD = 0.333). Results also demonstrated that this project gave students a better understanding of social determinants of health in an under-served country (M = 4.6; SD = 1.27) and the role of the NP in caring for culturally diverse populations (M = 4.6; SD = 1.27). Students conveyed that after this experience, they would feel more comfortable working for a practice that provided care to culturally diverse (M = 4.9; SD = 0.316) and underserved populations (M = 4.9; SD = 0.316).
Participation in an international service-learning project has been shown through self-reported measures to be an effective strategy to help students develop clinical and cultural confidence. This is the first study to describe an analytical grading rubric to assess NP competencies demonstrated during an international service-learning nurse-led clinic. The overall results were positive. Students scored high in their assessment and management skills, patient interaction, and the ability to provide culturally competent care. These findings have important implications as faculty seek to educate providers who can care for underserved populations. These experiences help students gain a better understanding of public health concerns in resource-poor environments. This project suggests that international service-learning may be extremely valuable for NP students, particularly in increasing confidence in their diagnostic abilities and caring for underserved populations. These experiences also have the potential to assist in acquisition of practice skills and foster cultural competence.
Nursing school administration and graduate nursing faculty should consider opportunities to develop collaborative partnerships with international organizations. NP students are exposed to underserved populations of a different culture and patients receive needed care that would otherwise be unavailable. Such opportunities can supplement clinical practice hours and are mutually beneficial to students and patients alike.
This project has several limitations. A major limitation was that a preassessment of the students' clinical practice competencies was not measured prior to the project, which would have been beneficial for analysis of skills acquisition. An analytic grading rubric with specific objectives was utilized to measure clinical competency at the end of the experience. Although this was not a validated tool, the rubric was created by the DNP faculty based on established National Organization of Nurse Practitioner Faculty NP core competencies. An additional limitation is that the researchers were also the DNP faculty evaluating the students' performance, which could have influenced the results by the researchers' involvement. This project also used a convenience sample from one cohort of students over a single semester. Implementing the project over several years with different groups of NP students may reveal more value than measuring a single cohort of students. In addition, the sample size was small, which limits generalizability. Five of the participants (50%) had not yet started their clinical practicum hours, which could have led to decreased confidence in their clinical abilities and lower practice competency scores.
An international service-learning nurse-led clinic used to complement clinical practice hours is a beneficial experience in assisting NP students in diagnostic and cultural confidence. These experiences also have the potential to improve existing NP student practice, teach students new diagnostic skills, and foster cultural competence. Nursing faculty have been challenged to be creative in developing alternative clinical experiences for NP students to supplement current clinical practicum. International experiences can benefit NP students in obtaining practice hours toward their degree while also enriching cultural competencies. Providing care to underserved populations in a different culture results in a mutually beneficial opportunity for students and the community served. Future research should evaluate preexperience clinical competencies, as well as postexperience competencies. In addition, objective evaluation tools to measure specific learning outcomes of NP students need to be developed.
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