Virtual Study-Abroad Through Web Conferencing: Sharing Knowledge and Building Cultural Appreciation in Nursing Education and Practice

Abstract

Background:

With a focus on building global citizens, a U.S. and Norwegian academic collaborative partnership fostered clinical learning experiences addressing cultural and health care comparisons. High-impact educational practices integrated into international clinical experiences, combined with virtual global learning classrooms, highlighted the Sustainable Development Goals.

Problem:

Given nursing education’s requirements, devising innovative strategies expanded global learning in brief but transformative experiences while integrating nontraveling students, especially relevant considering current pandemic-related travel restrictions.

Approach:

We developed an educational experience pairing U.S. students (17 in person; 64 through web conference) and Norwegian students (50 in person; 3 for web conference) in population health experiences, providing required clinical hours and a shared cultural exchange. Integration of nontraveling students in joint virtual global experiences broadened the global learning opportunity for all.

Conclusion:

This work offers insight into how faculty used a virtual global learning experience as a synergistic tool with traditional study abroad.

Keywords

global health international educational exchange baccalaureate nursing education cultural competency

Introduction

To prepare students for a world that is becoming ever more connected, a major focus across higher education institutions has been integrating global perspectives into their mission statements, thus expanding opportunities for students to engage in global learning experiences as part of high-impact educational practices (HIP) within a curriculum (Association of American Colleges & Universities, 2020). The globalization of higher education includes exposing students to other countries’ cultures and systems which can be accomplished in a myriad of ways, including international student or faculty exchange courses, study abroad, global clinical experiences, service activities, and virtual global classrooms. These experiences help students develop as global citizens who

recognize that, whether we are talking about education, health care, or social services, we know that: (1) what happens globally affects local communities and (2) local life in communities reflects the diverse experiences, cultures and people from across the globe. (Morrison-Beedy, 2019, January 25, para 2)

Combining local and global educational experiences to shape “glocal” approaches to teaching community health can benefit both traveling and home-based students. This strategy allows students to think globally while acting locally, utilizing a worldview approach to health.

Unfortunately, in the first quarter of 2020, these valuable global travel experiences ceased due to the COVID-19 pandemic. Different approaches to global educational endeavors were explored to continue providing deep learning experiences through the development of HIP in teaching and learning. One easily accessible and inexpensive solution to approaching global education is the use of web conferencing.

Background

The experience of traveling and studying abroad can be transformative. Global competencies are recognized as a key to personal growth and lifelong success; Nursing students with international experience report significant changes when it comes to increased self-awareness, cultural empathy, and leadership skills (Ferranto, 2015). We recognize that contrasting global experiences may include role conversions for students, from being a skilled native to a foreigner, or from being a student–learner to assuming the role of cultural informant.

Although there are challenges incorporating internationalization in a nursing curriculum, creativity and commitment can go a long way in ensuring success. A large state university in the Midwest United States and an University College in Oslo, Norway collaborated on a memorandum of agreement for the expansion of global learning experiences in 2017. In addition to a traditional study abroad student experience, both institutions wanted to create a domestic learning environment facilitating internationalization at home for students unable to travel abroad.

Purpose

Although many majors in higher education allow flexibility for multiple electives or semesters abroad, health-related curriculums are often constrained due to regulatory requirements associated with professional licensure. With the vast educational requirements of nursing curricula, it is important to devise ways to expand concentrated global learning opportunities for students within brief and transformative experiences. There are commonalities between service-learning principles and entry-level public health nursing competencies (C. L. Brown, 2017), so we capitalized on these commonalities by connecting U.S. and Norwegian students who were simultaneously enrolled in their respective community health nursing clinical courses to develop a global clinical experience. This article describes the joint academic venture that: (1) developed a brief overseas clinical experience for 17 second-degree U.S. students in a prelicensure nursing course partnered 1:1 or 1:2 with baccalaureate students in Norway to meet community health clinical requirements; (2) expanded global exposure of students in Norway to U.S. nursing curriculum and health system issues; and, most important, (3) implemented a virtual global classroom to benefit the U.S. students who could not participate in an overseas experience.

Evidence-Based Teaching Approaches and Preparation

Creating global citizens in nursing academia through international clinical partnerships requires thoughtful planning, flexible implementation, and commitment by both partners to work through challenges and share successes. Just as evidence-based practice guides clinical interventions for patients, integrating teaching strategies that are evidence-based is a critical component of international educational exchanges. Evidence-based teaching strategies were integrated to include student learning goals and strategies (Ambrose et al., 2010; Fink, 2013).

Conventional teaching methodologies (e.g., PowerPoint, guest lecture, videos, case studies) were paired with student-centered approaches (e.g., think–pair–share, project-based learning, role-plays, concept mapping) to meet learning outcomes of this combined theory-based and clinical course (P. C. Brown et al., 2014).

It was important to focus on topics that could be reflected in the international experience with effective assignments aligned to course outcomes that were authentic, scaffolded, varied, and achievable within the time frame. During the study abroad experience, multiple strategies extended the experience to student peers and faculty at home in the United States. These channels were both direct and concurrent via the virtual global classroom, or indirect, thinking in terms of the travelers as living avatars—eyes, ears, and actors through blog communications, social media, collaborative, and reflective writing.

U.S. students were required to take the community health course during summer semester 2019 and were offered the opportunity to complete their entire clinical experience abroad in a compressed 2-week format; students staying home would complete their required clinical hours throughout the summer semester. Over 75% of the class expressed an interest in participating in the experience demonstrating significant interest, and 20% of the student cohort enrolled to participate in the study abroad opportunity. The faculty were challenged finding a way to still provide that opportunity to those students who could not travel abroad.

As a HIP that positively affects student retention and engagement, study abroad has the potential to have a positive impact for students in relation to intercultural effectiveness (Kilgo et al., 2015). Key components of such a rich learning opportunity are more than accompanying students on the trip. Cultural informants are important to help provide context and answer questions accurately and appropriately in the moment. Preimmersion activities that are carefully constructed and connected to learning objectives are used to prepare participants for the differences they are about to experience, unpacking concepts such as stereotyping that encourage students to question their assumptions about the other (Holmes et al., 2015). Postimmersion activities are used to help students frame the experience, grapple with any felt cognitive dissonance, and understand and appreciate differences.

Site visits from U.S. students to Norway provided the factual and contextual background for detailed planning of professional and social activities to facilitate the international learning experience. Attention to detail was mandatory for academic credit in the U.S. program, as well as the number of individuals involved. Even minor adjustments at the invididual level, for example, episodes of illness abroad, could easily overburden administrative capacity when multiplied by 10 or 15. Interventions for the preparatory period covered essentials such as travel, housing, diet, and safety, in addition to multimodal orientation to assist in adapting to the Norwegian environment. About 50 Norwegian students were selected to collaborate with the 17 U.S. students for professional and social activities. The students were divided into small groups where they could get to know each other for the mutual purpose of cultural, educational, and social learning.

Community Health Course Content and Additional Predeparture Course for Travelers

A summary of prerecorded content about Norway, the Norwegian health care system, nursing education and the Norwegian university that was provided through an in-person lecture during a visit to the United States by a Norwegian faculty member was housed in the learning management system for the course in the United States. This material was required for students traveling to Norway and the session was captured via video recording along with other education videos for those students unable to attend, those staying home, and for repeated access. In addition, to provide more in-depth orientation for U.S. students traveling to Norway for the international experience, a half credit hour predeparture preparatory course was required that included a general overview of the country along with some information about culture, customs, and history. Students also participated in introductory discussion and workgroup activites setting the stage for understanding the Sustainable Development Goals (SDGs).

Predeparture course reading included blogs that discussed internationalizing activity and its impact in higher education (Morrison-Beedy, 2019; Morrison-Beedy et al., 2020). Students then wrote and submitted their own blogs that described their personal interest in a global experience. They also prepared a critique of the “Body ritual among the Nacirema” (Miner, 1956) which satirizes how Americans sometimes frame the world through their own value system and cast judgments. This assignment is useful for helping students view their international experience from a broader lens and recognizing that American-focused is not the only, or best way, to do things. See Table 1.

Table 1.

Schedule of Activity and Content.

Date	Content	Students traveling to Norway
February 2019	Norwegian nursing education and health care system	Attended in-person lecture during a visit to the United States by a Norwegian faculty member
May 2019	Norwegian nursing education and health care system	Video of February 2019 lecture available in learning management system for all students enrolled in the community health course.
	Predeparture course	Country, customs, culture, history, safety when traveling abroad; Predeparture course reading included information about internationalizing activity and its impact in higher education.
	Horace Miner’s (1956) satirical article depicting Americans as judgmental of other culture	Students prepared a critique of this article.
Departure of U.S. Community Health Students (17 out of 81) to Oslo, Norway
May and June 2019	Community health clinical experiences, public health core competencies and 17 Sustainable Development Goals, including similarities and differences between health care systems in Norway and the United States	All students in the community health course were required to respond to discussion prompts that related to their clinical experiences on the course discussion board and respond to peers. Students who traveled to Norway blogged about their community health experiences and shared their blog link to the discussion board which included photos.
Virtual global classroom day via web conferencing for all students
June 2019	IHI Case Study about care of a patient with alcohol abuse, family difficulties, homelessness and health care challenges	Link to IHI case study posted in learning management system; worked on case study in small groups within the Virtual Global Classroom in the United States and Norway; presented their group discussion findings through web conferencing (and in person for U.S. students in Norway)
	Nursing education and jobs as nurse’s aide/patient care associate, including similarities and differences between countries	U.S. students (staying home and those that traveled to Norway) and Norway students asked one another open questions of areas of interest through web conferencing (and in person for U.S. students in Norway).
	Norwegian health care system	Norwegian faculty member presented mini lecture to U.S. students in Norway and those in the United States through web conferencing.

Note. IHI = Institute for Healthcare Improvement.

In addition, 2 weeks prior to the overseas departure, U.S. students met and role-played in think–pair–share method about how to facilitate communication and learning with their Norwegian student partners and how to address conflicts and communication issues with patients or colleagues. The U.S. faculty overseeing the half credit course presented a broader global curriculum with a focus on the SDGs. These 17 goals adopted by world leaders in 2015 focus on a broad spectrum of influences including poverty, water, land, resources, health, education, and sustainability (United Nations, 2015). At this time, U.S. students were connected with their Norwegian student partners via social media or email so they could introduce themselves and share expectations which served to build comfort, community, and facilitate communication once together. Finally, a university-supported representative from the office of international affairs presented basic predeparture information including travel, financial, safety, and cultural topics.

Creating a Virtual Global Classroom to Connect Students From Both Countries

Due to travel cost, time commitment for studying abroad, and family/work obligations, some students are prohibited from participating in a study abroad trip, potentially limiting the global impact to a select subset of students with the greatest financial resources. Overall, just 10% of undergraduate students in the U.S. study abroad (U.S. Department of State, 2018) and only 5.5% of students studying in the United States are international (Institute of International Education, 2018) demonstrating the small percentages of students who connect and learn together in a traditional study abroad experience. However, it is possible to collaborate and learn with distant peers and educators through the technology of web conferencing, a virtual study abroad, where participants can see and hear one another and participate in a cultural exchange while remaining at home in their own environment. Using virtual technologies to connect disparate groups can “facilitate transformative intercultural learning experiences and build . . . student cultural competency [through the creation of] new spaces for internationalization . . . facilitating intercultural interaction and learning” (Hyett et al., 2019, p. 403). This method of engaging with peers and educators from other countries costs little using existing high-speed internet, webcams, and faculty time dedicated to developing these meaningful and well-constructed learning activities, especially important during pandemic travel restrictions.

Such virtual cultural encounters may increase student’s self-efficacy, helping them to remain open-minded and avoid stereotyping when caring for patients of a different culture (Henderson et al., 2016). Faculty must understand the impact of, and take responsibility for preimmersion, immersion, and postimmersion activities, just as in physical study abroad. To prevent cultural dominance and promote broad learning experiences, faculty must be mindful that instructional materials and lectures should emanate from, and be reflective of, each cultural group taking part in the experience. Using faculty and students as the cultural informants is helpful to achieve realism and accuracy in the virtual study abroad.

Students gain the opportunity to move through some of Bennett’s stages of intercultural competence from ethnocentrism (encountering our own culture as actuality) to ethnorelativism (encountering our own culture that includes and relates to other cultures; Stewart & Bennett, 1991) through the experience of web conferencing with distant peers and their faculty. These stages are foundational to the intercultural development inventory used today in schools and organizations.

Method

This project was shared with the office of responsible research practices from the U.S. university. It did not require review since the results are being used for quality improvement purposes and is presented as a factual account without an attempt to generalize. Student reflections were collected from the U.S. students in the community health nursing course. A year later, when the participants were no longer students in the course and being evaluated by the authors, reflection data were analyzed through qualitative methods (Melnyk et al., 2019) for continuous quality improvement of this innovative teaching–learning strategy to learn together about global community health.

Design

To facilitate U.S. student reflection about the virtual exchange, a single open-ended question was posed, “Share one experience from this virtual classroom.” Students had the option to complete the learning reflection in the course management system or not.

Setting and Sample

The U.S. students involved in the study abroad experience, either in person or virtually, were second-degree graduate students in a preregistered nursing licensure course, community health nursing. To enable students staying in the United States to take part in the global experience, a virtual classroom was implemented as an essential component of this course. During summer 2019, the U.S. community health nursing class size was 81; 17 travelled to Norway for a traditional study abroad experience while completing their clinical hours, and 64 remained in the United States completing their clinical hours and participated virtually via web conference.

The virtual web conference included the following locations and people:

In Norway, a small room with a single conference table was utilized for

○ 2 U.S. and one Norwegian instructor, and

○ 17 U.S. and three Norwegian students;

In the Midwest United States, a large lecture hall was used for

○ 1 U.S. instructor, and

○ 64 U.S. students.

Reflections were completed by U.S. students, 100% (n = 17) of the group that traveled to Norway and 91% (n = 60) of the group that stayed in the United States.

Implementation

Faculty from both institutions collaborated on the agenda and learning content that would fit into their respective course objectives, be interesting to the students, and provide students with an opportunity to learn with and through their international peers and faculty. As homework prior to the web conference, all students were provided a link to a case study mutually selected by the faculty from the Institute for Healthcare Improvement, A downward spiral: A case study in homelessness and were instructed to review the scenario.

The web conference occurred live/synchronously on Friday, June 7, 2019 and began at 3:00 P.M. Central European Time (CET)/9:00 A.M. Eastern Standard Time (EST). After student and faculty introductions, students formed small groups to discuss the assigned case study questions, and then collectively all groups shared the responses via web conferencing. Their case study answers served as the foundation for the virtual class discussion and revealed comparison information about U.S. and Norwegian health care systems, and the support services for the citizens of the respective countries. Students were able to compare and contrast how each would approach the situation of homelessness, including discernment of events associated with social needs and health care needs, facilitators and barriers in accessing health care, utilization of the emergency department, and experience and building trust with homeless patients.

At the conclusion of the case study, students were given an opportunity for open questions and answers with one another and the faculty from each country. They discussed topics such as higher education, nursing education, cost of education, job opportunities while in school and after graduation, nursing role and scope of nursing practice. This open discussion allowed the students to continue to compare and contrast the overall scope of practice and role of the nurse and nursing education across the two countries. After the students in Norway were excused, the U.S. students stayed for the last segment, a mini lecture reviewing the Norwegian health care system by the Norwegian faculty with time left for questions at the end.

At the conclusion of the web conference, U.S. students who remained home were led through a debriefing exercise where they had an opportunity to discuss their perceptions and taste Norwegian food (cookies). Faculty remained alert to statements that may cause students to deny, become defensive or minimize the experience of their peers from the Norwegian university. This is critical as it prevents students from perceiving implicit faculty agreement of such thoughts, which may lead to cementing or fossilizing them. Students in Norway also debriefed with faculty who were present with them about the overall virtual experience.

All U.S. students enrolled in the community health nursing class were provided with an opportunity to earn a point toward their class participation for completing a single question reflection. Responses ranged from a couple of sentences to a few paragraphs.

Data Analysis

A year after the study abroad, verbatim student reflection data were sorted into traveled abroad or stayed-home groups and then deidentified. Thematic analysis was completed separately by two authors to gain awareness of the lived experience of each student group. Data were sorted and simplified as themes and subthemes emerged during three to four rounds of data reduction. In addition to multiple coders and audit trail of verbatim transcripts, trustworthiness was obtained through former student member checks, representing each group (Melnyk et al., 2019).

Outcome Measures

Students who traveled abroad to Norway also learned from the virtual study-abroad experience. Their sentiments coalesced into three main categories or themes, including technology, classmates back home, and global collaboration. Most students in this group were in awe and appreciative of the technology that provided the opportunity to reconnect and share with their peers back home. A few felt that it was sometimes awkward to speak in front of a camera extemporaneously, to pause longer than usual and to listen when the audio sometimes faded. The study abroad group also enjoyed comparing and contrasting health care systems, and learning from diverse faculty (Table 2). Examples of their comments include the following: “Unique to be in class together halfway around the world,” “Great to see tele-nursing education,” “Takes patience and few minutes to get kinks worked out,” “Liked how the rest of the class got to listen to Norwegian faculty speak,” “Loved Norwegian student participation so peers back home could hear from them,” “Hear similarities and differences between Norway and US in terms of case study,” “Enjoyed interactive lecture,” “Effective international class,” and “Hope other classes incorporate global experiences in curriculum.”

Table 2.

U.S. Group That Traveled to Norway.

Themes	Subthemes
Technology	Appreciation, felt normal, impediments, awkward virtual class, patience and flexibility needed
Classmates back home	Reconnect, sharing knowledge and experiences
Global collaboration	Appreciate opportunity to compare and contrast, enjoyed Norwegian faculty lecture, sharing knowledge between Norway and the United States, new perspectives, appreciation of global education/experience

The group of students who stayed home and participated with those in Norway had much to share, sometimes paragraphs. Their sentiments created 10 different themes, including higher education cost differences and impact, experiences of nursing students, nursing role, care differences, other reflections, cultural appreciation, technology appreciation, things they learned, things they would like to learn, and technology challenges (Table 3).

Table 3.

U.S. Group that Stayed Home.

Themes	Subthemes
Higher education cost differences and impact	Free education in Norway, ramifications of free education in Norway, differences in education cost between Norway and the United States, something needs to change in U.S. higher education related to cost
Nursing student experience	Similar, compare and contrast, scope of practice, holistic care in Norway, Norway educational path, more clinical time in Norway, working and compensation as nursing students
Nursing role	Similarities and differences, differences in multidisciplinary team usage, holistic care in Norway, Norwegian infrastructure supports holistic nursing, availability of health care, philosophy of health care in Norway, cost of living in Norway, salary and taxes in Norway, benefits in Norway compared with the United States
Care differences	Emergency and homeless care, opioid-related care, nurses-on-wheels/community care
Other reflections	U.S. emergency care, U.S. health care system, U.S. higher education system
Cultural appreciation	International exposure, cultural appreciation, compare and contrast, interesting and intriguing
Technology appreciation	Enjoyed virtual class, technology appreciation, interactive international connection
I Learned . . .	Multiple things, such as: not to make assumptions with patients; importance of communication; differences in nursing, health care, and education
Would like to learn more about . . .	Multiple things, such as: pros and cons of each health care system, what could be used from Norway in the United States, how financial system in Norway supports citizens, ramifications of decriminalization of opioids in Norway, how to make U.S. higher education more affordable
Technology challenges	Difficult to hear, group too large in the United States

There were similarities and differences in main themes and subthemes among the groups as depicted in the venn diagram (Figure 1). All students spoke of global collaboration, cultural appreciation, new perspectives, and technology appreciation and impediments. The group of U.S. students who traveled to Norway were appreciative of the opportunity to have a global learning experience and were especially pleased about being able to share their clinical experiences in Oslo with their peers back home. The differences in reflections for the group of U.S. students who stayed home were related to the contrast in higher education costs, nursing student experience, nursing role, health care systems, care difference, and the desire to learn more.

Discussion

An important finding from this pilot was the importance of engaging students who remained at home and keeping them excited about the global classroom. As an assignment for the U.S. students traveling abroad, each wrote about a clinical day, linking at least one public health competency and a SDG to that experience and responded to at least two peers on a discussion board. However, to further increase the global experience for the students remaining in the United States, a requirement could have been made that all students would respond to at least one global experience. While the home faculty provided a cultural food experience, additional cultural experiences of music, dress, and other images may heighten awareness and interest.

Another way to further enhance the experience would be to require a written discussion board assignment, including all U.S. and all Norwegian students, with faculty providing guidance and oversight from each institution. This would engage all students in Norway and the United States, giving them a chance to be a cultural informant and further participate in a global experience while addressing logistical implementation challenges (e.g., time zones). Leading students through discussion questions and helping to keep the conversation going back and forth between sites is also part of the faculty role. Faculty from both countries could create global partner pairs and develop together mutual discussion prompts, requiring students from their respective countries to respond and start the process of being cultural informants. This work could help improve dialogue and familiarity with one another and aid in future collaborations through web conferencing.

To capitalize on motivation for extracurricular activities, 50 Norwegian partner students were recruited from those planning for a later international experience, student parliament or international and student welfare committees. Once established, the small groups and dyads were self-reinforcing as the meaning of comparative dialogue provided learning from converting the known to the unknown (for Norwegian students) and the familiar to the unknown (U.S. students). The combination of articulating one’s own culture and health care system, and active listening to broad perspectives, moves learning beyond telling a story—adding a critical, comparative opportunity to be shared with peers. Based on spontaneous feedback and conversations with the Norwegian students involved in this pilot, most reported both academic and personal beneficial effects from the collaboration with the U.S. students.

A few factors played into the small numbers of Norwegian students. The day of the week when we both could meet was Friday. The time of day that the U.S. students could meet (9:00 A.M. EST) created a major conflict for the Norway students being able to commit (3:00 P.M. CET). It was difficult for many Norwegian students due to the weekend and heading out of the city to go back home. We intend to plan differently moving forward so that student groups may be more similar in size. This will enable us to obtain more information about learning outcomes and rich qualitative data from both student groups.

Students’ own world views framed their experience with others from different cultures. The experience and reflective assignment linking storytelling with interpretation and analysis, invites multiple perspectives as it provides students an opportunity to explore cultural differences, thus enhancing the cognitive involvement through coconstruction of knowledge using collaborative reflections (Schaefer et al., 2020). This experience highlights the importance of learning from others to create new understandings of cultural differences through an authentic, HIP learning experience.

Holding more than one web conference between the same groups is effective in alleviating stage fright, allowing students to relax in the multicultural classroom. A discussion assignment and global partner pairs help familiarize the students to each other, thus alleviating stress and adding excitement by connecting virtually via web conferencing.

It is helpful to have technical support staff available to assist with any technological issues so that the streaming web conference can occur with as little interruption as possible, further adding to the realism of the virtual study abroad. Room design is another factor that can be difficult; The lecture hall in the United States was large and it was hard to capture video of all of the students at once. The U.S. lecture hall size also posed a problem with the group in Norway being able to hear, so the students in the United States walked to the podium microphone and that took time. Therefore, room selection that offers a cozier fit with closer proximity to the microphone(s) would be suggested. Attention to these details would enable students to more fully engage and absorb the experience with as little technology distraction as possible.

We gained experience integrating classroom activities that facilitated global learning via real-time web conferencing for those students who did not go overseas, extending the experience beyond those of students studying abroad. Our data revealed that this virtual exchange was effective for all U.S. student participants in learning about global collaboration, appreciation of culture, new perspectives, and technology. For those students who stayed home and participated remotely via web conferencing, they learned about higher education cost differences and impact, experiences of student nurses, role of nurses, health care systems, care differences, and a desire to learn more/continue such virtual exchanges.

We plan to include continuation of this virtual international collaboration annually, if not each semester. We also intend to collect feedback from students at each institution to learn similarities and differences in student lived experience through this novel teaching–learning strategy, a virtual study abroad.

Conclusion

This partnership of faculty from academic institutions across the globe, connecting in Norway and through synchronous web conferencing, advanced cultural and health care comparisons while building global citizens in nursing. With purposeful, informed preparation for the international experience as well as the virtual global classroom, integrating a global health perspective in nursing curriculum positively affected students who traveled for an overseas experience, those in the host institution, and those who continued in their home-based program. It is clear that students in the United States, who remained at home learned about their international partners through this virtual study abroad experience, particularly salient given the current COVID-19 pandemic. Creating learning strategies through which students develop intercultural competencies is important for broad reach and sustainability regardless of student financial impediments, scheduling conflicts prohibiting travel, or worldwide disease. While nothing can supplant the cultural richness of physically visiting another country, this work offers insight into how faculty may continue to engage in global learning experiences without travel.

Footnotes

Acknowledgements

We thank Lars Mathisen, PhD, RN (Dean, Lovisenberg Diaconal University College, Oslo, Norway), for conceptualizing the living avatar, and for interpretive comments and critique during preparation of this article.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Tara Spalla King

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