Creating International Student Experiences Through Academic–INGO Partnerships

Introduction

In the United States, changing demographic trends, catalyzed by an interconnected world and shifting patterns of migration, necessitate the need for health care workers who can offer culturally appropriate care for patients from diverse racial, ethnic, and cultural backgrounds (Choi & Kim, 2018). This is particularly important in undergraduate nursing education because the new entry-level essentials highlight the importance of developing and assessing global health competencies to ensure nurses fulfill their social responsibility to support health equity for all people (American Association of Colleges of Nursing [AACN], 2021). An understanding of global health is needed not only to support nursing practice with diverse patient populations but also to support nursing’s role in developing and advocating for policies that influence population health in local, national, and international levels (AACN, 2021).

Koplan et al. (2009) defined global health as “an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide” (p. 1995). Because of their critical role in supporting international health equity, health care professionals must develop the knowledge, skills, and values necessary to support global health and provide culturally appropriate care. To this end, students of the health professions increasingly participate in short-term experiences in global health (STEGHs), during which they engage in activities that include clinical practice and public health outreach within hosting communities (Prasad et al., 2019). These experiences are often undertaken in low-middle-income countries (LMICs) that have a deficit of health resources and stand to benefit from the services provided by visiting student groups.

Involvement in STEGHs can nurture an appreciation for global health issues and facilitate the development of cultural awareness (de Diego-Lázaro et al., 2020; Walters & Nwagwu, 2020). However, without thoughtful and careful implementation, STEGHs may cause inadvertent harm by taking advantage of a host community’s hospitality and resources while offering communities little in return (Loya & Peters, 2019; Melles, 2018; Nyunt et al., 2022). For example, student groups can burden the time of local health care workers, or communities might become reliant on outside aid and subsequently fail to develop local resources or solutions. Furthermore, challenges to the sustainability of health interventions initiated during STEGHs can impede achievement of appreciable improvement in local health outcomes (Levi, 2009). To illustrate, utilizing technology or medicines that are not available to the community may improve outcomes in the short term; however, the impact of such interventions would have negligible impact on health outcomes in a community that does not have access to those resources. Accordingly, care must be taken to design such experiences in a way that provides lasting benefits for hosting communities.

One strategy that academic institutions can use to design effective, mutually beneficial STEGHs is through development of a cross-cultural partnership with an international nongovernmental organization (INGO). It has been well established that INGOs play a key role in humanitarian work and provision of health outreach in underserved communities throughout the world (Pillay, 2022; Storeng et al., 2019). However, there is a paucity of descriptive information about academic–INGO partnerships for creating mutually beneficial STEGHs and educational partnerships. The purpose of this article is to describe the relationship between our undergraduate baccalaureate nursing program at Kennesaw State Universtiy and Comunidad Connect.

Academic–INGO Partnership

STEGH Development

In 2014, two nursing faculty at KSU identified STEGH as a strategy that could provide valuable, real-world clinical experience in global health for students. One faculty member had created an elective nursing course that allowed students to experience nursing in Eswatini, while the other faculty member had shadowed STEGH in rural Nicaragua. The faculty envisioned STEGH that could provide students with clinical hours in an international setting. Based on their experiences, faculty decided that a program in rural Nicaragua could offer a robust community health clinical experience. Many rural communities in the country struggle with access to health care and primary care is delivered through the public sector, lending well to an experience focused on population health.

After researching INGOs working in Nicaragua, faculty identified CC as an organization that resonated core values of our nursing program. In particular, CC’s strength-based approach to working with communities mirrored the philosophy espoused in the community health course. In addition, the organization would lend itself to the development of STEGH that could contribute to sustainable health benefits for hosting communities.

Faculty contacted the co-founder of CC, who lived in Atlanta, to schedule an initial meeting. The CC representative oriented faculty to the organization, its mission and values, and types of health initiatives they oversee. To ensure that the match between the organizations was appropriate, faculty traveled with INGO representatives to several Nicaraguan communities where they were able to observe the sustainable approach to community health used by CC. Together, the faculty and INGO representatives developed a draft itinerary that would meet the needs of the students while contributing to CC’s meaningful and sustainable community outreach.

Each STEGH begins with an assessment and planning phase. Faculty review the needs of the students and the types of activities necessary to meet course objectives. Representatives from the INGO outline current community priorities, ongoing health initiatives currently being implemented in the community, and areas that might be appropriate for student involvement. Aligning academic and community goals ensures that the program respects the mission, values, and philosophies of both institutions.

The brigadistas are instrumental to the success of the STEGH, not only by sharing their knowledge but also by working alongside students in the community. Thus, when students come to Nicaragua, they collaborate with ongoing projects that continue after they have departed. Examples of these activities include building clean cookstoves for families, laying concrete floors in family homes, and painting walls in homes with a mixture that attracts and kills mosquitoes. When participating in these activities, students learn about the relationship between the environment and health. For example, the clean cookstoves reduce the amount of smoke in the home and decrease respiratory illnesses, and the paint mixture helps to reduce the number of mosquito-borne illnesses. While in the homes, students also learn about the importance of clean water and how these families use and maintain their bio-sand water filters.

Students are also involved in developing and providing short, culturally appropriate health charlas for community members. The brigadistas are knowledgeable about the health education needs and provide significant input on the topics selected. Prior to implementation of the charla, the faculty and brigadistas review the content to ensure that it is accurate and culturally appropriate.

Conducting a family assessment using an interpreter has become a mainstay activity for students. During the family assessment, students gain proficiency in conducting an essential nursing skill. In turn, the INGO and community stakeholders are made aware of the families’ health priorities and needs. The brigadistas and local health care providers are able to develop appropriate interventions to meet the health challenges faced by the community’s most vulnerable members.

In addition to learning experiences within rural communities, students also visit local health care facilities. This activity provides students with a broader perspective of the country’s health care system, including the health and socioeconomic priorities and challenges. Students also learn about the approaches used to address obstacles related to accessing health care access. Finally, students are educated about Nicaragua’s culture and history through guided cultural experiences and community-based tourism.

Once the program itinerary is established, faculty recruit 12 students who are enrolled in the community health nursing course. During orientation to the STEGH, students meet with representatives from the INGO, who provide a deeper overview of the communities. While on the trip, INGO staff travel with students, creating opportunities for learning that always include the community perspective. At the end of each day, students participate in a debriefing session facilitated by faculty and INGO staff. Faculty can assist students in linking their experiences with course objectives. Similarly, the INGO staff help students connect their actions to the larger goal of maximizing community health and well-being. Students are also required to reflect on their experiences through reflective journaling, a process that further reinforces learning and achievement of course objectives.

Benefits for Students

Students benefit from the NGO–academic partnership in several ways. First, a program designed in collaboration with faculty and INGO leadership creates a rich experience that is not only educational but also allows students to engage in meaningful health outreach that they perceive as rewarding and contributes to personal and professional development. Faculty provide insight necessary for effective learning strategies, while the INGO ensures that activities are grounded in the community’s needs and priorities, and that the work can be sustained once students return home. Upon returning home, many students comment during post-trip meetings and reflective journals that the experience was “life changing” and that their time abroad would resonate throughout their nursing careers.

Many students felt that working side by side with the INGO increased their knowledge and appreciation for the community and families with whom they worked. Sharing their days with INGO staff gave students the sense that they were part of a team that was serving a larger purpose. Students often commented that the friendships they built with their INGO guides were rewarding and an impactful outcome of the program.

A common theme noted by reviewing student reflective journals was cultural appreciation. Many commented how they would be more empathetic when working with patients from backgrounds that are different from their own. One student stated,

I think my time in Nicaragua will make me a better nurse, because before I never really had stopped to think what it would be like for a patient who can’t speak English or who doesn’t understand how our healthcare system works.

Still other students remarked how their experience in another community gave them a greater sense of being part of a larger global community. “The strange thing is that I saw a lot more similarities than differences,” a student reflected. Another student shared, “The trip actually made the world feel smaller, like I know it sounds cliché, but it really made me feel like we are all part of one big community.” Some students were inspired and humbled by the sense of community they experienced while abroad. “It was amazing to see how the community all came together, to see how . . . enmeshed they are in each other’s lives. I don’t get that feeling of community at home,” one student wrote. Many students viewed INGO staff as role models, who exemplified what is to be a global citizen.

Benefits for the Community

The work that KSU nursing students perform in Nicaragua has benefited the community in multiple ways. First, family assessments performed by students provide CC with information about the health needs of some of the community’s most vulnerable residents. KSU faculty share the results of the assessments with the INGO, including recommendations for family-level interventions that address the identified health needs. Student assessments and recommendations thus become the foundation for outreach provided by CC, the brigadistas, and subsequent groups of volunteers. For example, a student interviewed a family consisting of a mother and two adult children, one of whom had significant cognitive and emotional disability. During the interview, students recognized that the mother was experiencing severe caregiver stress, and with their INGO guides, were able to suggest several strategies to alleviate the mother’s burden. Over the years, multiple families were identified who had similar needs, and CC was able to leverage their resources, their connections with Nicaragua’s Ministry of Health, and the knowledge and skills of volunteers to develop sustained interventions to improve the health and quality of life of these residents.

The STEGH further benefits the community through financial support. Program fees are paid by students as part of a study abroad fee and include travel costs, meals, lodging, INGO overhead, and fundings for projects and community initiatives. CC invests funds raised by STEGH program fees in community development programs. The monies raised by hosting visiting groups have contributed to projects such as the refurbishment of a local health clinic, access to clean water filters, improved floors for resident homes, and improved ovens and stoves that reduce community exposure to hazardous smoke generated by cooking.

Lessons Learned

Each STEGH that we have conducted in Nicaragua has been a unique experience for students, faculty, and the INGO representatives. Despite the extensive planning that goes along with each trip, we have found that flexibility during the trip is crucial and can be the key to a positive learning experience. Students and faculty need to be prepared for changes in the itinerary on a moment’s notice. For example, on our first trip we had planned to survey the community about their knowledge on diabetes. The evening before data collection was to begin, the son of a prominent community member was killed in an automobile accident. All activities in the community were postponed for several days so that mourning of the victim could be conducted, and community members could visit the family to pay their respect. Despite the family’s loss, observing how the community came together to support the family was a valuable learning experience for the students.

Flexibility is important but there are additional key elements that we know contribute to a productive trip. These include the following:

Conclusion

Given recent global events—including the continuing COVID-19 pandemic, worldwide food shortages, global climate change, and recent outbreaks of armed conflict—the importance of global health concepts in health professions curricula has become increasingly clear. Faculty of the health professions must find ways to prepare future health care workers to work in a global society and address the challenges that a globalized society brings. Implementing STEGHs is a common strategy used in academia to integrate global health concepts into curricula, but it is one that warrants careful consideration to ensure programs do not take advantage of hosting communities.

Our STEGH has important implications for nursing students. Participation provides students with opportunities to compare differences and similarities in health care between their host community and their own community, recognize and appreciate barriers encountered by vulnerable populations, examine their own biases, and engage in practice within the context of a culture other than their own. These opportunities enhance students’ ability to provide culturally appropriate nursing care, an essential characteristic needed in contemporary nursing practice, and represent an important strategy to assist students in meeting the global health competencies identified in the AACN’s (2021) new essentials of nursing education.