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Globally engaged nursing education: An academic program framework
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Globally engaged nursing education: An academic program framework Mary E. Riner, PhD, RN* Department of Environments for Health, Indiana University School of Nursing, Indianapolis, IN
article info
abstract
Article history: Received 30 November 2010 Revised 19 March 2011 Accepted 12 April 2011 Online 23 July 2011
Objective: This paper presents a model for designing, providing, and evaluating
Keywords: Global health International Nursing education Program framework
global experiential education, both local and internationally. Methods: A literature review was conducted to identify studies and models of global nursing education experiences in the scientific indexed literature and the gray literature on the Internet published by professional associations. Results: Key elements of the model developed include institutional and program mission and goals, global health core content, program characteristics, student characteristics, reflection, and perspective transformation. These factors combine to address the range of interweaving factors that need to be considered in providing well-designed global health offerings. Conclusions: The framework is offered for use in developing global experiences and in conducting studies to advance our understanding of what and how students learn and are transformed from participation in global education. Cite this article: Riner, M. E. (2011, DECEMBER). Globally engaged nursing education: An academic program framework. Nursing Outlook, 59(6), 308-317. doi:10.1016/j.outlook.2011.04.005.
Global health is concerned with saving lives by improving health throughout the world.1 Nurses are engaging in global health, both locally and internationally, as employees and volunteers with a diverse array of government, military, philanthropic, faithbased, academic, and health care organizations. Nursing students and our multicultural communities are challenging schools of nursing to provide global health education experiences as part of the nursing curriculum.
from engaging students with local immigrant and minority populations to taking students to other US communities to taking students abroad for international experiences. By engaging students in a range of global health education experiences, schools’ graduate nurses are prepared to participate in contemporary multicultural communities. Nurses with a global health perspective can contribute to our global civil society as informed citizens and to health care agencies by providing high-quality care to all persons.
To meet this challenge, nursing schools and faculty are providing nursing education experiences ranging
There is no single term that covers all the concepts encompassed by the words international, global, and
*Corresponding author: Dr. Mary E. Riner, Associate Professor, Department of Environments for Health, Indiana University School of Nursing, 1111 Middle Drive, NU 482, Indianapolis, IN 46202. E-mail address: [email protected] (M.E. Riner). 0029-6554/$ - see front matter Ó 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.outlook.2011.04.005
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intercultural. The American Council on Education (ACE) developed a helpful glossary that uses global learning as shorthand for 3 related types of learning: global (denoting the systems and phenomena that transcend national borders), international (focusing on nations and their relationships), and intercultural (focusing on knowledge and skills to understand and navigate cultural differences). ACE defines global learning as “the knowledge, skills, and attitudes that students acquire through a variety of experiences that enable them to understand world cultures and events; analyze global systems; appreciate cultural differences; and apply this knowledge and appreciation to their lives as citizens and workers.2 This definition weaves together a range of local to international education experiences. Although much has been written about global education for nursing students, little evidence exists about the design of these educational experiences in relation to what and how students learn. The purpose of this paper is to present a model of global engagement education for use in designing, providing, and evaluating experiential education locally and internationally. Major components of the model include global health core content, program characteristics, student characteristics, reflection for assessment, and perspective transformation. The ultimate goal is for nurse educators to have a conceptual model useful for developing, providing, evaluating, and conducting research on global engagement experiences.
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students who participated in global experiences than in students who did not.4,9 Students developed knowledge of reciprocity in relationships with others, an appreciation for the whole person,8 and they recognized universal human characteristics.7 They developed personal knowledge that led to increased self-confidence,7 and reported value changes and increases in tolerance, awareness of biases, and sensitivity to patient and family needs.6 They identified an appreciation for encountering opportunities of their host country culture.10 Students also perceived an increase in personal development as reflected in personal decisions and philosophy, values, and beliefs.9,11 The experience assisted students in clarifying career path/goals and increased motivation to continue service work.8 A 2-year alumni survey used Leininger’s model to study long-term impact of an international experience. Nurses reported using concepts of culture care accommodation and preservation in caring for Spanishspeaking immigrants and using the concept of culture care repatterning to use supplies more conservatively in recognition of the severe shortage they observed while abroad.8 When nursing curriculums include global experiences, students are more likely to develop global attitudes and view events from a world perspective. They are also more likely to value solutions to problems that will not only benefit them but will also benefit the broader world arena.12-14
Background Education Models Student Learning Rich reports of student learning outcomes are found in the international literature. Many studies used grounded theory and investigator developed tools. Results indicate that students’ world views were broadened3e5 and cultural awareness and understanding increased, as did awareness of cultural variations.6 Students developed nursing-specific skills including intercultural communication, provision of culturally appropriate care, and effective use of self.7 They found ways to respect the sacredness of the experience and advocate for change to improve health.8 Experiences abroad were found to increase understanding of population-based health problems,7 social justice, and globalization issues,8,9 and how access to sociopolitical resources influence health care.7 Seeing first-hand the reality of poverty, lack of housing, and malnutrition brought home to students the reality and impact of social factors on health.5 Students gained attitudes of appreciation versus criticism toward the US7 or changed perceptions about their own or the host culture.9 Cognitive development was higher in
The question that follows from identifying this wide range of student outcomes is how can we understand the design of the education experience in relation to student learning. Although 2 recent books on research in study abroad and conceptual frameworks for international service learning have been published, the development of educational models is in its early stage.15,16 2 models were identified in the nursing literature that address program design. Ryan and colleagues6,17 used a grounded theory approach to develop a conceptual map depicting processes and outcomes of an immersion experience. The process factors confirmed were situational predetermining factors of the program and student, modifying factors related to the onsite experience, and transitional factors involving strategies to adapt. These factors were considered key to achieving the student outcomes of personal and professional new views of self and practice. Haloburdo and Thompson7 developed a model of 4 components. The faculty role involves preplanning and orientation with defined expectations, post-experience
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debriefing, and feedback. The second component entails whether the experience includes direct nursing care, the type of country selected for the onsite experience, and course objectives. The last 2 components comprised integrating the experience into the curriculum, the length of time onsite, and the intensity of the learning experiences guided by a faculty or a liaison at the locale. Based on this emerging work on model development, a need for a comprehensive program education model was identified that would address the complex array of components involved in developing, designing, providing, and evaluating global nursing education experiences. The model presented here is built on the belief that comprehensive globally focused education experiences need to: (1) be framed within the institutional and program missions and goals, (2) include global health core content areas, (3) consider program and student characteristics, and (4) include reflection as a form of assessment and perspective transformation. The model presented is designed as a continuous feedback loop that involves these factors.
experiences allowed for progressive understanding to evolve of issues important in global experiential education. Once the key components of the model were identified, the literature was reviewed and synthesized for each component. Although the framework is presented in a linear fashion, it is important to note that system dynamics underlie it and that it models a continuous feedback loop.
Description of the Framework Institutional and Program Mission and Goals The mission and goals of the academic institution and nursing program serve as a springboard for deciding to offer global health courses, the type of experiences considered relevant, and development of affiliation placements. In a similar vein, changes in these goals can serve to increase or decrease the emphasis placed on global experiences. For example, when the university president sets a goal of engaging 10% of the student body in global experiences, this can result in new emphasis and resources being made available within the nursing program.
Methods A literature search was conducted using the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PubMed databases. Key search terms were global health, international health, international education, and study abroad. The search phrase “global learning AND higher education” yielded 88 articles with 20 retained, “international learning AND nursing” yielded 212 articles with 25 retained, “study abroad AND nursing” yielded 59 articles with 13 retained, and “international nursing AND higher education” yielded no articles for retention. Inclusion criteria were the literature had to be peer reviewed, English language publications; case studies of international programs; grounded theory; descriptive and experimental design studies; and conceptual articles on global education. In addition, a web search was conducted to identify important gray literature from professional associations involved in developing standards of best practice. The globally engaged nursing education framework (Figure 1) was also informed by the author’s experiences in providing global education. This included 12 years of experience in leading international, service-learning programs; participation in a 4-year initiative to embed global health experiences within the community health nursing practicum course in a local US-based community; involvement in an interdisciplinary, academic faculty learning community; a 6-year engagement in a multidisciplinary partnership with faculty and students at a university abroad; and participation in national academic learning initiatives about best practices in international service-learning. These
National nursing education bodies have standards for baccalaureate nursing education that can also be used to develop global learning experiences.18,19 Through a quad-level articulation process, faculty members can create curriculum plans that meet university mission and goals, national nursing education standards, program outcomes, and course competencies.
Global Health Core Content The global health core component of the model includes four areas of learning important to promoting student development of knowledge, skills, and attitudes for engaging in global health. Academic learning in the classroom serves as the foundation for the engagement experience. Learning can also be expected to occur throughout the experience and to occur in a new and more meaningful ways as the experience unfolds over time as a result of the experience.
Global Learning The use of global learning definitions, guidelines, and principles of learning to design the curriculum allows educators to start with the end in mind. Global competency is described by Brunstein20 as “a developed appreciation of other cultures and the ability to interact with people from foreign lands.” Hunter cites Brunstein in Brunstein identifying 5 dimensions that address important knowledge, attitudes, and skills. They include (a) the ability to work effectively in different international settings, (b) an awareness of the
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Figure 1 e Framework for globally engaged nursing education.
major current events of global change and the issues arising from such changes, (c) knowledge of global organizations and business activities, (d) capacity for effective communication across cultural and linguistic boundaries, and (e) a personal adaptability to diverse cultures.18 Many universities have goals, guidelines, or objectives for use in developing international curricular learning objectives.2 At one university, the International Learning Guidelines (Figure 2) were developed by a core faculty group as part of an international learning lab sponsored by the American Council on Education.21 These guidelines, or similar ones developed at a local institution can be used for designing global experiences.
Core principles of undergraduate learning is another faculty resource. At this same university, one of the principles is Understanding Society and Culture. It is defined as the ability of students to recognize their own cultural traditions and to understand and appreciate the diversity of the human experience.22 The outcome calls for students to demonstrate the ability to (a) compare and contrast the range of diversity and universality in human history, societies, and ways of life; (b) analyze and understand the interconnectedness of global and local communities; and (c) operate with civility in a complex world.22 Together these types of resources provide academic support and structure for designing and evaluating
Figure 2 e International Learning Guidelines.21
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global education experiences. These dimensions can be addressed in a variety of ways in orientation programs, course work, and experiential learning opportunities.
International Service-Learning and Social Consciousness International service-learning is considered a proven strategy of engaged learning that stands out as an effective means of increasing global awareness and knowledge, of deepening cross-cultural understanding and appreciation of diversity, and of experiencing some other part of the world first hand.23 It has been defined as “a structured academic experience in another country in which students (a) participate in an organized service activity that addresses identified community needs; (b) learn from direct interaction and cross-cultural dialogue with others; and (c) reflect on the experience in such a way as to gain a deeper understanding of global and intercultural issues, a broader appreciation of the host country and the discipline, and an enhanced sense of their own responsibilities as citizens, locally and globally.”24 Within nursing, international servicelearning experiences can include clinical services in a health care agency, community health promotion and education, and general service to the community intended to improve health conditions such as building a modern cooking structure to prevent burns from fires in a developing country, or tutoring adults learning English in a US community center. Social responsibility is important to national and international nurses’ organizations. When we view the global community as within nursing’s scope of practice, we find a call for being knowledgeable about the global health conditions25 and accepting the responsibility for initiating and supporting actions to meet the health and social needs of communities.26 Threading the development of global social consciousness into educational experiences can move students from distant objectivity about global health issues to close-up and personal experiences where they are more likely to care about what happens among people of other countries.24 Social consciousness has been described as “the nurses’ personal awareness of social injustices in their lives and in the lives of others and whether they are able to take action to address them.”27
Campinha-Bacote’s definition of cultural competence is particularly useful because it is developmental and focuses on nursing work within context. CampinhaBacote defines it as an “ongoing process in which the health care professional continuously strives to achieve the ability and availability to work effectively within the cultural context of the client (individual, family, community).”29 The learning experiences need to be designed using cultural competence models to take advantage of conceptual knowledge. For example, Leininger’s Sunrise Model was used by the author to help students learn about the health and community characteristics of population groups in both the local and international experiences. Purnell’s model was used to guide the interview questions when students conducted a family assessment in another country. Currier et al3 suggest that nursing shift from a cultural competence orientation to global cultural competence. This would require not only development of knowledge, attitudes, and skills about cultural differences, but also about the cultural, social, political, and economic systems that shape individuals’ lives on a global scale, the complex interactions among people, the moral and ethical obligations people have to one another, and how these influence health and health care. Using this type of approach, faculty can facilitate students’ capacity to address the health care needs of any person they encounter, regardless of their cultural background and where they encounter the person. Students can develop the knowledge, critical thinking, creativity, and problem-solving abilities to situate a given individual into the larger field of complex interacting forces that affect both their health and their access to the resources they need to regain their health. Language development is an important concern for developing cultural and global competence. It is a particular challenge for nursing programs where students are challenged to include a foreign language course in their program of study. Many universities offer short courses on language development for specific purposes like health care that can be incorporated into orientation sessions before departure for another country. The Center for Advanced Research on Language Acquisition31 has developed materials for students and faculty to support language and cultural learning to maximize study-abroad experiences as engaging and instructional.
Global Cultural Competence Development Country-Specific Knowledge Cultural competence is a key element of global engagement education. Without it, there is little likelihood of successful global engagement experience from which students experience growth and transformation. The works of Leininger,28 CampinhaBacote,29 and Purnell30 were most frequently used in the literature as models in global education courses for teaching cultural competence development.
Knowledge of the major health problems experienced by people in or from another country allows students to anticipate the care they may be expected to provide. Leininger’s Sunrise Model is a useful tool for designing learning experiences about the broad community sectors that influence health. Knowledge of these sectors allows students to understand health
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and the health care system within the context of the broader culture. The factors are technological, religious and philosophical, kinship and social, cultural values and lifeways; and political and legal, economic, and educational.28 Using these areas, faculty can develop learning assignment and experiences so that students develop culturally situated knowledge that allows them to appreciate the circumstances and world view of people for which they are providing care. Knowledge of the structure and delivery of health care in the host country offers students academic understanding of the services provided. Hands-on experience offers operational understanding of the process of delivering care and allows students to engage in providing nursing care. The World Health Organization (WHO) promotes understanding how non-health factors, or social determinants of health, influence health. Social determinants of health are the conditions in which people are born, grow, live, work, and age, including in the health system. These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels, which are themselves influenced by policy choices. The social determinants of health are mostly responsible for health inequitiesdthe unfair and avoidable differences in health status seen within and between countries.32
Program Characteristics Characteristics of the program are important to consider because they can influence how and what students learns.17,33 The 3 phases of the program are preexperience, onsite, and post-experience. Although the phases are arranged in a linear fashion, they are interconnected and simultaneously influence each other. For example, prior work by the faculty in developing a partnership with host agency staff can significantly influence the quality of the onsite learning experience.
Characteristics of the Pre-experience Initial preparation involves developing a well-designed program that is reviewed and approved by the school and institution. It requires establishing specific learning objectives that meet academic goals; developing the host community agency partnership and personal relationships with staff; planning for program administration; housing and meal arrangements; budgeting and fundraising; securing qualified faculty; and marketing, recruiting, and advising students.4,5,7,34-37 Pre-experience orientation and preparation of students is essential for maximum learning and adaptation during the experience.17 Students will adapt to the
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culture and have a more positive experience when they have specific knowledge about the design of the program and what they will be doing; where they will be living and having meals, the types of cultural sight-seeing experiences they can expect, and information about the clinical nursing experience, if applicable, in which they will participate.17 Additional best practices in preparation include language acquisition and cultural knowledge of the host community people; health precautions; and safety strategies including university policies, host country laws and best practices, ethical conduct, an orientation to service-learning, ethics of service in another country, and effectively representing the school and country.38-40 Learning strategies useful for preparing students need to address cognitive and affective learning. The orientation should use a range of strategies to maximize learning. Strategies may include readings with discussion, speakers, Internet research, case studies, role play, hearing from past students about their experiences, coping strategies for stress management, retreats for team building, and video conferences with the host agency staff.
Characteristics of the Onsite Experience The faculty role in facilitating the onsite experience is foundational to student adaptation and learning. When faculty members assist students in developing personal relationships with host country individuals and adapting to the local cultural and communication patterns, students can be expected to develop more positive attitudes that will facilitate adaptation to the experience.15 The design of the experience can be expected to influence development of increased cultural competence by focusing on the difference in the students’ existing worldview and the differences encountered during the experience. Six intersecting aspects of a cultural encounter can be used to understand how cultural competence is developed within a studyabroad experience. They include: (1) length of the encounter, (2) regularity and nature of contact with local residents, (3) level of cultural immersion and country characteristics, (4) socioeconomic congruence between the encounter site and the site of student origin, (5) cultural congruence between the encounter site and the student’s country of origin, and (6) need to learn a new language.34 These factors are supported by Kiely,33 who proposes that there is a direct relationship among dissonance type, intensity, duration, and the nature of learning processes that result. Service can be clinical work in a health care setting or agency, or it can be a project within the community that may have been initiated by the US agency. If the learning objectives focus on developing nursing knowledge of the host country, the experience needs to include contact with nurses and other health providers
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and patients where agency arrangements have been negotiated. Some schools operate free-standing clinics over spring break or the summer. These can be effective when there is strong involvement of local providers.41
Characteristics of the Post-experience The post-experience period is critical for assimilation and transition back home. It may involve individual and group debriefing; sharing a meal and photos; submitting required learning assignments and reflection journals; and public presentations to campus audiences, friends and family, financial supporters, and other interested persons. This is a time of reflection during which students incorporate the experience into their identity. Students submit final course assignments that focus on cognitive, personal, and professional development. Assignments need to be designed to elicit student awareness of changes that have occurred within themselves. It is important to recognize the interplay between the program context and the learner context at all 3 stages of the experience. Students select experiences for individual reasons, they engage in the experience based on their individual characteristics and bring closure to the experience differently. Reflection throughout each stage of the experience allows students to become aware of their motivations, values, and responses to challenges and how they are changing and have been changed as a result of the experience.
Learner Characteristics Kiely33 believes that when a student determines that they will engage in an international program, she or he is making a decision that involves contextual border crossing and this is the beginning of a transformational learning experience. Learner characteristics were rarely addressed in the studies reviewed. Understanding these characteristics can contribute significantly to understanding the learning achieved by students. Keily33 identifies 3 contextual borders that need to be considered to understand what and how students are transformed from global experiences and the differences among students. The contextual borders are personal (ie, personality traits, social roles, professional background); structural (ie, race, class, gender, religion, nationality); and historical (ie, current cultural, political, and socioeconomic positions between the student and the service site).33 Taken together, they represent characteristics Kiely believes influence how the learner responds to and experiences a major challenge to their world view. Four additional themes identified by Kiely are important to take into consideration. The degree to
which each student experiences dissonance, or incongruence, between their prior frame of reference and aspects of the learning context will shape the intensity of learning. High-intensity dissonance can result in ongoing learning. Dissonance types include historical, environmental, social, physical, economic, political, cultural, spiritual, communicative, and technological.33 The second theme is personalizing and represents how participants respond individually to and learn from different types of dissonance. Kiely describes it as visceral and emotional and compels students to assess internal strengths and weaknesses. Emotions and feelings include anger, happiness, sadness, helplessness, fear, anxiety, confusion, joy, nervousness, romanticizing, cynicism, sarcasm, selfishness, and embarrassment.32 The third theme is processing and is both an individual reflective learning process and a social, dialogic learning process. Processing consists of posing a problem and questioning, analyzing, and searching for causes and solutions to problems and issues. It occurs through various reflective and discursive processes such as journaling, reflection groups, community dialogues, walking, research, and observation.33 The last theme is connecting. It represents learning to affectively understand and empathize through relationships with community members, peers, and faculty. It is learning through nonreflective modes such as sensing, sharing, feelings, caring, participating, relating, listening, comforting, empathizing, intuiting, and doing.33 Ryan and Twibell17 make several propositions that parallel Kiely’s work.33 They propose that high degrees of personal flexibility result in more effective adaptation, that increased social support contributes to effective adaptation, that effective coping responses result in increased personal and professional growth, and that increased adaptation in the immersion experience is associated with increased personal and professional growth.
Reflection Reflection plays a key role in facilitating students’ capacity to articulate the academic learning, personal growth, and global engagement that occurs from experiential learning.42-44 In a concept analysis of reflection, Rogers describes it as a cognitive and affective process or activity that (1) requires active engagement on the part of the individual; (2) is triggered by an unusual or perplexing situation or experience; (3) involves examining one’s responses, beliefs, and premises in light of the situation at hand; and (4) results in integration of the new understanding into one’s experience.45
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In experiential education, reflection provides the transformative link between the action of serving and the ideas and understanding of learning.46 Eyler and Giles47 found that the more rigorous the reflection in service-learning, the better the learning, including academic outcomes; deeper understanding and better application of subject matter; increased complexity of problem and solution analysis; and openness to new ideas, problem-solving, and critical thinking skills. Effectively designed reflection is based on clearly defined learning goals, reflection prompts, and feedback to students that assists them in furthering their critical thinking about their learning. Reflection that is written down using a structured process has been referred to as articulated learning. In the model developed by Ash et al,43 4 guiding questions assist student reflection: (1) What did I learn?; (2) How, specifically, did I learn it?; (3) Why does this learning matter; and (4) In what ways will I use this learning, or what goals shall I set in accordance with what I have learned to improve myself, the quality of my learning, or the quality of my future experiences or service?43 Examples of a reflection prompt for the 3 key areas of learning are: (1) academic learningdWhat specific elements of our course materials related to this experience?; (2) personal growthdHow did this experience make me feel (positively and/or negatively)? How did I handle my emotions?; and (3) global engagementdWhat was I/someone else trying to accomplish?
Perspective Transformation Reflection is a core element of Transformational Learning Theory, a conceptual framework developed by adult education scholar Jack Mezirow.48,49 Transformational Learning Theory is proposed here as a way to understand and explain the relationship between the student and the global learning experience. In this
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theory, perspective transformation is the process of becoming critically aware of how and why our assumptions have come to constrain the way we perceive, understand, and feel about the world; changing these structures of habitual expectation to make possible a more inclusive, discriminating, and integrating perspective; and, finally, making a choice or otherwise acting on these new understandings.50 Transformative learning is a process whereby individuals engage in critical reflection to develop new perspectives, skills, and behaviors. According to Mezirow, “learning involves critical self-reflectiondreassessing the way we have posed problems and reassessing our own orientation to perceiving, knowing, believing, feeling and acting.”48 When individuals experience significant change in the way they understand their identity, culture, and behavior, they experience a perspective transformation.48 Mezirow’s stages of perspective transformation were used to frame prompting questions for student reflection assignments (Figure 3). These questions can facilitate the student’s reflection so that new knowledge, attitudes, and skills gained from the experience may have resulted in new views themselves, and opened up new possibilities for action. Drawing from the work of Ash et al43 and Mezirow,48 faculty can design reflection experiences that engage students in articulating their learning related to intended outcomes, like those in Figure 1. By specifically linking the reflection process to intended learning goals, students can articulate learning about academic learning, personal growth, and global engagement in health. We can use perspective transformation and reflective action pedagogy to understand taking the perspective of a globally engaged nurse. From Linthicum’s51 perspective as a community development specialist both in the US and in other countries, when people act, their action then affects the way they think
Figure 3 e Prompts for investigating perspective transformation in global engagement experiences. Adapted from Mezirow.48-49
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and vice versa. Action and reflection feed on each other, with each action leading to a deeper and more insightful reflection that in turn leads to a more courageous action.51 The purpose of learning from Paulo Freire’s perspective is the “rediscovery of power such that the more critically aware learners become the more they are able to transform society and subsequently their own reality.”52
Discussion In addition to using the GENE framework for designing global education experiences, it can be used in program evaluation and educational research. Program evaluation involves measuring aspects of the program design to identify their contribution to achieving course, program, and institution mission.46 There are several areas that need to be evaluated. They include university and school support and resources, site experience, student participation and financial support, and faculty preparation. It also includes achievement of program goals, program experience, and faculty and course evaluations. The evaluation component should include a program director report to allow summative qualitative reporting of the experience, student participation, and grade outcomes. These factors are dynamic and changes in any of them can significantly affect the program delivery. Educational research is needed to understand what and how students learn from global education experiences and how it relates to their practice of nursing.3,17 Work is currently underway to test the model’s capacity to demonstrate relationships of each component to student learning. Specific quantitative and qualitative measures and protocols are being developed. Partnerships with other schools are being developed to have sufficient numbers of students engaged in varying types of programs, with similarity in experiences to allow generalizability of findings.
Limitations The model presented here includes key elements identified in the literature and based on the author’s personal experience that are perceived as important in designing, providing, and evaluating learning from global experiential nursing education. It is based on the assumption that the desired outcome is a perspective transformation that allows the student to view themselves as being engaged in global health. The model needs to be tested for use in learning about student outcomes associated with gain in global health knowledge, attitudes, and skills; characteristics of the
program; student characteristics; and engagement in reflection.
Conclusion Nurse educators have the opportunity to design optimal global learning experiences by using program frameworks based on research, experience, and best practices in the field. If courses are designed, provided, and evaluated using education frameworks, our understanding of what and how students learn from these experiences can advance. The development of tools and processes for using the model to conduct research is currently underway.
references 1. Global Health Council. Home page. Available at: http:// www.globalhealth.org/. Accessed November 10, 2010. 2. Olson CL, Green MF, Hill BA. A Handbook for Advancing Comprehensive Internationalization: What Institutions Can Do and What Students Should Learn. Washington, DC: American Council on Education; 2006. 3. Currier C, Lucas J, Saint Arnault D. Study abroad and nursing: from cultural to global competence. In: Lewin R, editor. The Handbook of Practice and Research in Study Abroad. New York: Routledge Taylor & Francis Group; 2009. 4. Bently R, Ellison KJ. Increasing cultural competence in nursing through international service-learning experiences. Nurse Educ 2007;32:207-11. 5. Kirkham SR, Hofwegen LV, Pankratz D. Deeping the vision: sustaining social consciousness with nursing students following international learning experiences. Int J Nurs Educ Scholarsh 2009;6. Article 3. 6. Ryan M, Twibell R, Brigham C, et al. Learning to care for clients in their world, not mine. J Nurs Educ 2000; 39:401-8. 7. Haloburdo EP, Thompson MA. A comparison of international learning experiences for baccalaureate nursing students: developed and developing countries. J Nurs Educ 1998;37:113-21. 8. Evanson TA, Zust BL. The meaning of participation in an international service experience among baccalaureate nursing students. Int J Nurs Educ Scholarsh 2004;1. Article 21. 9. Zorn CR. The long-term impact on nursing students of participating in international education. J Prof Nurs 1996;12:106-10. 10. Edmonds ML. The lived experience of nursing students who study abroad: a qualitative inquiry. Journal of Studies in International Education 2010;14: 545-68. 11. Walsh LV, de Joseph J. “I saw it in a different light”: international learning experiences in baccalaureate nursing education. J Nurs Educ 2003;42:266-72. 12. Nussbaum M. Liberal education and global community. Liberal Education; 2004. Winter:42-7. 13. Crigger NJ, Brannigan M, Baird M. Compassionate nursing professions as good citizens of the world. Adv Nurs Sci 2006;29:15-26.
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14. Che MG, Spearman M, Manizad A. Constructive disequilibrium: cognitive and emotional development through dissonant experience in less familiar destinations. In: Lewin R, editor. The Handbook of Practice and Research in Study Abroad. New York: Routledge Taylor & Francis Group; 2009. 15. Lewin R. The Handbook of Practice and Research in Study Abroad. New York: Routledge Taylor & Francis Group; 2009. 16. Bringle RG, Hatcher JA, Jones SG. International Service Learning: Conceptual Frameworks and Research. Sterling, VA: Stylus; 2011. 17. Ryan M, Twibell S. Outcomes of a transcultural nursing immersion experience: confirmation of a dimensional matrix. J Transcult Nurs 2002;13:30-8. 18. American Association of Colleges of Nursing. The Essentials of Baccalaureate Education for Professional Nursing Practice. Available at: http://www.aacn.nche. edu/Education/pdf/BaccEssentials08.pdf. Accessed October 15, 2010. 19. National League for Nursing Accrediting Commission, Inc. NLNAC 2008 Standards and Criteria: Baccalaureate Degree Programs in Nursing. Available at: http://nlnac.org/manuals/SC2008_ BACCALAUREATE.htm. Accessed June 8, 2010. 20. Hunter WD. Got Global Competency? International Educator 2003;31:6-12. 21. Indiana University Purdue University Indianapolis. International Learning Guidelines. Office of International Affairs. Indianapolis, IN; 2005 22. Indiana University-Purdue University Indianapolis. Principles of Undergraduate Learning. Available at: http://www.iport.iupui.edu/selfstudy/tl/puls/. Accessed August 29, 2010. 23. Plater WM, Jones SG, Bringle RG, et al. Educating globally competent citizens through international service learning. In: Lewin R, editor. The Handbook of Practice and Research in Study Abroad. New York: Routledge Taylor & Francis Group; 2009. 24. Bringle RG, Hatcher JA. Innovative practices in service learning and curricular engagement. In: Sandman L, Jaeger A, Thornton C, editors. New Directions in Community Engagement. San Francisco: Jossey-Bass; 2009. 25. American Nurses Association. Code of Ethics for Nurses With Interpretive Statements. Available at: http://nursingworld.org/MainMenuCategories/ EthicsStandards/CodeofEthicsforNurses/Code-ofEthics.aspx. Accessed May 24, 2011. 26. International Council of Nurses. The ICN Code of Ethics for Nurses. Available at: http://www.icn.ch/ images/stories/documents/about/icncode_english. pdf. Accessed August 5, 2010. 27. Giddings LS. A theoretical model of social consciousness. Adv Nurs Sci 2005;28:224-39. 28. Leininger MM. The theory of cultural care diversity and universality. In: Leininger MM, editor. Culture Care Diversity and Universality: A Theory of Nursing. Mississauga, ON, Canada: Jones and Bartlett Publishers; 2001. 29. Campinha-Bacote J. A model and instrument for addressing cultural competence in health care. J Nurs Educ 1999;38:203-7. 30. Purnell L. A description of the Purnell model for cultural competence. J Transcult Nurs 2000;11:40-6. 31. Paige R, Cohen AD, Kappler B, et al. Maximizing Study Abroad: A Program Professionals’ Guide to Strategies
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for Language and Culture Learning and Use. University of Minnesota: Center for Advanced Research on Language Acquisition; 2003. World Health Organization. Social Determinants of Health. Available at: http://www.who.int/social_ determinants/en/. Accessed August 5, 2010. Kiely R. A transformative learning model for servicelearning: A longitudinal case study. Michigan Journal of Community Service Learning 2005;Fall:5e22. Currier C, Omar M, Talarczyk G, et al. Development and Implementation of a Semester Program in Mexico for Senior Nursing Students. J Prof Nurs 2000; 16:293-9. Harrison L, Malone K. A Study Abroad Experience in Guatemala: Learning First-Hand about Health, Education, and Social Welfare in a Low-Resource Country. Int J Nurs Scholarsh 2004;1. Article 16. Riner ME, Becklenberg A. Partnering With a Sister City Organization for an International Service-Learning Experience. J Transcult Nurs 2001;12:234-40. Currier C, Canady R, Saint Arnault D. Study abroad in Ghana: A path to cultural competence. Medical Humanities Report; 2007:28. The Forum on Education Abroad. Standards of Good Practice for Short-term Education Abroad Programs. Carlisle, PA: The Forum on Education Abroad; 2009. The Forum on Education Abroad. Code of Ethics for Education Abroad. Carlisle, PA: The Forum on Education Abroad; 2008. NAFSA. Statement of Ethical Principles. NAFSA Association of International Educators; 2009. Unite for Sight. What We Do. Available at: http://www. uniteforsight.org/what-we-do. Accessed March 16, 2011. Ash SL, Clayton PH. The articulated learning: an approach to reflection and assessment. Innovation Higher Education 2004;29:137-54. Ash SL, Clayton PH, Atkinson MP. Integrating reflection and assessment to captures and improve student learning. Michigan Journal of Community Service Learning 2005;11:49-60. Jameson JK, Clayton PH, Bringle RG. Investigating student learning within and across linked service-learning courses: Vol. 8. Advances in Service-Learning Research. Charlotte, NC: Information Age Publishing; 2008. Rogers RR. Reflection in higher education: a concept analysis. Innovative Higher Education 2001;26:37-57. Eyler J, Giles DE, Schmiede A. A Practitioner’s Guide to Reflection in Service-learning. Nashville, TN: Vanderbilt University; 1996. Eyler J, Giles D. Where’s the Learning in ServiceLearning? San Francisco: Jossey-Bass; 1999. Mezirow J. Transformative Dimensions of Adult Learning. San Francisco, CA: Jossey-Bass; 1991. Mezirow J. Learning to think like an adult: Core concepts of transformation theory. In: Mezirow J, et al., editors. Learning As Transformation. San Francisco: Jossey-Bass; 2000. Imel S. Transformative Learning in Adulthood. Columbus, OH: ERIC Clearinghouse on Adult, Career, and Vocational Education. [ED423426]. (1998). Linthicum RC. Building a People of Power. Colorado Springs, CO: Authentic Publishing; 2006. Taylor EW. Analyzing research on transformative learning theory. In: Mezirow J, et al., editors. Learning As Transformation. San Francisco: Jossey-Bass; 2000.
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www.nursingoutlook.org
Globally engaged nursing education: An academic program framework Mary E. Riner, PhD, RN* Department of Environments for Health, Indiana University School of Nursing, Indianapolis, IN
article info
abstract
Article history: Received 30 November 2010 Revised 19 March 2011 Accepted 12 April 2011 Online 23 July 2011
Objective: This paper presents a model for designing, providing, and evaluating
Keywords: Global health International Nursing education Program framework
global experiential education, both local and internationally. Methods: A literature review was conducted to identify studies and models of global nursing education experiences in the scientific indexed literature and the gray literature on the Internet published by professional associations. Results: Key elements of the model developed include institutional and program mission and goals, global health core content, program characteristics, student characteristics, reflection, and perspective transformation. These factors combine to address the range of interweaving factors that need to be considered in providing well-designed global health offerings. Conclusions: The framework is offered for use in developing global experiences and in conducting studies to advance our understanding of what and how students learn and are transformed from participation in global education. Cite this article: Riner, M. E. (2011, DECEMBER). Globally engaged nursing education: An academic program framework. Nursing Outlook, 59(6), 308-317. doi:10.1016/j.outlook.2011.04.005.
Global health is concerned with saving lives by improving health throughout the world.1 Nurses are engaging in global health, both locally and internationally, as employees and volunteers with a diverse array of government, military, philanthropic, faithbased, academic, and health care organizations. Nursing students and our multicultural communities are challenging schools of nursing to provide global health education experiences as part of the nursing curriculum.
from engaging students with local immigrant and minority populations to taking students to other US communities to taking students abroad for international experiences. By engaging students in a range of global health education experiences, schools’ graduate nurses are prepared to participate in contemporary multicultural communities. Nurses with a global health perspective can contribute to our global civil society as informed citizens and to health care agencies by providing high-quality care to all persons.
To meet this challenge, nursing schools and faculty are providing nursing education experiences ranging
There is no single term that covers all the concepts encompassed by the words international, global, and
*Corresponding author: Dr. Mary E. Riner, Associate Professor, Department of Environments for Health, Indiana University School of Nursing, 1111 Middle Drive, NU 482, Indianapolis, IN 46202. E-mail address: [email protected] (M.E. Riner). 0029-6554/$ - see front matter Ó 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.outlook.2011.04.005
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intercultural. The American Council on Education (ACE) developed a helpful glossary that uses global learning as shorthand for 3 related types of learning: global (denoting the systems and phenomena that transcend national borders), international (focusing on nations and their relationships), and intercultural (focusing on knowledge and skills to understand and navigate cultural differences). ACE defines global learning as “the knowledge, skills, and attitudes that students acquire through a variety of experiences that enable them to understand world cultures and events; analyze global systems; appreciate cultural differences; and apply this knowledge and appreciation to their lives as citizens and workers.2 This definition weaves together a range of local to international education experiences. Although much has been written about global education for nursing students, little evidence exists about the design of these educational experiences in relation to what and how students learn. The purpose of this paper is to present a model of global engagement education for use in designing, providing, and evaluating experiential education locally and internationally. Major components of the model include global health core content, program characteristics, student characteristics, reflection for assessment, and perspective transformation. The ultimate goal is for nurse educators to have a conceptual model useful for developing, providing, evaluating, and conducting research on global engagement experiences.
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students who participated in global experiences than in students who did not.4,9 Students developed knowledge of reciprocity in relationships with others, an appreciation for the whole person,8 and they recognized universal human characteristics.7 They developed personal knowledge that led to increased self-confidence,7 and reported value changes and increases in tolerance, awareness of biases, and sensitivity to patient and family needs.6 They identified an appreciation for encountering opportunities of their host country culture.10 Students also perceived an increase in personal development as reflected in personal decisions and philosophy, values, and beliefs.9,11 The experience assisted students in clarifying career path/goals and increased motivation to continue service work.8 A 2-year alumni survey used Leininger’s model to study long-term impact of an international experience. Nurses reported using concepts of culture care accommodation and preservation in caring for Spanishspeaking immigrants and using the concept of culture care repatterning to use supplies more conservatively in recognition of the severe shortage they observed while abroad.8 When nursing curriculums include global experiences, students are more likely to develop global attitudes and view events from a world perspective. They are also more likely to value solutions to problems that will not only benefit them but will also benefit the broader world arena.12-14
Background Education Models Student Learning Rich reports of student learning outcomes are found in the international literature. Many studies used grounded theory and investigator developed tools. Results indicate that students’ world views were broadened3e5 and cultural awareness and understanding increased, as did awareness of cultural variations.6 Students developed nursing-specific skills including intercultural communication, provision of culturally appropriate care, and effective use of self.7 They found ways to respect the sacredness of the experience and advocate for change to improve health.8 Experiences abroad were found to increase understanding of population-based health problems,7 social justice, and globalization issues,8,9 and how access to sociopolitical resources influence health care.7 Seeing first-hand the reality of poverty, lack of housing, and malnutrition brought home to students the reality and impact of social factors on health.5 Students gained attitudes of appreciation versus criticism toward the US7 or changed perceptions about their own or the host culture.9 Cognitive development was higher in
The question that follows from identifying this wide range of student outcomes is how can we understand the design of the education experience in relation to student learning. Although 2 recent books on research in study abroad and conceptual frameworks for international service learning have been published, the development of educational models is in its early stage.15,16 2 models were identified in the nursing literature that address program design. Ryan and colleagues6,17 used a grounded theory approach to develop a conceptual map depicting processes and outcomes of an immersion experience. The process factors confirmed were situational predetermining factors of the program and student, modifying factors related to the onsite experience, and transitional factors involving strategies to adapt. These factors were considered key to achieving the student outcomes of personal and professional new views of self and practice. Haloburdo and Thompson7 developed a model of 4 components. The faculty role involves preplanning and orientation with defined expectations, post-experience
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debriefing, and feedback. The second component entails whether the experience includes direct nursing care, the type of country selected for the onsite experience, and course objectives. The last 2 components comprised integrating the experience into the curriculum, the length of time onsite, and the intensity of the learning experiences guided by a faculty or a liaison at the locale. Based on this emerging work on model development, a need for a comprehensive program education model was identified that would address the complex array of components involved in developing, designing, providing, and evaluating global nursing education experiences. The model presented here is built on the belief that comprehensive globally focused education experiences need to: (1) be framed within the institutional and program missions and goals, (2) include global health core content areas, (3) consider program and student characteristics, and (4) include reflection as a form of assessment and perspective transformation. The model presented is designed as a continuous feedback loop that involves these factors.
experiences allowed for progressive understanding to evolve of issues important in global experiential education. Once the key components of the model were identified, the literature was reviewed and synthesized for each component. Although the framework is presented in a linear fashion, it is important to note that system dynamics underlie it and that it models a continuous feedback loop.
Description of the Framework Institutional and Program Mission and Goals The mission and goals of the academic institution and nursing program serve as a springboard for deciding to offer global health courses, the type of experiences considered relevant, and development of affiliation placements. In a similar vein, changes in these goals can serve to increase or decrease the emphasis placed on global experiences. For example, when the university president sets a goal of engaging 10% of the student body in global experiences, this can result in new emphasis and resources being made available within the nursing program.
Methods A literature search was conducted using the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PubMed databases. Key search terms were global health, international health, international education, and study abroad. The search phrase “global learning AND higher education” yielded 88 articles with 20 retained, “international learning AND nursing” yielded 212 articles with 25 retained, “study abroad AND nursing” yielded 59 articles with 13 retained, and “international nursing AND higher education” yielded no articles for retention. Inclusion criteria were the literature had to be peer reviewed, English language publications; case studies of international programs; grounded theory; descriptive and experimental design studies; and conceptual articles on global education. In addition, a web search was conducted to identify important gray literature from professional associations involved in developing standards of best practice. The globally engaged nursing education framework (Figure 1) was also informed by the author’s experiences in providing global education. This included 12 years of experience in leading international, service-learning programs; participation in a 4-year initiative to embed global health experiences within the community health nursing practicum course in a local US-based community; involvement in an interdisciplinary, academic faculty learning community; a 6-year engagement in a multidisciplinary partnership with faculty and students at a university abroad; and participation in national academic learning initiatives about best practices in international service-learning. These
National nursing education bodies have standards for baccalaureate nursing education that can also be used to develop global learning experiences.18,19 Through a quad-level articulation process, faculty members can create curriculum plans that meet university mission and goals, national nursing education standards, program outcomes, and course competencies.
Global Health Core Content The global health core component of the model includes four areas of learning important to promoting student development of knowledge, skills, and attitudes for engaging in global health. Academic learning in the classroom serves as the foundation for the engagement experience. Learning can also be expected to occur throughout the experience and to occur in a new and more meaningful ways as the experience unfolds over time as a result of the experience.
Global Learning The use of global learning definitions, guidelines, and principles of learning to design the curriculum allows educators to start with the end in mind. Global competency is described by Brunstein20 as “a developed appreciation of other cultures and the ability to interact with people from foreign lands.” Hunter cites Brunstein in Brunstein identifying 5 dimensions that address important knowledge, attitudes, and skills. They include (a) the ability to work effectively in different international settings, (b) an awareness of the
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Figure 1 e Framework for globally engaged nursing education.
major current events of global change and the issues arising from such changes, (c) knowledge of global organizations and business activities, (d) capacity for effective communication across cultural and linguistic boundaries, and (e) a personal adaptability to diverse cultures.18 Many universities have goals, guidelines, or objectives for use in developing international curricular learning objectives.2 At one university, the International Learning Guidelines (Figure 2) were developed by a core faculty group as part of an international learning lab sponsored by the American Council on Education.21 These guidelines, or similar ones developed at a local institution can be used for designing global experiences.
Core principles of undergraduate learning is another faculty resource. At this same university, one of the principles is Understanding Society and Culture. It is defined as the ability of students to recognize their own cultural traditions and to understand and appreciate the diversity of the human experience.22 The outcome calls for students to demonstrate the ability to (a) compare and contrast the range of diversity and universality in human history, societies, and ways of life; (b) analyze and understand the interconnectedness of global and local communities; and (c) operate with civility in a complex world.22 Together these types of resources provide academic support and structure for designing and evaluating
Figure 2 e International Learning Guidelines.21
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global education experiences. These dimensions can be addressed in a variety of ways in orientation programs, course work, and experiential learning opportunities.
International Service-Learning and Social Consciousness International service-learning is considered a proven strategy of engaged learning that stands out as an effective means of increasing global awareness and knowledge, of deepening cross-cultural understanding and appreciation of diversity, and of experiencing some other part of the world first hand.23 It has been defined as “a structured academic experience in another country in which students (a) participate in an organized service activity that addresses identified community needs; (b) learn from direct interaction and cross-cultural dialogue with others; and (c) reflect on the experience in such a way as to gain a deeper understanding of global and intercultural issues, a broader appreciation of the host country and the discipline, and an enhanced sense of their own responsibilities as citizens, locally and globally.”24 Within nursing, international servicelearning experiences can include clinical services in a health care agency, community health promotion and education, and general service to the community intended to improve health conditions such as building a modern cooking structure to prevent burns from fires in a developing country, or tutoring adults learning English in a US community center. Social responsibility is important to national and international nurses’ organizations. When we view the global community as within nursing’s scope of practice, we find a call for being knowledgeable about the global health conditions25 and accepting the responsibility for initiating and supporting actions to meet the health and social needs of communities.26 Threading the development of global social consciousness into educational experiences can move students from distant objectivity about global health issues to close-up and personal experiences where they are more likely to care about what happens among people of other countries.24 Social consciousness has been described as “the nurses’ personal awareness of social injustices in their lives and in the lives of others and whether they are able to take action to address them.”27
Campinha-Bacote’s definition of cultural competence is particularly useful because it is developmental and focuses on nursing work within context. CampinhaBacote defines it as an “ongoing process in which the health care professional continuously strives to achieve the ability and availability to work effectively within the cultural context of the client (individual, family, community).”29 The learning experiences need to be designed using cultural competence models to take advantage of conceptual knowledge. For example, Leininger’s Sunrise Model was used by the author to help students learn about the health and community characteristics of population groups in both the local and international experiences. Purnell’s model was used to guide the interview questions when students conducted a family assessment in another country. Currier et al3 suggest that nursing shift from a cultural competence orientation to global cultural competence. This would require not only development of knowledge, attitudes, and skills about cultural differences, but also about the cultural, social, political, and economic systems that shape individuals’ lives on a global scale, the complex interactions among people, the moral and ethical obligations people have to one another, and how these influence health and health care. Using this type of approach, faculty can facilitate students’ capacity to address the health care needs of any person they encounter, regardless of their cultural background and where they encounter the person. Students can develop the knowledge, critical thinking, creativity, and problem-solving abilities to situate a given individual into the larger field of complex interacting forces that affect both their health and their access to the resources they need to regain their health. Language development is an important concern for developing cultural and global competence. It is a particular challenge for nursing programs where students are challenged to include a foreign language course in their program of study. Many universities offer short courses on language development for specific purposes like health care that can be incorporated into orientation sessions before departure for another country. The Center for Advanced Research on Language Acquisition31 has developed materials for students and faculty to support language and cultural learning to maximize study-abroad experiences as engaging and instructional.
Global Cultural Competence Development Country-Specific Knowledge Cultural competence is a key element of global engagement education. Without it, there is little likelihood of successful global engagement experience from which students experience growth and transformation. The works of Leininger,28 CampinhaBacote,29 and Purnell30 were most frequently used in the literature as models in global education courses for teaching cultural competence development.
Knowledge of the major health problems experienced by people in or from another country allows students to anticipate the care they may be expected to provide. Leininger’s Sunrise Model is a useful tool for designing learning experiences about the broad community sectors that influence health. Knowledge of these sectors allows students to understand health
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and the health care system within the context of the broader culture. The factors are technological, religious and philosophical, kinship and social, cultural values and lifeways; and political and legal, economic, and educational.28 Using these areas, faculty can develop learning assignment and experiences so that students develop culturally situated knowledge that allows them to appreciate the circumstances and world view of people for which they are providing care. Knowledge of the structure and delivery of health care in the host country offers students academic understanding of the services provided. Hands-on experience offers operational understanding of the process of delivering care and allows students to engage in providing nursing care. The World Health Organization (WHO) promotes understanding how non-health factors, or social determinants of health, influence health. Social determinants of health are the conditions in which people are born, grow, live, work, and age, including in the health system. These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels, which are themselves influenced by policy choices. The social determinants of health are mostly responsible for health inequitiesdthe unfair and avoidable differences in health status seen within and between countries.32
Program Characteristics Characteristics of the program are important to consider because they can influence how and what students learns.17,33 The 3 phases of the program are preexperience, onsite, and post-experience. Although the phases are arranged in a linear fashion, they are interconnected and simultaneously influence each other. For example, prior work by the faculty in developing a partnership with host agency staff can significantly influence the quality of the onsite learning experience.
Characteristics of the Pre-experience Initial preparation involves developing a well-designed program that is reviewed and approved by the school and institution. It requires establishing specific learning objectives that meet academic goals; developing the host community agency partnership and personal relationships with staff; planning for program administration; housing and meal arrangements; budgeting and fundraising; securing qualified faculty; and marketing, recruiting, and advising students.4,5,7,34-37 Pre-experience orientation and preparation of students is essential for maximum learning and adaptation during the experience.17 Students will adapt to the
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culture and have a more positive experience when they have specific knowledge about the design of the program and what they will be doing; where they will be living and having meals, the types of cultural sight-seeing experiences they can expect, and information about the clinical nursing experience, if applicable, in which they will participate.17 Additional best practices in preparation include language acquisition and cultural knowledge of the host community people; health precautions; and safety strategies including university policies, host country laws and best practices, ethical conduct, an orientation to service-learning, ethics of service in another country, and effectively representing the school and country.38-40 Learning strategies useful for preparing students need to address cognitive and affective learning. The orientation should use a range of strategies to maximize learning. Strategies may include readings with discussion, speakers, Internet research, case studies, role play, hearing from past students about their experiences, coping strategies for stress management, retreats for team building, and video conferences with the host agency staff.
Characteristics of the Onsite Experience The faculty role in facilitating the onsite experience is foundational to student adaptation and learning. When faculty members assist students in developing personal relationships with host country individuals and adapting to the local cultural and communication patterns, students can be expected to develop more positive attitudes that will facilitate adaptation to the experience.15 The design of the experience can be expected to influence development of increased cultural competence by focusing on the difference in the students’ existing worldview and the differences encountered during the experience. Six intersecting aspects of a cultural encounter can be used to understand how cultural competence is developed within a studyabroad experience. They include: (1) length of the encounter, (2) regularity and nature of contact with local residents, (3) level of cultural immersion and country characteristics, (4) socioeconomic congruence between the encounter site and the site of student origin, (5) cultural congruence between the encounter site and the student’s country of origin, and (6) need to learn a new language.34 These factors are supported by Kiely,33 who proposes that there is a direct relationship among dissonance type, intensity, duration, and the nature of learning processes that result. Service can be clinical work in a health care setting or agency, or it can be a project within the community that may have been initiated by the US agency. If the learning objectives focus on developing nursing knowledge of the host country, the experience needs to include contact with nurses and other health providers
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and patients where agency arrangements have been negotiated. Some schools operate free-standing clinics over spring break or the summer. These can be effective when there is strong involvement of local providers.41
Characteristics of the Post-experience The post-experience period is critical for assimilation and transition back home. It may involve individual and group debriefing; sharing a meal and photos; submitting required learning assignments and reflection journals; and public presentations to campus audiences, friends and family, financial supporters, and other interested persons. This is a time of reflection during which students incorporate the experience into their identity. Students submit final course assignments that focus on cognitive, personal, and professional development. Assignments need to be designed to elicit student awareness of changes that have occurred within themselves. It is important to recognize the interplay between the program context and the learner context at all 3 stages of the experience. Students select experiences for individual reasons, they engage in the experience based on their individual characteristics and bring closure to the experience differently. Reflection throughout each stage of the experience allows students to become aware of their motivations, values, and responses to challenges and how they are changing and have been changed as a result of the experience.
Learner Characteristics Kiely33 believes that when a student determines that they will engage in an international program, she or he is making a decision that involves contextual border crossing and this is the beginning of a transformational learning experience. Learner characteristics were rarely addressed in the studies reviewed. Understanding these characteristics can contribute significantly to understanding the learning achieved by students. Keily33 identifies 3 contextual borders that need to be considered to understand what and how students are transformed from global experiences and the differences among students. The contextual borders are personal (ie, personality traits, social roles, professional background); structural (ie, race, class, gender, religion, nationality); and historical (ie, current cultural, political, and socioeconomic positions between the student and the service site).33 Taken together, they represent characteristics Kiely believes influence how the learner responds to and experiences a major challenge to their world view. Four additional themes identified by Kiely are important to take into consideration. The degree to
which each student experiences dissonance, or incongruence, between their prior frame of reference and aspects of the learning context will shape the intensity of learning. High-intensity dissonance can result in ongoing learning. Dissonance types include historical, environmental, social, physical, economic, political, cultural, spiritual, communicative, and technological.33 The second theme is personalizing and represents how participants respond individually to and learn from different types of dissonance. Kiely describes it as visceral and emotional and compels students to assess internal strengths and weaknesses. Emotions and feelings include anger, happiness, sadness, helplessness, fear, anxiety, confusion, joy, nervousness, romanticizing, cynicism, sarcasm, selfishness, and embarrassment.32 The third theme is processing and is both an individual reflective learning process and a social, dialogic learning process. Processing consists of posing a problem and questioning, analyzing, and searching for causes and solutions to problems and issues. It occurs through various reflective and discursive processes such as journaling, reflection groups, community dialogues, walking, research, and observation.33 The last theme is connecting. It represents learning to affectively understand and empathize through relationships with community members, peers, and faculty. It is learning through nonreflective modes such as sensing, sharing, feelings, caring, participating, relating, listening, comforting, empathizing, intuiting, and doing.33 Ryan and Twibell17 make several propositions that parallel Kiely’s work.33 They propose that high degrees of personal flexibility result in more effective adaptation, that increased social support contributes to effective adaptation, that effective coping responses result in increased personal and professional growth, and that increased adaptation in the immersion experience is associated with increased personal and professional growth.
Reflection Reflection plays a key role in facilitating students’ capacity to articulate the academic learning, personal growth, and global engagement that occurs from experiential learning.42-44 In a concept analysis of reflection, Rogers describes it as a cognitive and affective process or activity that (1) requires active engagement on the part of the individual; (2) is triggered by an unusual or perplexing situation or experience; (3) involves examining one’s responses, beliefs, and premises in light of the situation at hand; and (4) results in integration of the new understanding into one’s experience.45
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In experiential education, reflection provides the transformative link between the action of serving and the ideas and understanding of learning.46 Eyler and Giles47 found that the more rigorous the reflection in service-learning, the better the learning, including academic outcomes; deeper understanding and better application of subject matter; increased complexity of problem and solution analysis; and openness to new ideas, problem-solving, and critical thinking skills. Effectively designed reflection is based on clearly defined learning goals, reflection prompts, and feedback to students that assists them in furthering their critical thinking about their learning. Reflection that is written down using a structured process has been referred to as articulated learning. In the model developed by Ash et al,43 4 guiding questions assist student reflection: (1) What did I learn?; (2) How, specifically, did I learn it?; (3) Why does this learning matter; and (4) In what ways will I use this learning, or what goals shall I set in accordance with what I have learned to improve myself, the quality of my learning, or the quality of my future experiences or service?43 Examples of a reflection prompt for the 3 key areas of learning are: (1) academic learningdWhat specific elements of our course materials related to this experience?; (2) personal growthdHow did this experience make me feel (positively and/or negatively)? How did I handle my emotions?; and (3) global engagementdWhat was I/someone else trying to accomplish?
Perspective Transformation Reflection is a core element of Transformational Learning Theory, a conceptual framework developed by adult education scholar Jack Mezirow.48,49 Transformational Learning Theory is proposed here as a way to understand and explain the relationship between the student and the global learning experience. In this
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theory, perspective transformation is the process of becoming critically aware of how and why our assumptions have come to constrain the way we perceive, understand, and feel about the world; changing these structures of habitual expectation to make possible a more inclusive, discriminating, and integrating perspective; and, finally, making a choice or otherwise acting on these new understandings.50 Transformative learning is a process whereby individuals engage in critical reflection to develop new perspectives, skills, and behaviors. According to Mezirow, “learning involves critical self-reflectiondreassessing the way we have posed problems and reassessing our own orientation to perceiving, knowing, believing, feeling and acting.”48 When individuals experience significant change in the way they understand their identity, culture, and behavior, they experience a perspective transformation.48 Mezirow’s stages of perspective transformation were used to frame prompting questions for student reflection assignments (Figure 3). These questions can facilitate the student’s reflection so that new knowledge, attitudes, and skills gained from the experience may have resulted in new views themselves, and opened up new possibilities for action. Drawing from the work of Ash et al43 and Mezirow,48 faculty can design reflection experiences that engage students in articulating their learning related to intended outcomes, like those in Figure 1. By specifically linking the reflection process to intended learning goals, students can articulate learning about academic learning, personal growth, and global engagement in health. We can use perspective transformation and reflective action pedagogy to understand taking the perspective of a globally engaged nurse. From Linthicum’s51 perspective as a community development specialist both in the US and in other countries, when people act, their action then affects the way they think
Figure 3 e Prompts for investigating perspective transformation in global engagement experiences. Adapted from Mezirow.48-49
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and vice versa. Action and reflection feed on each other, with each action leading to a deeper and more insightful reflection that in turn leads to a more courageous action.51 The purpose of learning from Paulo Freire’s perspective is the “rediscovery of power such that the more critically aware learners become the more they are able to transform society and subsequently their own reality.”52
Discussion In addition to using the GENE framework for designing global education experiences, it can be used in program evaluation and educational research. Program evaluation involves measuring aspects of the program design to identify their contribution to achieving course, program, and institution mission.46 There are several areas that need to be evaluated. They include university and school support and resources, site experience, student participation and financial support, and faculty preparation. It also includes achievement of program goals, program experience, and faculty and course evaluations. The evaluation component should include a program director report to allow summative qualitative reporting of the experience, student participation, and grade outcomes. These factors are dynamic and changes in any of them can significantly affect the program delivery. Educational research is needed to understand what and how students learn from global education experiences and how it relates to their practice of nursing.3,17 Work is currently underway to test the model’s capacity to demonstrate relationships of each component to student learning. Specific quantitative and qualitative measures and protocols are being developed. Partnerships with other schools are being developed to have sufficient numbers of students engaged in varying types of programs, with similarity in experiences to allow generalizability of findings.
Limitations The model presented here includes key elements identified in the literature and based on the author’s personal experience that are perceived as important in designing, providing, and evaluating learning from global experiential nursing education. It is based on the assumption that the desired outcome is a perspective transformation that allows the student to view themselves as being engaged in global health. The model needs to be tested for use in learning about student outcomes associated with gain in global health knowledge, attitudes, and skills; characteristics of the
program; student characteristics; and engagement in reflection.
Conclusion Nurse educators have the opportunity to design optimal global learning experiences by using program frameworks based on research, experience, and best practices in the field. If courses are designed, provided, and evaluated using education frameworks, our understanding of what and how students learn from these experiences can advance. The development of tools and processes for using the model to conduct research is currently underway.
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