Developing Korean nursing students' global health competencies: A mixed methods approach to service learning in rural Vietnam

Journal Pre-proof Developing Korean nursing students' global health competencies: A mixed methods approach to service learning in rural Vietnam

Sangeun Lee, Junghee Kim, Jong gun Kim, Truong Duc Tu, B&xxx1EEB;i Thi Thanh Loan, Hyeonkyeong Lee PII:

S0260-6917(19)30606-9

DOI:

https://doi.org/10.1016/j.nedt.2019.104300

Reference:

YNEDT 104300

To appear in:

Nurse Education Today

Received date:

18 April 2019

Revised date:

11 September 2019

Accepted date:

18 November 2019

Please cite this article as: S. Lee, J. Kim, J.g. Kim, et al., Developing Korean nursing students' global health competencies: A mixed methods approach to service learning in rural Vietnam, Nurse Education Today(2019), https://doi.org/10.1016/j.nedt.2019.104300

This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

© 2019 Published by Elsevier.

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Type of manuscript: Research papers

Title. DEVELOPING KOREAN NURSING STUDENTS’ GLOBAL HEALTH COMPETENCIES: A MIXED METHODS APPROACH TO SERVICE LEARNING IN RURAL VIETNAM

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Authors.

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Sangeun LEE*, MSN, RN, Research assistant.

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Yonsei University, College of Nursing and Mo-Im Kim Nursing Research Institute

Seoul, Republic of Korea, 03722

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E-mail: [email protected]

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50-1 Yonsei-ro, Seodaemun-gu

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Junghee KIM*, PhD, RN, Research Professor.

Yonsei University, College of Nursing and Mo-Im Kim Nursing Research Institute

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50-1 Yonsei-ro, Seodaemun-gu

Seoul, Republic of Korea, 03722 E-mail: [email protected]

Jong gun KIM, PhD, RN, Assistant professor. Hoseo University, Department of Nursing 20, 79th Street, Hoseo-ro, Baebang-eup Asan, Chungnam, Republic of Korea, 31499 E-mail: [email protected] Truong Duc Tu, MD, MS, Principal Medical College Quang Tri Quang-tri Medical College, Block 3, East Luong Ward, Dong Ha City, Quang Tri

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province, Vietnam E-mail: [email protected] Bừi Thi Thanh Loan, Head of Department of Basic Sciences Quang-tri Medical College, Block 3, East Luong Ward, Dong Ha City, Quang Tri province, Vietnam E-mail: [email protected]

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Hyeonkyeong LEE, PhD, RN, Professor, Associate Dean of Academic Affairs.

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Yonsei University, College of Nursing and Mo-Im Kim Nursing Research Institute 50-1 Yonsei-ro, Seodaemun-gu

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Seoul, Republic of Korea, 03722 E-mail: [email protected]

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*Both authors contributed equally to this work.

Corresponding author.

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Hyeonkyeong Lee, PhD, RN (Corresponding author)

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Professor, Associate Dean of Academic Affairs Yonsei University, College of Nursing and Mo-Im Kim Nursing Research Institute 50-1 Yonsei-ro, Seodaemun-gu Seoul, Republic of Korea, 03722 Email: [email protected] Telephone: 82-2-2228-3373 Fax: 82-2-392-5440

Acknowledgements. We express our appreciation to all study participant and Quang-tri community for their constant effort in this study. We are also grateful to all the members of Happy Quang-tri

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Project. This research was supported by 2016 Global Nursing Internship Program in Yonsei University College of Nursing.

Declarations of Interest. Declarations of interest: none

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Funding sources.

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This research was supported by Mo-Im Kim Nursing Research Institute from the

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College of Nursing at Yonsei University.

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Ethical Approval.

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Not applicable.

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DEVELOPING KOREAN NURSING STUDENTS’ GLOBAL HEALTH COMPETENCIES: A MIXED METHODS APPROACH TO SERVICE LEARNING IN RURAL VIETNAM

ABSTRACT Background: Owing to globalization, there is a need for enhanced global health competencies

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among nursing students. In this context, global service learning programs are important

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opportunities for nursing students.

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Objectives: To explore the effect of a short-term service learning program in a developing

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country on the global health competencies of students attending a South Korean nursing

Design: A mixed methods design.

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college.

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Setting: The Global Nursing Internship is a two-week pre-experience, eight-day on-site, and

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one-week post-experience program.

Participants: The on-site activities involved 15 nursing students participating in global health activities in a rural Vietnamese community. Methods: A self-reported questionnaire was used to assess changes in global health competencies in six domains, measured on a four-point Likert scale. Student satisfaction with each activity was measured on a five-point Likert scale. After completing the program, the participants wrote a self-reflection essay. The Wilcoxon signed rank test was used to analyze global health competencies, and content analysis was used to analyze participants’ selfreflections. Results: Regarding global health competencies, the overall mean score showed a significant

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increase at the post-program evaluation (Z = -3.41, p = .001). A pre-post-program comparison showed that the health care in low-resource settings domain displayed the greatest increase in scores. The mean overall satisfaction with the program was high (mean = 4.31, standard deviation = 0.17). In the students’ view, as expressed in their essays, their global health knowledge and attitude had improved. Conclusions: The program was useful in promoting global health competencies, empathy, and

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confidence and should be embedded among the essential requirements of nursing curricula.

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Suggestions are provided to develop an enhanced pre-experience program that could help

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students prepare better for on-site activities. As cultural competency is crucial for nurses,

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nursing educators should consider integrating similar global service learning programs into

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their existing nursing curricula.

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Keywords: Global health; Cultural diversity; Education; Public health

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INTRODUCTION With the increasing pace of globalization in recent years, health professionals are faced with growing demands to achieve the global health objectives of the sustainable development goals (SDGs). As primary patient advocates, nurses are required to possess the essential competencies for advancing global health (Global Advisory Panel on the Future of Nursing & Midwifery, 2017). Global health has been redefined as “a system-based,

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ecological, and transdisciplinary approach to research, education, and practice which seeks to

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provide innovative, integrated, and sustainable solutions to address complex health problems

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across national boundaries and improve health for all” (Wernli et al., 2016). This emphasizes

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the importance of multidisciplinary work, which includes nursing, to identify sustainable solutions for health equity. In addition, both the Lancet (Frenk et al., 2010) and World Health

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Organization’s (2013) reports on health professional education and training have highlighted

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the importance of competency-based education for implementing educational reforms. In particular, global health competencies (GHCs) have gained significance in nursing

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over the last decade. Wilson et al. (2012) proposed six areas of GHCs: global burden of disease; health implications of migration, travel, and displacement; social/environmental determinants of health; globalization of health/health care; health care in low-resource settings; and health as a human right. There is an increased emphasis on these GHCs in nursing curricular and co-curricular activities. In response to the complex global health environment changes of the 21st century, several GHC models have been proposed for students in different health professions, including medical students (Association of Faculties of Medicine of Canada Resource Group/Global Health Education Consortium Committee, 2010), public health students (Calhoun et al., 2008), and nursing students (Wilson et al., 2012). In addition to the

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competencies required by different types of health professionals, the educational committee of the Consortium of Universities for Global Health (CUGH) has identified 12 core GHCs (Wilson et al., 2014). In recognition of the increasing importance of GHCs in health professions, nursing educators have made attempts to incorporate various programs into nursing education. One such method to gain knowledge, skills, and experience in dealing with global health issues is

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the implementation of global service learning programs, which have been started in

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underdeveloped countries. Earlier studies on nursing students have shown evidence of the

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effects of international service learning programs (Curtin et al., 2015; Hwang et al., 2015;

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Abunab et al., 2016; Kohlbry, 2016). Most of these were short-term activities in underdeveloped countries including the Philippines, Dominican Republic, Ghana, and

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Mexico. Participants reported that they were able to play the role of professional student

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nurses; they also realized their own personal development and reported a widened global perspective after participating in the programs. In addition, the programs were effective in

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enhancing critical thinking, global leadership capacity, and global cultural capacity (Hwang et al., 2015; Kohlbry, 2016). The programs also improved empathy and the ability to communicate effectively with patients in different environments and helped students develop cultural competency, a sense of social justice, and knowledge of health care systems other than their own (Curtin et al., 2015). Although there have been several studies on nurses and other health care workers (Battat et al., 2016; Cushman et al., 2015; Walpole et al., 2016), studies on what might constitute appropriate education and training for the development of GHCs among nursing students are limited. Nursing students have participated in many global health activities; however, to date, their impact on GHCs has not been studied. Therefore, based on Riner’s (2011) framework

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for globally engaged nursing education, this study aimed to describe the effects of a shortterm global service learning program (Global Nursing Internship [GNI]) focused on the GHCs proposed by Wilson et al. (2014) and to elucidate the lessons learned from the program. It also aimed to assist nurse educators in developing global service learning programs for nursing students.

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METHODS

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Study design

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This study adopted a mixed methods design to define the changes in nursing students’

Description of the GNI program

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GHCs after participation in the global health program.

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The GNI program was designed to develop the GHCs of nursing students who

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voluntarily applied and were selected by a student committee in 2016. A college of nursing located in Seoul, Korea has been conducting the GNI program since 2012, following the changes in the curricula of prestigious nursing institutes around the world. The GNI program aims to provide nursing students with opportunities to become involved in nursing practice in global health, to practice servant leadership, as well as to improve global citizenship despite cultural differences. The GNI 2016 comprised 15 undergraduate students, four coordinators (one undergraduate student and three graduate students), and one faculty member who was responsible for overseeing the program. The participants visited Quang Tri Province in the North Central Coast region of Vietnam, where the program was conducted in collaboration

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with Quang Tri Medical College. The program involved a two-week pre-experience (predeparture training), seven days of on-site activities, and a one-week post-experience phase. The pre-experience workshops covered topics such as global development cooperation, global health and nursing, gender equality, Vietnam’s health and social environment, and safety and preparedness for international health emergencies. This training was focused on providing information about the on-site activities, which included an overview of Vietnamese

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health issues and interventions, the Vietnamese health care system and nursing education, and

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health-related cultural issues. After this pre-departure experience, supervised by team coordinators, a week-long group activity was conducted to prepare educational materials and

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supplies for nursing interventions in Vietnam. During the on-site activities, in the mornings,

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students administered health center-based interventions such as chronic disease screening,

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health education, health assessment, and home visits to local residents. In the afternoons, they administered school health interventions on various topics such as cardiopulmonary

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resuscitation, secondhand smoking prevention, and peer communication to middle school

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students through a summer camp. On the last day of the on-site activities, the student participants organized a cultural exchange performance, health fair, charity bazaar, and South Korean-Vietnamese student forum in collaboration with Vietnamese students and community residents. Toward the end of every day, the students spent an hour reflecting on what they had gained from the daily activity and gave each other feedback. After returning from the on-site activities, students were directed to discuss the program outcomes, reflect on their activities, and present their experiences to their peers (Table 1). The program was based on a revised version of Riner’s (2011) framework for globally engaged nursing education (Figure 1). The framework comprises six components: goals, core content, program characteristics, learner characteristics, reflection, and perspective

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transformation. In this study, perspective transformation entailed improving the students’ GHCs through the GNI program.

Measures The CUGH has developed a GHC tool (Wilson et al., 2014), the Korean version of

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which was used in this study (Lee et al., 2015). The tool consists of 30 items in six areas:

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(1) global burden of disease, (2) health implications of migration, travel, and displacement, (3)

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social and environmental determinants of health, (4) globalization of health and health care,

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(5) health care in low-resource settings, and (6) health as a human right and development resource. Each item was rated on a four-point Likert scale ranging from 1 = “I strongly

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disagree” to 4 = “I strongly agree.” We assessed GHCs both at the beginning and completion

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of the program. The participants’ satisfaction with the GNI program was also assessed on a five-point Likert scale ranging from 1 = “very dissatisfied” to 5 = “very satisfied.” In addition,

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each student wrote a self-reflection essay regarding their experiences, learning, and impressions about the program.

Data analysis All the quantitative data were analyzed using SPSS version 21.0 (IBM, USA). Descriptive statistics, including averages and standard deviations, were calculated. The Wilcoxon signed rank test was performed to define the differences in GHCs before and after the program. The level of statistical significance was set at p < .05. By analyzing the self-report records using directive content analysis, we could

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confirm the validity of existing theories. Then, by analyzing the content using existing theories or previous research findings, we could propose conceptual expansion (Hsieh and Shannon, 2005). The content was analyzed based on the six categories of GHCs for nurses, as classified by Wilson et al. (2012). Two authors, who were nursing doctoral students with qualitative research training and global health experience, reviewed the participants’ selfreflection essays. They read each report carefully, highlighting all meaningful text. All

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highlighted text was coded based on the six competency categories. Text that could not be

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coded into any of these categories was categorized separately under the heading of “soft skills.” The doctoral students then discussed whether the categories and content were

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global health research and education.

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appropriate and reviewed the content with the principal investigator, who has expertise in

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RESULTS

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Demographic characteristics of the participants The demographic characteristics of the participants are reported in Table 2. The average age was 21.80 years (standard deviation (SD) = 3.65, range 19–34). Among the one male and 14 female students, nine were juniors and six were at the sophomore level. In total, 87% of the students (n = 13) had international experience, with an average length of stay of 202 days. All the participants reported their English proficiency to be above the mid-high level.

GHC level and subsequent changes

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The participants’ pre-test mean of the GHCs was 2.79 (SD = 0.35); this significantly changed to 3.49 (SD = 0.23) in the post-test (Z = -3.41, p = .001). Participants scored the lowest in the globalization of health and health care domain (pre-test, mean (M) = 2.43, SD = 0.47; post-test, M = 3.14, SD = 0.33) and highest in the social and environmental determinants of health domain (pre-test, M = 3.39, SD = 0.48; post-test, M = 3.88, SD = 0.18). The pre-post program changes in all six GHC domains were significant: global burden of

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disease (Z = -2.82, p = .005), health implications of migration, travel and displacement (Z = -

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3.18, p = .001), social and environmental determinants of health (Z = -2.81, p = .005),

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globalization of health and health care (Z = -2.93, p = .003), health care in low-resource settings (Z = -3.42, p = .001), and health as a human right and developmental resource (Z = -

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3.15, p = .002; Table 3).

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Program satisfaction

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To evaluate satisfaction with the program, we considered preliminary preparation, local activities, satisfaction with each activity, and goal achievement. The mean overall satisfaction score was 4.31 (SD = 0.17). The participants evaluated their goal achievement to be high (M = 4.50, SD = 0.33) while their satisfaction with the pre-departure program was low (M = 3.95, SD = 0.42). They were most satisfied with primary health care for children and school-based health education, whereas they felt that the South Korean-Vietnamese student health forum needed improvement.

Themes and students’ quotes The self-reflective journals were analyzed based on the six categories of GHCs (Table

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4). Students’ soft skills, which were not included in the six competencies, formed a different category. The themes extracted from the analysis included (1) “understanding global health” from the global burden of disease domain, (2) “understanding health care considering cultural differences” from the health implications of migration, travel, and displacement domain, (3) “impact of poor environment on access to health care services” and “influence of communication factors on health care” from the social and environmental determinants of

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health domain, (4) “understanding health care systems in different countries” from the

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globalization of health and health care domain, (5) “vulnerable health care environment” and “nursing interventions according to cultural characteristics” from the health care in low-

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resource settings domain, and (6) “understanding global health organization” from the health

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as a human right and developmental resource domain. In the domain of soft skills, positive

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perspective, empathy, and confidence were identified from the themes “experience beyond

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health.”

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service activity,” “empathy as a global citizen,” and “confidence in strengthening global

DISCUSSION

In line with the growing need for GHCs in nursing students, the goal of this study was to evaluate the effectiveness of the GNI program, a short-term program in developing countries aimed at enhancing the GHCs of nursing students. According to the quantitative results, participants’ overall GHC level was significantly increased while the qualitative results also showed an enhanced confidence in the knowledge of global health and culturally adaptive nursing practice. In particular, nursing students reported that the program was a valuable experience for learning about the aspects of GHCs, such as the global burden of disease; health implications of migration, travel and displacement; social and environmental

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determinants of health; globalization of health and health care; health care in low-resource settings; and health as a human right and developmental resource. These findings show an increased understanding of the health problems in a developing country as well as growing global cultural sensitivity in students. The GNI program played a significant role in enhancing the cultural competencies of nursing students as identified from the analysis of their self-reflective journals. Cultural

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competency building would have resulted from Vietnamese cultural education, global health

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collaboration, and global development cooperation, which resulted from the (a) one-week

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advance education, (b) on-site primary health screening test for local residents, (c) South Korean-Vietnamese student health forum, and (d) students’ cultural education. In Curtin et

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al.’s (2013) study, interaction with people from a different culture was found to positively

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affect participants’ self-confidence. In another study of American students who participated

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in a one to three-week international service learning program, cultural competency in terms of cultural knowledge and skills significantly increased after the training program. Students

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learned that different cultures have different health care norms and that they have to be creative in finding solutions that take into consideration the patients’ cultural beliefs while providing them with care (Kohlbry, 2016). In the current multicultural society, our findings have implications for clinical practice both locally and globally, as cultural competency is crucial for nurses. Thus, nursing educators should consider integrating similar global service learning programs into their existing nursing curricula. In addition, an enhanced sense of global citizenship was found to be the most positive feedback in the students’ evaluation. An Australian study reported an increase in participants’ global citizenship after a four-week Cambodian international learning program. Nursing and midwifery students who participated in this program also reported that they were positively

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affected by the cultural diversity and challenges (Tuckett and Crompton, 2014). In this study, during the child health assessment and school-based activities, the nursing students were required to adapt to cultural differences through a high level of interaction with the local residents, which would help improve their global citizenship. The on-site activities provided students with numerous opportunities to develop soft skills, such as empathy with vulnerable populations, positive perspectives on different cultures, and confidence to interact with local

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residents whose lifestyles differed from their own. All these are essential attributes of global

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citizenship, and should, therefore, form the basis of the development of GHCs in nursing students.

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In this study, fluency of language and communication skills influenced active

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interaction with local interpreters, which helped improve cultural acceptance and global

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citizenship in the country. Nursing students recognized that communication barriers were a social determinant preventing effective delivery of health care services through the GNI

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program. A previous study reported a positive correlation between cultural competencies and

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foreign language skills in nursing students (Yang et al., 2013). In addition, after participating in service learning programs, interaction with a translator was found to be more effective (Curtin et al., 2015). This is consistent with Hwang et al.’s (2015) findings on the communication skills of South Korean nursing students who participated in a global health program. In the global health context, nurses’ communication skills are an important factor in assessing community residents’ health and providing the necessary care. Therefore, it is essential to teach students the language of the target community before the commencement of global service learning programs. This service learning program strengthened the GHCs of participating nursing students. In recent years, interprofessional education has become important in global health programs to improve the health status of the participants in a community (Jogerst et al., 2015).

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Interprofessional education has shown a significant effect on health outcomes in various institutions (Herath et al., 2017). Student-related improvements have included enhanced teamwork, communication skills, confidence, and professional identity (Granheim et al., 2018). Therefore, future studies must implement an interprofessional education component in global health service learning programs. This study had several strengths. First, it developed a theory-driven program specific

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to nursing students based on Riner’s (2011) framework, which provides useful guidelines for

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developing global service learning programs right from goal setting to outcome evaluation.

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Second, using a mixed methods design that included a self-report survey and a reflection essay helped identify not only overall program satisfaction and GHCs but also the

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participants’ experiences and the personal changes they observed. Finally, the study

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illustrates that this service learning program can help health professionals develop and

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acquire GHCs. However, the relatively small sample size and short duration of the program make it difficult to generalize these results. Since the short preparation time is a drawback,

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future research should consider the benefits of increasing the preparation time by linking this program to regular courses. In addition, teamwork between nurses and nursing educators could contribute to successful curriculum design and implementation.

CONCLUSIONS This study explored the effect of the GNI program in promoting the GHCs of nursing college students. The GNI program, a short-term service learning program in a developing country consisting of pre-departure activities, on-site activities, and a post-program evaluation, is an exemplary training program for providing nursing students with a cultural emersion opportunity. The findings of this study demonstrate the effectiveness and value of

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global service learning programs for developing GHCs, which have been gaining greater attention in nursing education as a method to voice nurses’ opinions and increase the nursing

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impact for achieving the SDGs.

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I., Ventura, C., 2012. Global health competencies for nurses in the Americas. Journal of Professional Nursing 28 (4), 213-222.

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https://doi.org/10.1016/j.profnurs.2011.11.021.

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World Health Organization., 2013. Transforming and scaling up health professionals’ education and training: World Health Organization Guidelines 2013. Geneva, Switzerland: WHO, 2013.

Yang, S.Y., Lim, H.N., Lee, J.H., 2013. The study on relationship between cultural competency and empathy of nursing students. Journal of Korean Academic Society of Nursing Education 19 (2), 183-193. https://doi.org/10.5977/jkasne.2013.19.2.183.

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Figure 1. Global Nursing Internship conceptual framework.

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Table 1. On-site Activities of the GNI Program Day

Hours

1

4

Activity  Local hospital visits

Contents/Intervention  Observation of the local hospitals and understanding the primary health care system in Quang Tri Province, Vietnam  Comparison with South Korean health care system  Seminar with global health experts

 Expert

of

4

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leadership

4

 Home visits  Home visits to 15 vulnerable households: family health

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2

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seminar

assessment and health education

education  School health 1

prevention and chronic disease management

 Organizing a summer camp (4 days, 3 hours/day)

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3

 Individual health education for secondhand smoking

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health

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 Community  Health screenings (BP, BST, urine test)

 Daily

 Health education for physical, mental, and social health  Self-reflection on daily activities and feedback

evaluation 3

4

 Disease

 Chronic disease screening for 102 local residents

managemen  Health screenings (BP, BST, urine test) t

 Group health education for 265 local residents (secondhand smoking prevention and chronic disease management such as HTN and DM)

3

 School

 CPR, secondhand smoking prevention skills, hand washing

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Day

Hours

Activity

Contents/Intervention

health 1

 Daily

 Self-reflection on daily activities and feedback

evaluation

health screening 3

 School health

1

 Daily

 Health screening for local kindergarteners (Vision, height, weight, anemia test)  Sharing the results with the teachers and parents

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 Children’s

 CPR, dental hygiene, food and nutrition, reproductive health

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4

education, and peer communication  Self-reflection on daily activities and feedback

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4

4

 Community  Environment improvement activity with local youth union activities

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5

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evaluation

members and students

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 Cleaning up and wall painting in local kindergarten

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 Provision of trash bins with health messages for agricultural waste

3

 School health

1

 Daily

 CPR, reproductive health education, and peer communication

 Self-reflection on daily activities and feedback

evaluation 6

4

 Cultural and  South Korean-Vietnamese student cultural exchange health fairs

 Student health exhibition  Charity bazaar for fundraising Health fair with 1000 local people

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Day

Hours 2

Activity  Student forum with local students

1

 Daily

Contents/Intervention  Comparison of nursing education between South Korea and Vietnam  Case competition on community health projects in Vietnam with limited budget  Self-reflection on daily activities and feedback

8

 Site visit

 Cultural experiences in Vietnamese museum, traditional

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market, palace, etc.

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7

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evaluation

Notes. BP: Blood pressure, BST: Blood sugar test, HTN: Hypertension, DM: Diabetes

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mellitus; CPR: Cardiopulmonary resuscitation.

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Table 2. General Characteristics of the Participants Variables

Categories

n (%)

Age (years)

1

2nd

9

3rd

6

Yes

13 (87%)

No

2 (13%)

Mid-high level

15 (100%)

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English proficiency

Male

Range

21.80 (3.65)

19–34

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Overseas experience

14

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School grade

Female

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Gender

M (SD)

202 days

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Table 3. Changes in Global Health Competencies Pre- and Post-Global Health Program (N = 15) Pre-test

Post-test

M (SD)

M (SD)

2.79 (.35)

3.49 (.23)

2.82 (.60) and 2.89 (.41)

Variables

Total global health competency score Global burden of disease implications

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migration,

travel,

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3.44 (.35)

-2.82

.005

3.51 (.30)

-3.18

.001

3.88 (.18)

-2.81

.005

2.43 (.47)

3.14 (.33)

-2.93

.003

2.66 (.54)

3.55 (.36)

-3.42

.001

2.56 (.41)

3.38 (.49)

-3.15

.002

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Health

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displacement

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Globalization of health and health care

3.39 (.48)

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Social and environmental determinants of health

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Health care in low-resource settings

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Health as a human right and development resource

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Table 4. Themes and Significant Statements Category

Themes

I. Global burden

Significant statements - “The Global Nursing Internship

- Understanding of global

of disease

health

program was an opportunity to understand Vietnam’s health care system and health problems, to

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carry out health education and

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health activities, and to gain an

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overall understanding of global

-

Understanding health care

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II. Health

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development cooperation and

considering cultural

migration,

differences

displacement

-

“…It made one think about how to perform nursing in the context of cultural differences.”

-

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travel, and

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implications of

global health.”

“…I felt that if the people we treat are from other cultures, we realize the degree and extent to which we need to become sensitive when providing nursing services.”

-

“Owing to the cultural differences, there was a lot of discussion among participants on the progress of the program, and I realized how much the process

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was helpful.”

III. Social and

-

Impact of poor

-

“I understood the low level of

environmental

environment on access to

medical access and poor medical

determinants of

health care services

conditions in rural areas through a discussion with grandmothers.”

health Influence of

-

“I regretted not knowing any

of

-

Vietnamese and felt it would have

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communication factors on health care

been nice if I knew a little of the

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language before the program.”

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that when I screened for chronic diseases,

-

Understanding health care

I

learned

short

Vietnamese sentences from the

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IV. Globalization

“The most memorable thing is

translator and used them to tell the residents to exercise well and avoid eating salty food.” -

“…The process of visiting a

of health and

systems in different

medical institution and comparing

health care

countries

it to the South Korean system and medical institutions was quite interesting.”

V. Health care in low-resource

-

Vulnerable health care environment

-

“Very vulnerable to infection problems …”

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-

settings

-

VI. Health as a human right

-

Nursing interventions

“I realized they really needed

according to cultural

nursing interventions tailored to

characteristics

the community.” -

Understanding global health organization

“…It was an opportunity to understand the activities of global organizations related to global

development

health and to increase global

resource

citizenship.”

perspective

empathy, and

expanded

confidence

through

-

“Communication with local residents from

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opportunities for global citizenship and capacity

Empathy as a

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global citizen

-

learned more …”

different cultural backgrounds provides

activities -

“I thought I was going to serve, but I realized I

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Experience,

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-

Positive

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-

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Soft skills:

of

and

Confidence in strengthening global health

-

building…” “I feel good about myself for having served ... I have confidence in myself and the system…”

Figure 1