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Interprofessional global service learning: A pharmacy and nursing practice experience in Botswana
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Currents in Pharmacy Teaching and Learning 7 (2015) 169–178
Research
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Interprofessional global service learning: A pharmacy and nursing practice experience in Botswana Linda I. Davis, PharmD, MA, TTSa,*, Dolores J. Wright, PhD, RNb, Matthew S. Gutierrez, PharmDa, Jennifer J. Nam, PharmDa, Jenny Nguyena, Andrew T. Waite, PharmDa a
b
School of Pharmacy, Loma Linda University, Loma Linda, CA School of Nursing, Loma Linda University West Hall, School of Nursing, Loma Linda, CA
Abstract Objectives: To develop, implement, and assess an interprofessional global service-learning experience in rural government-run clinics and a community hospital for pharmacy and nursing students. Design: An interprofessional educational experience was developed for volunteer pharmacy students to collaborate with nursing students in an established study-abroad elective course. Students participated in interprofessional activities for 27 days in Kanye, Botswana, where they engaged in clinical practice in community clinics and hospital units for 15 days between June 18 and July 15. Assessment: Five pharmacy students and 11 nursing students participated in the program. A qualitative survey assessed student perceptions of the interprofessional clinical experience while reflection papers assessed service learning. Conclusions: Global service learning is a valuable opportunity to prepare collaborative teamwork among pharmacy and nursing students. In addition, partnerships with other health care programs’ established educational experiences can facilitate pharmacy program expansion into global interprofessional practice experiences. Though validated assessments of global service learning impact on cultural competency and compassion were not performed here, preliminary evidence from reflective papers and student debriefing sessions suggest an interprofessional global service-learning experience develops both. More research is needed to measure the degree to which interprofessional global service learning can impact cultural competency and the expression of compassion. r 2015 Elsevier Inc. All rights reserved.
Keywords: Interprofessional; Global; Pharmacy; Nursing; Service learning
Introduction As health care institutions strive to develop and advance patient care, health professionals must work together to synchronize therapeutic regimens. Historically, physicians have been perceived as the health care professional bearing full responsibility for patient care and outcomes. In order to provide more effective and efficient patient care, the Institute * Corresponding author: Linda I. Davis, PharmD, MA, TTS, School of Pharmacy, Loma Linda University, 1627 E. Brockton Avenue, Redlands, CA 92374. E-mail: [email protected] http://dx.doi.org/10.1016/j.cptl.2014.11.017 1877-1297/r 2015 Elsevier Inc. All rights reserved.
of Medicine (IOM) Health Professions Education Summit recommended that all health professionals be educated to operate as an interdisciplinary team.1 The Accreditation Council for Pharmacy Education (ACPE) has embraced this recommendation, agreeing that pharmacists must be educated to deliver patient-centered care as members of an interprofessional team. Achieving this goal would require curricula that addresses evidence-based practice, health promotion, disease prevention, patient safety, cultural competence, health literacy, health care disparities, and interprofessional practice.2 The definition of interprofessional education (IPE) according to the World Health Organization (WHO) is
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“When students from two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes.”3 Moreover, ten of the ACPE guidelines include an interprofessional education requirement. Of these requirements, seven were new guidelines in the 2011 revision. The ACPE appendices B, C, and D also mention interprofessionalism five times, three of which are new additions.2 As recommended by the ACPE guidelines, many pharmacy programs are taking steps to integrate (IPE) into their curricula.4–6 IPE has been introduced in didactic education as well as in experiential education to improve patient outcomes. The ACPE guidelines suggest APPE rotations should be conducted in settings where “…continuity of care throughout the health care delivery system, including the availability and sharing of information regarding a patient’s condition, medications, and other therapies…” is emphasized.2 Following these guidelines and yet stepping outside the customary boundaries, a number of universities have begun to take interprofessional education abroad. For example, the College of Pharmacy at North Dakota State University developed an Advanced Pharmacy Practice Experience (APPE) rotation in which students participate in a ten-day global mission trip working with other medical professionals including medical and nursing students. One of the goals of this program is to improve student cultural competency assessment scores, while facilitating student opportunities to provide hypertension and diabetes screening, medication, nutrition and health promotion counseling, in addition to participation in pharmacy operations in Guatemala.7 Introducing service learning into IPE adds another layer of complexity. The ACPE describes service learning as “a structured learning experience with clearly defined objectives that combines performing service in the community with preparation, reflection, and discussion.”2 The Interprofessional Education Collaborative Expert Panel (IECEP) describes service learning as having several characteristics, stating “Service learning projects are frequently used as valuesbased educational opportunities to help students develop person and patient-centered knowledge and skills with a community/population-orientation around the health and health care needs of the at risk, vulnerable, and underserved.”3 Whether or not a particular community is considered underserved may be relative. The educational experience reported here took place in the southern African country of Botswana, in Kanye, which is a small rural village approximately one hour from the capital. While Botswana provides universal access to health care, the health care services in Kanye remain under-resourced with respect to equipment, supplies, and staffing. Therefore, it is argued that Kanye represents an underserved community and thus this is a service-learning experience by both IECEP and ACPE definitions. The Loma Linda University (LLU) School of Pharmacy and School of Nursing worked together to design and implement a global service-learning IPE program for pharmacy students in conjunction with an already established course for
nursing students. The entire experience included 27 days of IPE activities. Students trained and served in government-run clinics and a community hospital affiliated with a college of nursing in Kanye, Botswana, for 15 days. The five objectives specific to this global service-learning IPE experience were as follows: (1) to learn about and from different health care professionals within a collaborative team, (2) to develop personal and professional skills needed to meet health care needs of people in settings where there are limited resources, (3) to provide a cross-cultural experience in health care delivery, (4) to develop an appreciation for people with differing values, traditions, and health needs, and (5) to foster or reinforce a personal commitment to serve at home or abroad. Pharmacy student participation was integrated into a program that the School of Nursing had been offering for the past eight years. This program involved a collaborative relationship between the LLU School of Nursing, the Kanye Seventh-day Adventist College of Nursing (KSDACON), the Kanye Seventh-day Adventist Hospital, and the neighboring government-run clinics. The School of Nursing at the LLU developed this program to provide senior baccalaureate nursing students with the opportunity to participate in an elective study-abroad, service-learning clinical rotation offered in the required Public Health Nursing course. This was designed prior to the American Association of Colleges of Nursing recommendation for cultural competence education.8 During the program, nursing faculty observed nursing student instruction in clinic dispensaries could be enhanced with drug-information expertise. As a result, a pharmacy faculty member was approached for pharmacy student participation in an IPE experience. One nursing professor and one pharmacy professor traveled with the students and served as preceptors for this experience. The nursing faculty member arranged clinical sites prior to arrival in Botswana. While in Botswana she coordinated and confirmed lodging, travel, and food accommodations. She also coordinated with the hospital, the KSDACON, and the Kanye SDA Church for opportunities for the Loma Linda team to observe surgeries, speak to the KSDACON students, offer children’s Bible school classes, and provide worship music. The School of Pharmacy professor established partnerships with the inpatient pharmacy, outpatient pharmacy, HIV medication adherence counseling center, and hospital units to facilitate pharmacy student participation. She also defined roles with physicians and nurses who provided additional student supervision and precepting. The pharmacy professor rotated between sites to precept students and also met with students daily to debrief clinical, IPE, and cross-cultural experiences. Design Administrative, application, travel, cultural, and clinical preparation The memorandum of understanding (MOU) developed between the LLU and the KSDACON is reviewed yearly and
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signed by the administrators of both institutions. The MOU defines each institution’s responsibilities in areas of theoretical and clinical education, health care, cultural norms, and values. The LLU faculty members accompany the students in the dormitories of the host institution. The KSDACON faculty members secure temporary permits for the students and write letters requesting clinical sites in the local health district. They also facilitate such cultural experiences as a visit to the Kgotla, the local tribal council, and the nearest diamond mine. The study-abroad trip is scheduled during June and July when the KSDACON students are at home on winter break. Thus, the American students are not competing with the local nursing students for housing or clinical sites. The size of the group has varied in the past; however, the faculty has determined that 20 students is the maximum number of students that can be accommodated by the Rural Health Administration clinics. The travel and housing accommodation arrangements were also coordinated with ease. A travel agency provided all flight arrangements, and the KSDACON provided all the ground transportation to and from the airport as well as each clinic. Their cafeteria could also accommodate the group, providing three warm meals a day. The process for nursing and pharmacy students to enter this educational experience includes an application, approval by the school’s academic review committee, fundraising, payment, and travel clearance.9 Applications included stated reasons for desire to participate, interest in IPE teamwork, academic standing, and passport status. A fundraising letter template was issued to the students from the University’s Student Global Mission Service office. The School of Pharmacy paid for half of pharmacy student travel, lodging, and food expenses while nursing students paid travel expenses as part of a course fee. The students completed travel preparation forms from the University’s Global Health Institute that assisted in providing travel visas, travel health insurance, emergency planning, and offered advice to prospective travelers. Students were required to visit the University’s travel clinic to update their immunization status and obtain any necessary prophylactic medication (e.g., antimalarials, as Botswana is considered a malaria-endemic area during certain seasons). All students brought a month’s supply of their prescription and nonprescription medications with them. Though nursing participants were all senior-level baccalaureate students, pharmacy students were from three levels of the doctoral program and, thus, had varying levels of therapeutics education. Five pharmacy students participated: one entering fourth-year rotations, three entering the third professional year, and one entering the second professional year of the doctoral program. Due to the complexity of understanding HIV, pharmacy students attended an Infectious Disease Grand Rounds seminar and discussion session at the Jerry L. Pettis Memorial Veterans Medical Center led by the attending infectious disease physician and attended by infectious disease residents and fellows prior to the overseas experience. Students were oriented to the AIDS Info Guidelines for the Use of Antiretroviral Agents in
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HIV-1-Infected Adults and Adolescents and were later tested by the pharmacy preceptor on drug names, mechanisms of action, dosing, adverse reactions, and monitoring parameters.10 There were no differences in the clinical opportunities made available to pharmacy students of each level. In the months prior to departure, pharmacy and nursing students met several times to learn about the country of Botswana and the village of Kanye. They researched the World Health Organization (WHO), Centers for Disease Control and Prevention, and U.S. State Department websites to learn about the health concerns facing the people of Botswana. The students also had access to the Botswana Treatment Guide 2007 that identifies common diagnoses in the country and their recommended treatments.11 Students were encouraged to become familiar with the culture of Botswana by reading books and articles about the country. The No. 1 Ladies’ Detective Agency was recommended since the book gives a picture of important cultural icons.12 Pharmacy and nursing students also viewed DVD presentations produced by nursing students who participated during preceding years. These preparations facilitated the student’s transition into a new culture and health care practice model and also provided an opportunity for student introductions prior to the trip. Since the LLU nursing students arrived in Kanye ahead of the pharmacy students, three of the government-run clinics had already acclimated to having LLU student assistance on hand. In the absence of Kanye nursing students, who were gone for winter break, and clinic understaffing, the help from the pharmacy students was welcomed. The nursing students graciously helped orient pharmacy students to the practice site facilities, resources, expectations, and opportunities to serve. Clinical sites Nursing students were assigned to specific governmentrun clinics within the village of Kanye for the duration of their course, while pharmacy students rotated through sites to gain exposure to a variety of settings. Over the course of 15 days, pharmacy students spent three or four days in each site paired with different nursing students, except for one rotation where students participated in the hospital’s inpatient and outpatient pharmacy services. Some of the clinics were managed by physicians while others were managed by nurse practitioners and midwives. The prevalence of different diagnoses and clinical procedures varied at each facility. For example, one had a higher number of pediatric burns while another had more adult sexually transmitted disease testing, prevention, and treatment. Pharmacy students also rotated through the Kanye Hospital pediatric unit, as well as the labor and delivery unit together with nursing students. Some students elected to observe surgeries in the operating room and patient care in the emergency department. The community hospital and surrounding governmentrun clinics were accustomed to having local nursing
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students train with them and did not appear to have any difficulty integrating pharmacy students into the work flow. A hospital pharmacist provided administration insights during the pharmacy student rotation, which included operational legal requirements, government affiliations, and medication purchasing. Pharmacy students also participated in the inpatient pharmacy inventory management with other pharmacists. In addition, the students had the opportunity to dispense and counsel regarding prescriptions in the hospital’s outpatient pharmacy. Prior to departure on the final day, pharmacy and nursing students worked in the hospital’s outpatient pharmacy preparing a surplus of pre-packaged oral medications. Clinical activities and interventions Clinic involvement for pharmacy and nursing students consisted of assisting with taking vital signs, child growth surveillance, clinician consultation, wound care, immunizations, outpatient surgical procedures, medication dispensing, and patient counseling. Pharmacy and nursing students worked together to obtain patient weight, temperature, and blood pressure readings. Parents were surveyed regarding pediatric health in each clinic’s Child Welfare Center. Here, students dispensed child oral rehydration salts and zinc sulfate as they counseled parents regarding gastrointestinal symptoms and dehydration. Pharmacy and nursing students also conducted patient consultations at various clinics with physicians and nurse practitioners. Nursing students changed dressings at wound care stations and counseled regarding infection prevention and pain management with pharmacy student assistance. Pharmacy and nursing students also worked closely together at the clinic immunization stations. Students prepared and administered oral and subcutaneous vaccinations while providing vaccination schedule information. Though pharmacy students did not inject large-volume intramuscular injections, they drew up the solutions for nursing students to administer. Nursing and pharmacy students engaged in a collaborative partnership throughout the clinics, as well as in clinic dispensaries. Nursing students oriented pharmacy students to each clinic’s dispensary including prescription packaging and the handwritten labeling procedures. Pharmacy students offered suggestions to optimize the dispensaries’ organization, shared information on dose verification, and offered medication counseling, including whether or not medications should be taken with food, administration times, and how to minimize side effects. The pairing of students at each clinic and rotation site provided continuous opportunities for clinical teamwork, which benefited both groups of students. Differences in health care and health care delivery systems Students witnessed health care and health care delivery differences throughout their clinical experience. They were familiarized with the range of programs that the Botswana
public health system utilizes to address its elevated HIV prevalence of 23% among adults.13,14 In addition to the government-funded HIV clinics that provide no-cost antiretroviral medication through a stringent adherence program, an international campaign also focuses on decreasing HIV transmission through young adult and middle-age male circumcisions.15,16 Students helped patients register and offered ancillary support to local practitioners performing the circumcisions. In populations overwhelmed by this epidemic, Voluntary Medical Male Circumcision has demonstrated a decrease in HIV transmission by 60% among circumcised men.15,17 While observing live births in the hospital, pharmacy and nursing students observed that all mothers experienced natural childbirth without pain medications, demonstrating cultural norms as well as variations in pain tolerance and expectations. Pharmacy students rotated through the hospital’s inpatient pharmacy where all aspects of pharmacy operation practices were observed. While similarities were noted, there were also differences between Botswana’s pharmacy operational procedures and those the students were familiar within the United States. In the outpatient setting, patients were required to provide their own empty bottles for liquid medications. This practice presented a challenge for students as they observed patients being turned away who did not have bottles or only had unsanitary containers on hand. While only a temporary solution, students felt compelled to purchase amber liquid bottles at the village pharmacy and donate them to the hospital for its outpatient pharmacy. Cultural competence While this global educational experience enabled pharmacy and nursing students to experience health care and health care education in a different country, it also allowed them to understand and appreciate the traditions and values of a different culture. For instance, although the prospect of having a Jwaneng Diamond Mine tour was exciting to students, it was only after completing the tour of the mine and the mine’s hospital that students were able to fully grasp the importance of the diamond mines to the people of Botswana. The diamond mines are integral to the economic infrastructure of the country’s health care system. Pride in their diamond mines became evident when Botswana mine workers, pharmacists, and other health care professionals at the mine’s hospital spoke with the students on a guided tour. It was also eye-opening to consider that the revenue generated from the mines provided government funding for health care professional education abroad. A unique opportunity to participate in two tribal weddings also augmented students’ cultural awareness of how a developing nation sustains its traditions in the face of modernization. Ceremonies were held in a large open hut among a Kgotla, local tribal council, with village members segregated by gender and married women distinguished by wearing blue shawls. The ceremony elucidated the
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sacredness of marriage in Botswana and prohibited the attendance of divorcees.18 The two sets of couples asking to be betrothed were older than students anticipated. This was attributed to the modernization effects of higher education in sub-Saharan Africa, where “late” marriage is becoming the norm.19 While attending another wedding ceremony students learned about the cultural value of the lobola payment, which the western world typically defines as a bride-price. In the observed marriage ceremony, a groom paid eight cattle to the bride’s family. Locally, the lobola is viewed as evidence that a man is able to support a family. In contrast to the varying events facilitating cultural sensitivity to health care differences, a shared value was observed. Students witnessed the beliefs and traditions of the people of Kanye as they participated in Protestant and Catholic weekend services along with the hospital and college’s daily devotionals. It became evident that much of Kanye’s inspiration for health care service came from a desire to honor God and Jesus’ teaching to care for the sick and wounded as found in the story of the Good Samaritan.20 Inspired with them, the LLU students and faculty participated in the KSDACON and local church services by leading worship, teaching children, and sharing devotional messages. Evaluation and assessment The LLU pharmacy and nursing students were required to write a reflection paper at the end of their experience. This is a requirement for all LLU students who engage in global service and has notably been used in other global experiences described in the literature.7,21 This reflection paper addressed and documented objectives 2 through 5, which were met during the educational experience. Reflection papers addressed personal growth opportunities and professional skills acquired in relation to meeting health care needs with limited resources (objective 2). Students remarked on the cross-cultural experiences encountered in Kanye’s health care delivery (objective 3). Papers articulated appreciation for differing values, traditions, and health needs (objective 4). Lastly, students described how the trip inspired them to serve the underserved either globally and/ or locally in the future (objective 5). Following the conclusion of the service-learning experience, an anonymous Institutional Review Board (IRB)approved qualitative survey was sent to all students as an IPE assessment. The purpose of the survey was to assess role perception pre- and post-practice experience, selfperceived value, and perceived value of other professionals. The survey also linked the educational experience to the first objective by documenting and measuring what was learnt regarding different professions (object 1). Of the seven questions, four were Likert scale assessments on perceived value of students to the health care team, IPE impact on perception of other professions, as well as perceived value of a different profession on medication safety, and improved patient outcomes. Two of the
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questions were multiple-choice regarding perceived roles of the other profession before and after the clinical practice experience. One open-ended question asked the student to describe what they had learned from the other profession. The Qualtrics survey tool was used to administer the survey via an e-mail link. There was a 75% response rate among nursing students (n = 9).g Nursing student perceptions of pharmacist role prior to the trip were selected from multiple-choice options, including medication distributor, drug-information experts, patient advocates, colleagues, and health care providers/ clinicians. All responders viewed pharmacists as druginformation experts prior to the service-learning experience. Other top preconceptions of pharmacists included medication distributor and health care providers/clinicians, each of which were selected by 67% (n ¼ 6) of nursing students. After the trip, however, the perceptions of the nursing students about pharmacists were more uniformly distributed across all five options, with patient advocates and colleagues being selected by 56% (n ¼ 5) and 67% (n ¼ 6), respectively, a 33% increase for both. Overall, 56% (n ¼ 5) of the nursing students surveyed agreed or strongly agreed with the statement that working alongside pharmacy students changed their perception of the pharmacy profession. See the Table for survey questions and complete results for nursing and pharmacy surveys. Among pharmacy students, there was an 80% response rate (n ¼ 4). Similar to nursing students, the pharmacy student’s views also changed during the IPE experience. Overall, 75% (n ¼ 3) of respondents agreed with the statement that working alongside nursing students changed their perception of the nursing profession while one pharmacy student neither agreed nor disagreed with the statement. All pharmacy student respondents stated they perceived the nursing role as taking patient vital signs and orders from doctors prior to the educational experience. The other top two perceptions prior to the experience were that nurses are patient advocates, and that they administer medication and injections, each role selected by 75% (n ¼3) of pharmacy students. Similar to the results from the nursing survey, the pharmacy student perceptions about nurses were more uniformly distributed after the experience with the role of colleagues receiving responses from all pharmacy students (an increase of 75%) and the remainder four perceptions receiving three responses each. The selection of more roles from both pharmacy and nursing surveys after the trip suggests IPE experiences can help health care
g One LLU medical student on a surgical rotation interacting minimally with pharmacy students, as they observed surgeries, was invited to participate in this anonymous survey. Due to the limited interaction with pharmacy and nursing students, medicine has been excluded from IPE consideration in this experience. If the student did participate in the survey, nursing responses would be better described as nursing and medical student responses.
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students understand the diverse and comprehensive scopes of practice of different professions. Questions four through six assessed the perceptions of pharmacy and nursing student contributions to the team, medication safety, and improving patient outcomes utilizing a Likert scale. In response to the statement “I feel the pharmacy students made a positive contribution to the team,” 56% (n ¼ 5) of nursing students strongly agreed and 44% (n ¼ 4) agreed. In response to the statement “I feel the addition of pharmacy students to future medical training trips is necessary and crucial to patient medication safety,” 56% (n ¼ 5) of nursing students strongly agreed and 44% (n ¼ 4) agreed. In response to the statement “I feel the addition of pharmacy
students to future medical training trips is necessary and crucial to improve patient outcomes,” 44% (n ¼ 4) of nursing students strongly agreed and 56% (n ¼ 5) agreed. In response to the statement “I feel I made a positive contribution to the team,” 50% of pharmacy students strongly agreed and 50% agreed. In response to the statement “I feel the addition of nursing students to future medical training trips is necessary and crucial to patient medication safety,” 25% of pharmacy students strongly agreed and 75% agreed. In response to the statement “I feel the addition of nursing students to future medical training trips is necessary and crucial to improve patient outcomes,” 75% of pharmacy students strongly agreed and 25% agreed.
Table Qualitative survey results Questions
Responses,
For nursing students
n¼9
1 and 2.
3.
4.
5.
6.
Which role best describes your perceptions of pharmacists before/after the trip? (select all that apply) Medication distributor Drug-information experts Patient advocates Colleagues Health care providers/clinicians
Pre
Post
Difference
6 9 2 3 6
7 8 5 6 7
þ1 1 þ3 þ3 þ1
Working alongside pharmacy students on the Botswana trip changed my perception of the pharmacy profession. Strongly disagree Disagree Neutral Agree Strongly Agree
0 1 3 4 1
I feel that the pharmacy students made a positive contribution to the team. Strongly disagree Disagree Neutral Agree Strongly Agree
0 0 0 4 5
I feel that the addition of pharmacy students to the team for future medical training trips is necessary and crucial to patient medication safety. Strongly disagree Disagree Neutral Agree Strongly agree
0 0 0 4 5
I feel that the addition of pharmacy students to the team for future medical training trips is necessary and crucial to improve patient outcomes. Strongly disagree Disagree Neutral Agree Strongly agree
0 0 0 5 4
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Table Continued Questions
Responses,
For nursing students
n¼9
7.
Specific drug-related information, their role and scope of practice, pharmacy expertise is valuable and collaboration is valuable, and great teamwork
What specific things did you learn from working with pharmacy students?
For pharmacy students 1 and 2. Which role best describes your perceptions of nurses before the trip? (select all that apply) Patient advocates Administer of medications and injections Take patient vital signs and orders from doctors Colleagues Health care providers/clinicians 3.
4.
5.
6.
7.
n¼4 Pre
Post
Difference
3 3 4 1 1
3 3 3 4 3
0 0 1 þ3 þ2
Working alongside nursing students on the Botswana trip changed my perception of the nursing profession. Strongly disagree Disagree Neutral Agree Strongly agree
0 0 1 3 0
I feel that I made a positive contribution to the team. Strongly disagree Disagree Neutral Agree Strongly agree
0 0 0 2 2
I feel that the addition of nursing students to the team for future medical training trips is necessary and crucial to patient medication safety. Strongly disagree Disagree Neutral Agree Strongly agree
0 0 0 3 1
I feel that the addition of nursing students to the team for future medical training trips is necessary and crucial to improve patient outcomes. Strongly disagree Disagree Neutral Agree Strongly agree
0 0 0 1 3
What specific things did you learn from working with nursing students?
How to collaborate and the combined activities that are accomplished, how much can be learned from students and nurses, new respect for nurses, patient education can be a multidisciplinary approach to improve patient outcomes, and a different way to interact with patients
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The final question was “What specific things did you learn from working with pharmacy [nursing] students?” Four nursing students responded to the last question. One stated they learned about pharmacist’s role and scope of practice. Another shared pharmacy students provided specific drug-related information. Another appreciated the teamwork. The fourth mentioned valuing pharmacy expertise and collaboration. Three of the five pharmacy students on the trip responded to the last question. One pharmacy student shared that this experience revealed other dimensions of the nursing profession, which changed the student’s understanding of nurses. The student stated patient education can be accomplished through a multidisciplinary approach and that working together with nurses can improve patient outcomes. Another student stated they learned how to collaborate and what it can accomplish. Another mentioned obtaining a new respect for nurses, commenting that they had learned a new way to interact with patients, and that there was much they could learn from nurses and nursing students. Common themes in the responses provided by both groups of students included increased understanding of the roles and scopes of practice of the other profession, greater valuing of the other profession, learning how to collaborate, and appreciation of the opportunity to experience teamwork with a different discipline. Recommendations for future initiatives There are a number of recommendations for future IPE global experiences. First, administering a standardized, validated survey addressing IPE and cultural competence prior to and after the experience would be beneficial for the curricular justification of Introductory and Advanced Pharmacy Practice Experiences abroad. In the absence of such a survey, the SPICE survey could be modified for specific professions joined in IPE interactions in addition to a cultural competency survey.22 Second, the School of Pharmacy may consider structuring this experience to mirror the School of Nursing’s Public Health Nursing elective by providing the experience as an APPE. It is recommended that in addition to working with the Botswana hospital’s inpatient and outpatient pharmacies, global APPE students could continue to work with nursing students in the clinic dispensaries to fill prescriptions, provide counseling, take patient vital signs, administer immunizations, and participate in provider consultations. It is further proposed that pharmacy students could also partner with nursing students to identify a vulnerable population and provide an educational intervention addressing a specific public health need. Though pharmacy students contributed to clinic health promotion presentations, nursing students surveyed the village for the health needs assessment, selected the topic, and performed most of the research. Finally, as part of an APPE, students could be required to document clinical interventions and participate
in a team-building activity before the trip, as has been done in other pharmacy global service-learning experiences.23 Although pharmacy and nursing students presented their experience to their respective student bodies, faculty, and administration on the first week of the fall quarter, in the future this IPE experience can be presented to the student body, faculty, and administration of a university-wide weekly forum to highlight steps toward service-learning IPE experiences within curricula. Service learning is not currently a required component of the LLU School of Pharmacy’s experiential curriculum, but it has been integrated into the Pharmaceutical Care Laboratory III and the Social Behavioral Pharmacy courses. ACPE guidance on the inclusion of service learning within pharmacy practice experiences states pharmacy schools “should ensure that, in general, such activities… are integrated into the required academic curriculum.” The LLU encourages and facilitates volunteering in interprofessional global mission trips during Christmas, spring, and summer breaks while professional student organizations coordinate health screening/education events within the local community. Service learning is currently required of some health care programs at LLU, and other programs are pursuing its inclusion in the future. It is our recommendation that all health care programs require a service-learning component within clinical experience curricula while volunteer opportunities continue to be offered. Service-learning experiences among at-risk, vulnerable, underserved persons can build student leadership capacity23,24 and reawaken or develop compassion. Didactic education is valuable for relaying facts, teaching technique, and refining analytical skills, but an important pedagogy model for developing or maintaining compassion is in the lived experiences of service learning. In communities where excess abounds, cynicism is on the rise, and students are strained by the competing demands of study, internships, and new clinical situations,25 a balanced service experience can rekindled a sense of compassionate purpose. Academic medical research on empathy indicates medical students’ empathy scores decline during the final years of education in several countries including the United States. Its authors prompt administrators to ensure empathy training is provided along with opportunities for discussing challenges faced and reflection rooted in emotion and empathy to improve cognitive processing capacity and thus minimize the decline of affective empathy.25 Pharmacy literature speaks of understanding and empathizing with the patient illness experience in the didactic setting,26 empathetic patient counseling techniques,27,28 empathy assessment,29,30 and an increase in self-reported empathy during ambulatory patient encounters,31 yet more can be said of how to develop or maintain empathy and compassion. As pharmacy and other health professions struggle with how to cultivate and maintain compassion in their graduates,32 evidence in nursing and physical therapy literature suggests service learning provides an effective approach for its development.
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In Develop Student Compassion through Service-Learning, Brown states, “Compassion comes from within. For compassion to surface, nursing students need to be exposed to situations that help them understand the issues and challenges faced by people.” She states, “The goal of developing compassion through service learning is twofold. First, it is to provide hands-on experiences for nursing students by immersing them in the lives of others. Second, it helps students understand the difficulties of… social justice issues.” In a service-learning experience here, compassion was said to emerge during assessment and analysis as biases dissipate and students realize that poverty can come to anyone.33 Crandell et al.32 states that student physical therapist participation in service-learning experiences develops patient management skills and may support the development of compassion expression. With regards to student preferences and perceptions, millennial students are said to prefer experiential activities and teamwork.33 Crandell states students perceived service learning is a beneficial learning model in their professionalism development. Service learning also “appears to enhance a positive civic mindedness suggesting once students engage in community service, they are more likely continue service after graduation.”32 Students therefore not only value the servicelearning pedagogic model but also many students are likely to engage in these opportunities as volunteers in addition to any curricular mandates. Lastly, IPE can be further improved by integrating multiple health care professions into the same experience. Professors can initiate IPE partnerships with interprofessional guest lecturers or interdisciplinary didactic collaborations. This is one way to discover global clinical educational opportunities and create IPE experiences for pharmacy students. Alliances with other professions in interprofessional education can also be facilitated through university administrative support to faculty partnerships but may only advance as more accrediting institutions require increased interprofessional educational experiences. Summary The pharmacy and nursing students involved in this Botswana service-learning experience were oriented to work closely as an effective team with clear responsibilities to collaborate in patient assessments, health education, health promotion, medication distribution, and counseling as well as other IPE activities. Understanding the expected duties compelled students to quickly develop partnerships with their student colleagues and the health professionals at each site to accomplish shared goals. Daily patient care goals were met while other educational objectives were documented in the qualitative survey and student reflection papers. The qualitative survey assessed role perception preand post-practice experience and perceived value of other professionals in regards to medication safety and improved patient outcomes. Through the reflection papers, students
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considered personal and professional skills developed in meeting health care needs with limited resources. Student reflections also included the cross-cultural experiences encountered in Kanye’s health care delivery and articulated appreciation for differing values, traditions, and health needs. Students also described how the experience inspired a commitment to continue to serve the underserved globally and/or locally. Overall, this was an excellent preliminary practice experience in Botswana for the LLU School of Pharmacy, which was facilitated by joining an established nursing practicum course that had a MOU, travel and housing accommodations, and extraordinary cultural experiences. Acknowledgments The authors are grateful for the support of the Botswana Rural Health Administration Clinics, the Kanye SDA Hospital, Kanye SDA College of Nursing, the LLU School of Nursing, the LLU School of Pharmacy, and Anne Berit Petersen, MS, MPH, without whom this experience and publication could not have been made possible. References 1. Greiner AC, Knebel E, Board on Health Care Services (HCS) & Institute of Medicine (IOM). National Research Council. Health Professions Education: A Bridge to Quality. Washington, DC: The National Academies Press; 1–192. 2. Accreditation Council for Pharmacy Education, Accreditation Standards and Guideline for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree. Chicago, Illinois: Accreditation Council for Pharmacy Education; 1–97. 3. Interprofessional education collaborative expert panel. Core competencies for interprofessional collaborative practice: report of an expert panel. 2011;1-56. 4. Pittenger AL, Westberg S, Rowan M, Schweiss S. An interprofessional diabetes experience to improve pharmacy and nursing students’ competency in collaborative practice. Am J Pharm Educ. 2013;77(9): Article 197. 5. Baker MJ, Durham CF. Interprofessional education: a survey of students’ collaborative competency outcomes. J Nurs Educ. 2013;52(12):713–718. 6. Shrader S, Griggs C. Multiple interprofessional education activities delivered longitudinally within a required clinical assessment course. Am J Pharm Educ. 2014;78(1): Article 14. 7. Werremeyer AB, Skoy ET. A medical mission to Guatemala as an advanced pharmacy practice experience. Am J Pharm Educ. 2012;76(8):1–8. 8. American Association of Colleges of Nursing. The essentials of baccalaureate education for professional nursing practice. 〈http://www.aacn.nche.edu/education-resources/baccessentials 08.pdf〉: 2008 Accessed November 23, 2014. 9. Wright DJ. Planning a study abroad clinical experience. J Nurs Educ. 2010;49(5):280–286. 10. National Institute of Health. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents.
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L.I. Davis et al. / Currents in Pharmacy Teaching and Learning 7 (2015) 169–178 〈http://aidsinfo.nih.gov/guidelines〉; 2013 Accessed November 23, 2014. Kennedy I. Botswana Treatment Guide 2007. . Gaborone, Botswana: Ministry of Health National Standing Committee on Drugs; 2007. Smith AM. The No. 1 Ladies’ Detective Agency. New York, NY: Pantheon; 1998. Ministry of Health Republic of Botswana. Botswana HIV/AIDS programmes-HIV and AIDS quality management—Department of HIV/AIDS prevention and care; 2012. Centers for Disease Control and Prevention (CDC). Botswana HIV/AIDS assets and strategic focus—Division of Global HIV/ AIDS. 〈http://www.cdc.gov/globalaids/global-hiv-aids-at-cdc/ countries/Botswana/〉; 2014 Accessed November 23, 2014. Njeuhmeli E, Forsythe S, Reed J, et al. Voluntary medical male circumcision: modeling the impact and cost of expanding male circumcision for HIV prevention in eastern and southern Africa. PLoS Med. 2011;8(11):1–15. Wamai RG, Morris BJ, Waskett JH, et al. Criticisms of African trials fail to withstand scrutiny: male circumcision does prevent HIV infection. J Law Med. 2012;20(1):93–123. World Health Organization (WHO).World Health Organization and Joint United Nations Programme on HIV/AIDS. UN resources on male circumcision for HIV prevention. 〈http:// www.who.int/hiv/pub/malecircumcision/MC_inventory.pdf〉; 2010;1-48. Accessed November 23, 2014. Ruth. Setlhatlhanyo, Kanye, Botswana Tribal Wedding Tour Guide Communication; 2012. Garenne M. Age at marriage and modernization in sub-saharan Africa. S Afr J Demogr. 2004;9(2):59–79. Holy Bible. Luke 10:25-37. Nashville, TN: Thomas Nelson Publishers; 1991. Lincoln Balandin S, Sen M, Wilkins R, Trembath D. Twelve tips for effective international clinical placements. Med Teach. 2007;29(9):872–877. Meeting abstracts 114th Annual Meeting of the American Association of Colleges of Pharmacy, Chicago, Il, July 13-17,
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2013. Am J Pharm Educ. 2013;77(5):1–152 http://www.ajpe. org/doi/pdf/10.5688/ajpe775109, Accessed November 23, 2014. Brown DA, Brown DL, Yocum CK. Planning a pharmacy-led medical mission trip, part 2: servant leadership and team dynamics. Ann Pharmacother. 2012;46(6):895–900. Brown DA, Ferrill MJ. Planning a pharmacy-led medical mission trip, part 3: development and implementation of an elective medical missions Advanced Pharmacy Practice Experience rotation. Ann Pharmacother. 2012;46(7–8):1111–1114. Youssef FF, Nunes P, Sa B, Williams S. An exploration of changes in cognitive and emotional empathy among medical students in the Caribbean. Int J Med Educ. 2014;5: 185–192. Zimmermann M. Integrating medical humanities into a pharmaceutical care seminar on dementia. Am J Pharm Educ. 2013;77(1): Article 16. Beardsley R. Communication Skills in Pharmacy Practice, 5th ed, Baltimore, Maryland: Lippincott Williams & Wilkins; 2007. Berger BA, Villaume WA. Motivational Interviewing for Health Care Professionals. Washington, D.C.: American Pharmacists Association; 2013. Fjortoft N, Van Winkle LJ, Hojat M. Measuring empathy in pharmacy students. Am J Pharm Educ. 2011;75(6): Article 109. Chen JT, LaLopa J, Dang DK. Impact of patient empathy modeling on pharmacy students caring for the underserved. Am J Pharm Educ. 2008;72(2): Article 40. Whitley HP. Active-learning diabetes simulation in an Advanced Pharmacy Practice Experience to develop patient empathy. Am J Pharm Educ. 2012;76(10): Article 203. Crandell CE, Wiegand MR, Brosky JA. Examining the role of service-learning on development of professionalism in doctor of physical therapy students: a case report. J Allied Health. 2013;42(1):e25–e32. Brown E. Develop student compassion through servicelearning. J Christ Nurs. 2013;30(4):234–237.
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Research
http://www.pharmacyteaching.com
Interprofessional global service learning: A pharmacy and nursing practice experience in Botswana Linda I. Davis, PharmD, MA, TTSa,*, Dolores J. Wright, PhD, RNb, Matthew S. Gutierrez, PharmDa, Jennifer J. Nam, PharmDa, Jenny Nguyena, Andrew T. Waite, PharmDa a
b
School of Pharmacy, Loma Linda University, Loma Linda, CA School of Nursing, Loma Linda University West Hall, School of Nursing, Loma Linda, CA
Abstract Objectives: To develop, implement, and assess an interprofessional global service-learning experience in rural government-run clinics and a community hospital for pharmacy and nursing students. Design: An interprofessional educational experience was developed for volunteer pharmacy students to collaborate with nursing students in an established study-abroad elective course. Students participated in interprofessional activities for 27 days in Kanye, Botswana, where they engaged in clinical practice in community clinics and hospital units for 15 days between June 18 and July 15. Assessment: Five pharmacy students and 11 nursing students participated in the program. A qualitative survey assessed student perceptions of the interprofessional clinical experience while reflection papers assessed service learning. Conclusions: Global service learning is a valuable opportunity to prepare collaborative teamwork among pharmacy and nursing students. In addition, partnerships with other health care programs’ established educational experiences can facilitate pharmacy program expansion into global interprofessional practice experiences. Though validated assessments of global service learning impact on cultural competency and compassion were not performed here, preliminary evidence from reflective papers and student debriefing sessions suggest an interprofessional global service-learning experience develops both. More research is needed to measure the degree to which interprofessional global service learning can impact cultural competency and the expression of compassion. r 2015 Elsevier Inc. All rights reserved.
Keywords: Interprofessional; Global; Pharmacy; Nursing; Service learning
Introduction As health care institutions strive to develop and advance patient care, health professionals must work together to synchronize therapeutic regimens. Historically, physicians have been perceived as the health care professional bearing full responsibility for patient care and outcomes. In order to provide more effective and efficient patient care, the Institute * Corresponding author: Linda I. Davis, PharmD, MA, TTS, School of Pharmacy, Loma Linda University, 1627 E. Brockton Avenue, Redlands, CA 92374. E-mail: [email protected] http://dx.doi.org/10.1016/j.cptl.2014.11.017 1877-1297/r 2015 Elsevier Inc. All rights reserved.
of Medicine (IOM) Health Professions Education Summit recommended that all health professionals be educated to operate as an interdisciplinary team.1 The Accreditation Council for Pharmacy Education (ACPE) has embraced this recommendation, agreeing that pharmacists must be educated to deliver patient-centered care as members of an interprofessional team. Achieving this goal would require curricula that addresses evidence-based practice, health promotion, disease prevention, patient safety, cultural competence, health literacy, health care disparities, and interprofessional practice.2 The definition of interprofessional education (IPE) according to the World Health Organization (WHO) is
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“When students from two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes.”3 Moreover, ten of the ACPE guidelines include an interprofessional education requirement. Of these requirements, seven were new guidelines in the 2011 revision. The ACPE appendices B, C, and D also mention interprofessionalism five times, three of which are new additions.2 As recommended by the ACPE guidelines, many pharmacy programs are taking steps to integrate (IPE) into their curricula.4–6 IPE has been introduced in didactic education as well as in experiential education to improve patient outcomes. The ACPE guidelines suggest APPE rotations should be conducted in settings where “…continuity of care throughout the health care delivery system, including the availability and sharing of information regarding a patient’s condition, medications, and other therapies…” is emphasized.2 Following these guidelines and yet stepping outside the customary boundaries, a number of universities have begun to take interprofessional education abroad. For example, the College of Pharmacy at North Dakota State University developed an Advanced Pharmacy Practice Experience (APPE) rotation in which students participate in a ten-day global mission trip working with other medical professionals including medical and nursing students. One of the goals of this program is to improve student cultural competency assessment scores, while facilitating student opportunities to provide hypertension and diabetes screening, medication, nutrition and health promotion counseling, in addition to participation in pharmacy operations in Guatemala.7 Introducing service learning into IPE adds another layer of complexity. The ACPE describes service learning as “a structured learning experience with clearly defined objectives that combines performing service in the community with preparation, reflection, and discussion.”2 The Interprofessional Education Collaborative Expert Panel (IECEP) describes service learning as having several characteristics, stating “Service learning projects are frequently used as valuesbased educational opportunities to help students develop person and patient-centered knowledge and skills with a community/population-orientation around the health and health care needs of the at risk, vulnerable, and underserved.”3 Whether or not a particular community is considered underserved may be relative. The educational experience reported here took place in the southern African country of Botswana, in Kanye, which is a small rural village approximately one hour from the capital. While Botswana provides universal access to health care, the health care services in Kanye remain under-resourced with respect to equipment, supplies, and staffing. Therefore, it is argued that Kanye represents an underserved community and thus this is a service-learning experience by both IECEP and ACPE definitions. The Loma Linda University (LLU) School of Pharmacy and School of Nursing worked together to design and implement a global service-learning IPE program for pharmacy students in conjunction with an already established course for
nursing students. The entire experience included 27 days of IPE activities. Students trained and served in government-run clinics and a community hospital affiliated with a college of nursing in Kanye, Botswana, for 15 days. The five objectives specific to this global service-learning IPE experience were as follows: (1) to learn about and from different health care professionals within a collaborative team, (2) to develop personal and professional skills needed to meet health care needs of people in settings where there are limited resources, (3) to provide a cross-cultural experience in health care delivery, (4) to develop an appreciation for people with differing values, traditions, and health needs, and (5) to foster or reinforce a personal commitment to serve at home or abroad. Pharmacy student participation was integrated into a program that the School of Nursing had been offering for the past eight years. This program involved a collaborative relationship between the LLU School of Nursing, the Kanye Seventh-day Adventist College of Nursing (KSDACON), the Kanye Seventh-day Adventist Hospital, and the neighboring government-run clinics. The School of Nursing at the LLU developed this program to provide senior baccalaureate nursing students with the opportunity to participate in an elective study-abroad, service-learning clinical rotation offered in the required Public Health Nursing course. This was designed prior to the American Association of Colleges of Nursing recommendation for cultural competence education.8 During the program, nursing faculty observed nursing student instruction in clinic dispensaries could be enhanced with drug-information expertise. As a result, a pharmacy faculty member was approached for pharmacy student participation in an IPE experience. One nursing professor and one pharmacy professor traveled with the students and served as preceptors for this experience. The nursing faculty member arranged clinical sites prior to arrival in Botswana. While in Botswana she coordinated and confirmed lodging, travel, and food accommodations. She also coordinated with the hospital, the KSDACON, and the Kanye SDA Church for opportunities for the Loma Linda team to observe surgeries, speak to the KSDACON students, offer children’s Bible school classes, and provide worship music. The School of Pharmacy professor established partnerships with the inpatient pharmacy, outpatient pharmacy, HIV medication adherence counseling center, and hospital units to facilitate pharmacy student participation. She also defined roles with physicians and nurses who provided additional student supervision and precepting. The pharmacy professor rotated between sites to precept students and also met with students daily to debrief clinical, IPE, and cross-cultural experiences. Design Administrative, application, travel, cultural, and clinical preparation The memorandum of understanding (MOU) developed between the LLU and the KSDACON is reviewed yearly and
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signed by the administrators of both institutions. The MOU defines each institution’s responsibilities in areas of theoretical and clinical education, health care, cultural norms, and values. The LLU faculty members accompany the students in the dormitories of the host institution. The KSDACON faculty members secure temporary permits for the students and write letters requesting clinical sites in the local health district. They also facilitate such cultural experiences as a visit to the Kgotla, the local tribal council, and the nearest diamond mine. The study-abroad trip is scheduled during June and July when the KSDACON students are at home on winter break. Thus, the American students are not competing with the local nursing students for housing or clinical sites. The size of the group has varied in the past; however, the faculty has determined that 20 students is the maximum number of students that can be accommodated by the Rural Health Administration clinics. The travel and housing accommodation arrangements were also coordinated with ease. A travel agency provided all flight arrangements, and the KSDACON provided all the ground transportation to and from the airport as well as each clinic. Their cafeteria could also accommodate the group, providing three warm meals a day. The process for nursing and pharmacy students to enter this educational experience includes an application, approval by the school’s academic review committee, fundraising, payment, and travel clearance.9 Applications included stated reasons for desire to participate, interest in IPE teamwork, academic standing, and passport status. A fundraising letter template was issued to the students from the University’s Student Global Mission Service office. The School of Pharmacy paid for half of pharmacy student travel, lodging, and food expenses while nursing students paid travel expenses as part of a course fee. The students completed travel preparation forms from the University’s Global Health Institute that assisted in providing travel visas, travel health insurance, emergency planning, and offered advice to prospective travelers. Students were required to visit the University’s travel clinic to update their immunization status and obtain any necessary prophylactic medication (e.g., antimalarials, as Botswana is considered a malaria-endemic area during certain seasons). All students brought a month’s supply of their prescription and nonprescription medications with them. Though nursing participants were all senior-level baccalaureate students, pharmacy students were from three levels of the doctoral program and, thus, had varying levels of therapeutics education. Five pharmacy students participated: one entering fourth-year rotations, three entering the third professional year, and one entering the second professional year of the doctoral program. Due to the complexity of understanding HIV, pharmacy students attended an Infectious Disease Grand Rounds seminar and discussion session at the Jerry L. Pettis Memorial Veterans Medical Center led by the attending infectious disease physician and attended by infectious disease residents and fellows prior to the overseas experience. Students were oriented to the AIDS Info Guidelines for the Use of Antiretroviral Agents in
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HIV-1-Infected Adults and Adolescents and were later tested by the pharmacy preceptor on drug names, mechanisms of action, dosing, adverse reactions, and monitoring parameters.10 There were no differences in the clinical opportunities made available to pharmacy students of each level. In the months prior to departure, pharmacy and nursing students met several times to learn about the country of Botswana and the village of Kanye. They researched the World Health Organization (WHO), Centers for Disease Control and Prevention, and U.S. State Department websites to learn about the health concerns facing the people of Botswana. The students also had access to the Botswana Treatment Guide 2007 that identifies common diagnoses in the country and their recommended treatments.11 Students were encouraged to become familiar with the culture of Botswana by reading books and articles about the country. The No. 1 Ladies’ Detective Agency was recommended since the book gives a picture of important cultural icons.12 Pharmacy and nursing students also viewed DVD presentations produced by nursing students who participated during preceding years. These preparations facilitated the student’s transition into a new culture and health care practice model and also provided an opportunity for student introductions prior to the trip. Since the LLU nursing students arrived in Kanye ahead of the pharmacy students, three of the government-run clinics had already acclimated to having LLU student assistance on hand. In the absence of Kanye nursing students, who were gone for winter break, and clinic understaffing, the help from the pharmacy students was welcomed. The nursing students graciously helped orient pharmacy students to the practice site facilities, resources, expectations, and opportunities to serve. Clinical sites Nursing students were assigned to specific governmentrun clinics within the village of Kanye for the duration of their course, while pharmacy students rotated through sites to gain exposure to a variety of settings. Over the course of 15 days, pharmacy students spent three or four days in each site paired with different nursing students, except for one rotation where students participated in the hospital’s inpatient and outpatient pharmacy services. Some of the clinics were managed by physicians while others were managed by nurse practitioners and midwives. The prevalence of different diagnoses and clinical procedures varied at each facility. For example, one had a higher number of pediatric burns while another had more adult sexually transmitted disease testing, prevention, and treatment. Pharmacy students also rotated through the Kanye Hospital pediatric unit, as well as the labor and delivery unit together with nursing students. Some students elected to observe surgeries in the operating room and patient care in the emergency department. The community hospital and surrounding governmentrun clinics were accustomed to having local nursing
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students train with them and did not appear to have any difficulty integrating pharmacy students into the work flow. A hospital pharmacist provided administration insights during the pharmacy student rotation, which included operational legal requirements, government affiliations, and medication purchasing. Pharmacy students also participated in the inpatient pharmacy inventory management with other pharmacists. In addition, the students had the opportunity to dispense and counsel regarding prescriptions in the hospital’s outpatient pharmacy. Prior to departure on the final day, pharmacy and nursing students worked in the hospital’s outpatient pharmacy preparing a surplus of pre-packaged oral medications. Clinical activities and interventions Clinic involvement for pharmacy and nursing students consisted of assisting with taking vital signs, child growth surveillance, clinician consultation, wound care, immunizations, outpatient surgical procedures, medication dispensing, and patient counseling. Pharmacy and nursing students worked together to obtain patient weight, temperature, and blood pressure readings. Parents were surveyed regarding pediatric health in each clinic’s Child Welfare Center. Here, students dispensed child oral rehydration salts and zinc sulfate as they counseled parents regarding gastrointestinal symptoms and dehydration. Pharmacy and nursing students also conducted patient consultations at various clinics with physicians and nurse practitioners. Nursing students changed dressings at wound care stations and counseled regarding infection prevention and pain management with pharmacy student assistance. Pharmacy and nursing students also worked closely together at the clinic immunization stations. Students prepared and administered oral and subcutaneous vaccinations while providing vaccination schedule information. Though pharmacy students did not inject large-volume intramuscular injections, they drew up the solutions for nursing students to administer. Nursing and pharmacy students engaged in a collaborative partnership throughout the clinics, as well as in clinic dispensaries. Nursing students oriented pharmacy students to each clinic’s dispensary including prescription packaging and the handwritten labeling procedures. Pharmacy students offered suggestions to optimize the dispensaries’ organization, shared information on dose verification, and offered medication counseling, including whether or not medications should be taken with food, administration times, and how to minimize side effects. The pairing of students at each clinic and rotation site provided continuous opportunities for clinical teamwork, which benefited both groups of students. Differences in health care and health care delivery systems Students witnessed health care and health care delivery differences throughout their clinical experience. They were familiarized with the range of programs that the Botswana
public health system utilizes to address its elevated HIV prevalence of 23% among adults.13,14 In addition to the government-funded HIV clinics that provide no-cost antiretroviral medication through a stringent adherence program, an international campaign also focuses on decreasing HIV transmission through young adult and middle-age male circumcisions.15,16 Students helped patients register and offered ancillary support to local practitioners performing the circumcisions. In populations overwhelmed by this epidemic, Voluntary Medical Male Circumcision has demonstrated a decrease in HIV transmission by 60% among circumcised men.15,17 While observing live births in the hospital, pharmacy and nursing students observed that all mothers experienced natural childbirth without pain medications, demonstrating cultural norms as well as variations in pain tolerance and expectations. Pharmacy students rotated through the hospital’s inpatient pharmacy where all aspects of pharmacy operation practices were observed. While similarities were noted, there were also differences between Botswana’s pharmacy operational procedures and those the students were familiar within the United States. In the outpatient setting, patients were required to provide their own empty bottles for liquid medications. This practice presented a challenge for students as they observed patients being turned away who did not have bottles or only had unsanitary containers on hand. While only a temporary solution, students felt compelled to purchase amber liquid bottles at the village pharmacy and donate them to the hospital for its outpatient pharmacy. Cultural competence While this global educational experience enabled pharmacy and nursing students to experience health care and health care education in a different country, it also allowed them to understand and appreciate the traditions and values of a different culture. For instance, although the prospect of having a Jwaneng Diamond Mine tour was exciting to students, it was only after completing the tour of the mine and the mine’s hospital that students were able to fully grasp the importance of the diamond mines to the people of Botswana. The diamond mines are integral to the economic infrastructure of the country’s health care system. Pride in their diamond mines became evident when Botswana mine workers, pharmacists, and other health care professionals at the mine’s hospital spoke with the students on a guided tour. It was also eye-opening to consider that the revenue generated from the mines provided government funding for health care professional education abroad. A unique opportunity to participate in two tribal weddings also augmented students’ cultural awareness of how a developing nation sustains its traditions in the face of modernization. Ceremonies were held in a large open hut among a Kgotla, local tribal council, with village members segregated by gender and married women distinguished by wearing blue shawls. The ceremony elucidated the
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sacredness of marriage in Botswana and prohibited the attendance of divorcees.18 The two sets of couples asking to be betrothed were older than students anticipated. This was attributed to the modernization effects of higher education in sub-Saharan Africa, where “late” marriage is becoming the norm.19 While attending another wedding ceremony students learned about the cultural value of the lobola payment, which the western world typically defines as a bride-price. In the observed marriage ceremony, a groom paid eight cattle to the bride’s family. Locally, the lobola is viewed as evidence that a man is able to support a family. In contrast to the varying events facilitating cultural sensitivity to health care differences, a shared value was observed. Students witnessed the beliefs and traditions of the people of Kanye as they participated in Protestant and Catholic weekend services along with the hospital and college’s daily devotionals. It became evident that much of Kanye’s inspiration for health care service came from a desire to honor God and Jesus’ teaching to care for the sick and wounded as found in the story of the Good Samaritan.20 Inspired with them, the LLU students and faculty participated in the KSDACON and local church services by leading worship, teaching children, and sharing devotional messages. Evaluation and assessment The LLU pharmacy and nursing students were required to write a reflection paper at the end of their experience. This is a requirement for all LLU students who engage in global service and has notably been used in other global experiences described in the literature.7,21 This reflection paper addressed and documented objectives 2 through 5, which were met during the educational experience. Reflection papers addressed personal growth opportunities and professional skills acquired in relation to meeting health care needs with limited resources (objective 2). Students remarked on the cross-cultural experiences encountered in Kanye’s health care delivery (objective 3). Papers articulated appreciation for differing values, traditions, and health needs (objective 4). Lastly, students described how the trip inspired them to serve the underserved either globally and/ or locally in the future (objective 5). Following the conclusion of the service-learning experience, an anonymous Institutional Review Board (IRB)approved qualitative survey was sent to all students as an IPE assessment. The purpose of the survey was to assess role perception pre- and post-practice experience, selfperceived value, and perceived value of other professionals. The survey also linked the educational experience to the first objective by documenting and measuring what was learnt regarding different professions (object 1). Of the seven questions, four were Likert scale assessments on perceived value of students to the health care team, IPE impact on perception of other professions, as well as perceived value of a different profession on medication safety, and improved patient outcomes. Two of the
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questions were multiple-choice regarding perceived roles of the other profession before and after the clinical practice experience. One open-ended question asked the student to describe what they had learned from the other profession. The Qualtrics survey tool was used to administer the survey via an e-mail link. There was a 75% response rate among nursing students (n = 9).g Nursing student perceptions of pharmacist role prior to the trip were selected from multiple-choice options, including medication distributor, drug-information experts, patient advocates, colleagues, and health care providers/ clinicians. All responders viewed pharmacists as druginformation experts prior to the service-learning experience. Other top preconceptions of pharmacists included medication distributor and health care providers/clinicians, each of which were selected by 67% (n ¼ 6) of nursing students. After the trip, however, the perceptions of the nursing students about pharmacists were more uniformly distributed across all five options, with patient advocates and colleagues being selected by 56% (n ¼ 5) and 67% (n ¼ 6), respectively, a 33% increase for both. Overall, 56% (n ¼ 5) of the nursing students surveyed agreed or strongly agreed with the statement that working alongside pharmacy students changed their perception of the pharmacy profession. See the Table for survey questions and complete results for nursing and pharmacy surveys. Among pharmacy students, there was an 80% response rate (n ¼ 4). Similar to nursing students, the pharmacy student’s views also changed during the IPE experience. Overall, 75% (n ¼ 3) of respondents agreed with the statement that working alongside nursing students changed their perception of the nursing profession while one pharmacy student neither agreed nor disagreed with the statement. All pharmacy student respondents stated they perceived the nursing role as taking patient vital signs and orders from doctors prior to the educational experience. The other top two perceptions prior to the experience were that nurses are patient advocates, and that they administer medication and injections, each role selected by 75% (n ¼3) of pharmacy students. Similar to the results from the nursing survey, the pharmacy student perceptions about nurses were more uniformly distributed after the experience with the role of colleagues receiving responses from all pharmacy students (an increase of 75%) and the remainder four perceptions receiving three responses each. The selection of more roles from both pharmacy and nursing surveys after the trip suggests IPE experiences can help health care
g One LLU medical student on a surgical rotation interacting minimally with pharmacy students, as they observed surgeries, was invited to participate in this anonymous survey. Due to the limited interaction with pharmacy and nursing students, medicine has been excluded from IPE consideration in this experience. If the student did participate in the survey, nursing responses would be better described as nursing and medical student responses.
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students understand the diverse and comprehensive scopes of practice of different professions. Questions four through six assessed the perceptions of pharmacy and nursing student contributions to the team, medication safety, and improving patient outcomes utilizing a Likert scale. In response to the statement “I feel the pharmacy students made a positive contribution to the team,” 56% (n ¼ 5) of nursing students strongly agreed and 44% (n ¼ 4) agreed. In response to the statement “I feel the addition of pharmacy students to future medical training trips is necessary and crucial to patient medication safety,” 56% (n ¼ 5) of nursing students strongly agreed and 44% (n ¼ 4) agreed. In response to the statement “I feel the addition of pharmacy
students to future medical training trips is necessary and crucial to improve patient outcomes,” 44% (n ¼ 4) of nursing students strongly agreed and 56% (n ¼ 5) agreed. In response to the statement “I feel I made a positive contribution to the team,” 50% of pharmacy students strongly agreed and 50% agreed. In response to the statement “I feel the addition of nursing students to future medical training trips is necessary and crucial to patient medication safety,” 25% of pharmacy students strongly agreed and 75% agreed. In response to the statement “I feel the addition of nursing students to future medical training trips is necessary and crucial to improve patient outcomes,” 75% of pharmacy students strongly agreed and 25% agreed.
Table Qualitative survey results Questions
Responses,
For nursing students
n¼9
1 and 2.
3.
4.
5.
6.
Which role best describes your perceptions of pharmacists before/after the trip? (select all that apply) Medication distributor Drug-information experts Patient advocates Colleagues Health care providers/clinicians
Pre
Post
Difference
6 9 2 3 6
7 8 5 6 7
þ1 1 þ3 þ3 þ1
Working alongside pharmacy students on the Botswana trip changed my perception of the pharmacy profession. Strongly disagree Disagree Neutral Agree Strongly Agree
0 1 3 4 1
I feel that the pharmacy students made a positive contribution to the team. Strongly disagree Disagree Neutral Agree Strongly Agree
0 0 0 4 5
I feel that the addition of pharmacy students to the team for future medical training trips is necessary and crucial to patient medication safety. Strongly disagree Disagree Neutral Agree Strongly agree
0 0 0 4 5
I feel that the addition of pharmacy students to the team for future medical training trips is necessary and crucial to improve patient outcomes. Strongly disagree Disagree Neutral Agree Strongly agree
0 0 0 5 4
L.I. Davis et al. / Currents in Pharmacy Teaching and Learning 7 (2015) 169–178
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Table Continued Questions
Responses,
For nursing students
n¼9
7.
Specific drug-related information, their role and scope of practice, pharmacy expertise is valuable and collaboration is valuable, and great teamwork
What specific things did you learn from working with pharmacy students?
For pharmacy students 1 and 2. Which role best describes your perceptions of nurses before the trip? (select all that apply) Patient advocates Administer of medications and injections Take patient vital signs and orders from doctors Colleagues Health care providers/clinicians 3.
4.
5.
6.
7.
n¼4 Pre
Post
Difference
3 3 4 1 1
3 3 3 4 3
0 0 1 þ3 þ2
Working alongside nursing students on the Botswana trip changed my perception of the nursing profession. Strongly disagree Disagree Neutral Agree Strongly agree
0 0 1 3 0
I feel that I made a positive contribution to the team. Strongly disagree Disagree Neutral Agree Strongly agree
0 0 0 2 2
I feel that the addition of nursing students to the team for future medical training trips is necessary and crucial to patient medication safety. Strongly disagree Disagree Neutral Agree Strongly agree
0 0 0 3 1
I feel that the addition of nursing students to the team for future medical training trips is necessary and crucial to improve patient outcomes. Strongly disagree Disagree Neutral Agree Strongly agree
0 0 0 1 3
What specific things did you learn from working with nursing students?
How to collaborate and the combined activities that are accomplished, how much can be learned from students and nurses, new respect for nurses, patient education can be a multidisciplinary approach to improve patient outcomes, and a different way to interact with patients
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L.I. Davis et al. / Currents in Pharmacy Teaching and Learning 7 (2015) 169–178
The final question was “What specific things did you learn from working with pharmacy [nursing] students?” Four nursing students responded to the last question. One stated they learned about pharmacist’s role and scope of practice. Another shared pharmacy students provided specific drug-related information. Another appreciated the teamwork. The fourth mentioned valuing pharmacy expertise and collaboration. Three of the five pharmacy students on the trip responded to the last question. One pharmacy student shared that this experience revealed other dimensions of the nursing profession, which changed the student’s understanding of nurses. The student stated patient education can be accomplished through a multidisciplinary approach and that working together with nurses can improve patient outcomes. Another student stated they learned how to collaborate and what it can accomplish. Another mentioned obtaining a new respect for nurses, commenting that they had learned a new way to interact with patients, and that there was much they could learn from nurses and nursing students. Common themes in the responses provided by both groups of students included increased understanding of the roles and scopes of practice of the other profession, greater valuing of the other profession, learning how to collaborate, and appreciation of the opportunity to experience teamwork with a different discipline. Recommendations for future initiatives There are a number of recommendations for future IPE global experiences. First, administering a standardized, validated survey addressing IPE and cultural competence prior to and after the experience would be beneficial for the curricular justification of Introductory and Advanced Pharmacy Practice Experiences abroad. In the absence of such a survey, the SPICE survey could be modified for specific professions joined in IPE interactions in addition to a cultural competency survey.22 Second, the School of Pharmacy may consider structuring this experience to mirror the School of Nursing’s Public Health Nursing elective by providing the experience as an APPE. It is recommended that in addition to working with the Botswana hospital’s inpatient and outpatient pharmacies, global APPE students could continue to work with nursing students in the clinic dispensaries to fill prescriptions, provide counseling, take patient vital signs, administer immunizations, and participate in provider consultations. It is further proposed that pharmacy students could also partner with nursing students to identify a vulnerable population and provide an educational intervention addressing a specific public health need. Though pharmacy students contributed to clinic health promotion presentations, nursing students surveyed the village for the health needs assessment, selected the topic, and performed most of the research. Finally, as part of an APPE, students could be required to document clinical interventions and participate
in a team-building activity before the trip, as has been done in other pharmacy global service-learning experiences.23 Although pharmacy and nursing students presented their experience to their respective student bodies, faculty, and administration on the first week of the fall quarter, in the future this IPE experience can be presented to the student body, faculty, and administration of a university-wide weekly forum to highlight steps toward service-learning IPE experiences within curricula. Service learning is not currently a required component of the LLU School of Pharmacy’s experiential curriculum, but it has been integrated into the Pharmaceutical Care Laboratory III and the Social Behavioral Pharmacy courses. ACPE guidance on the inclusion of service learning within pharmacy practice experiences states pharmacy schools “should ensure that, in general, such activities… are integrated into the required academic curriculum.” The LLU encourages and facilitates volunteering in interprofessional global mission trips during Christmas, spring, and summer breaks while professional student organizations coordinate health screening/education events within the local community. Service learning is currently required of some health care programs at LLU, and other programs are pursuing its inclusion in the future. It is our recommendation that all health care programs require a service-learning component within clinical experience curricula while volunteer opportunities continue to be offered. Service-learning experiences among at-risk, vulnerable, underserved persons can build student leadership capacity23,24 and reawaken or develop compassion. Didactic education is valuable for relaying facts, teaching technique, and refining analytical skills, but an important pedagogy model for developing or maintaining compassion is in the lived experiences of service learning. In communities where excess abounds, cynicism is on the rise, and students are strained by the competing demands of study, internships, and new clinical situations,25 a balanced service experience can rekindled a sense of compassionate purpose. Academic medical research on empathy indicates medical students’ empathy scores decline during the final years of education in several countries including the United States. Its authors prompt administrators to ensure empathy training is provided along with opportunities for discussing challenges faced and reflection rooted in emotion and empathy to improve cognitive processing capacity and thus minimize the decline of affective empathy.25 Pharmacy literature speaks of understanding and empathizing with the patient illness experience in the didactic setting,26 empathetic patient counseling techniques,27,28 empathy assessment,29,30 and an increase in self-reported empathy during ambulatory patient encounters,31 yet more can be said of how to develop or maintain empathy and compassion. As pharmacy and other health professions struggle with how to cultivate and maintain compassion in their graduates,32 evidence in nursing and physical therapy literature suggests service learning provides an effective approach for its development.
L.I. Davis et al. / Currents in Pharmacy Teaching and Learning 7 (2015) 169–178
In Develop Student Compassion through Service-Learning, Brown states, “Compassion comes from within. For compassion to surface, nursing students need to be exposed to situations that help them understand the issues and challenges faced by people.” She states, “The goal of developing compassion through service learning is twofold. First, it is to provide hands-on experiences for nursing students by immersing them in the lives of others. Second, it helps students understand the difficulties of… social justice issues.” In a service-learning experience here, compassion was said to emerge during assessment and analysis as biases dissipate and students realize that poverty can come to anyone.33 Crandell et al.32 states that student physical therapist participation in service-learning experiences develops patient management skills and may support the development of compassion expression. With regards to student preferences and perceptions, millennial students are said to prefer experiential activities and teamwork.33 Crandell states students perceived service learning is a beneficial learning model in their professionalism development. Service learning also “appears to enhance a positive civic mindedness suggesting once students engage in community service, they are more likely continue service after graduation.”32 Students therefore not only value the servicelearning pedagogic model but also many students are likely to engage in these opportunities as volunteers in addition to any curricular mandates. Lastly, IPE can be further improved by integrating multiple health care professions into the same experience. Professors can initiate IPE partnerships with interprofessional guest lecturers or interdisciplinary didactic collaborations. This is one way to discover global clinical educational opportunities and create IPE experiences for pharmacy students. Alliances with other professions in interprofessional education can also be facilitated through university administrative support to faculty partnerships but may only advance as more accrediting institutions require increased interprofessional educational experiences. Summary The pharmacy and nursing students involved in this Botswana service-learning experience were oriented to work closely as an effective team with clear responsibilities to collaborate in patient assessments, health education, health promotion, medication distribution, and counseling as well as other IPE activities. Understanding the expected duties compelled students to quickly develop partnerships with their student colleagues and the health professionals at each site to accomplish shared goals. Daily patient care goals were met while other educational objectives were documented in the qualitative survey and student reflection papers. The qualitative survey assessed role perception preand post-practice experience and perceived value of other professionals in regards to medication safety and improved patient outcomes. Through the reflection papers, students
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considered personal and professional skills developed in meeting health care needs with limited resources. Student reflections also included the cross-cultural experiences encountered in Kanye’s health care delivery and articulated appreciation for differing values, traditions, and health needs. Students also described how the experience inspired a commitment to continue to serve the underserved globally and/or locally. Overall, this was an excellent preliminary practice experience in Botswana for the LLU School of Pharmacy, which was facilitated by joining an established nursing practicum course that had a MOU, travel and housing accommodations, and extraordinary cultural experiences. Acknowledgments The authors are grateful for the support of the Botswana Rural Health Administration Clinics, the Kanye SDA Hospital, Kanye SDA College of Nursing, the LLU School of Nursing, the LLU School of Pharmacy, and Anne Berit Petersen, MS, MPH, without whom this experience and publication could not have been made possible. References 1. Greiner AC, Knebel E, Board on Health Care Services (HCS) & Institute of Medicine (IOM). National Research Council. Health Professions Education: A Bridge to Quality. Washington, DC: The National Academies Press; 1–192. 2. Accreditation Council for Pharmacy Education, Accreditation Standards and Guideline for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree. Chicago, Illinois: Accreditation Council for Pharmacy Education; 1–97. 3. Interprofessional education collaborative expert panel. Core competencies for interprofessional collaborative practice: report of an expert panel. 2011;1-56. 4. Pittenger AL, Westberg S, Rowan M, Schweiss S. An interprofessional diabetes experience to improve pharmacy and nursing students’ competency in collaborative practice. Am J Pharm Educ. 2013;77(9): Article 197. 5. Baker MJ, Durham CF. Interprofessional education: a survey of students’ collaborative competency outcomes. J Nurs Educ. 2013;52(12):713–718. 6. Shrader S, Griggs C. Multiple interprofessional education activities delivered longitudinally within a required clinical assessment course. Am J Pharm Educ. 2014;78(1): Article 14. 7. Werremeyer AB, Skoy ET. A medical mission to Guatemala as an advanced pharmacy practice experience. Am J Pharm Educ. 2012;76(8):1–8. 8. American Association of Colleges of Nursing. The essentials of baccalaureate education for professional nursing practice. 〈http://www.aacn.nche.edu/education-resources/baccessentials 08.pdf〉: 2008 Accessed November 23, 2014. 9. Wright DJ. Planning a study abroad clinical experience. J Nurs Educ. 2010;49(5):280–286. 10. National Institute of Health. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents.
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L.I. Davis et al. / Currents in Pharmacy Teaching and Learning 7 (2015) 169–178 〈http://aidsinfo.nih.gov/guidelines〉; 2013 Accessed November 23, 2014. Kennedy I. Botswana Treatment Guide 2007. . Gaborone, Botswana: Ministry of Health National Standing Committee on Drugs; 2007. Smith AM. The No. 1 Ladies’ Detective Agency. New York, NY: Pantheon; 1998. Ministry of Health Republic of Botswana. Botswana HIV/AIDS programmes-HIV and AIDS quality management—Department of HIV/AIDS prevention and care; 2012. Centers for Disease Control and Prevention (CDC). Botswana HIV/AIDS assets and strategic focus—Division of Global HIV/ AIDS. 〈http://www.cdc.gov/globalaids/global-hiv-aids-at-cdc/ countries/Botswana/〉; 2014 Accessed November 23, 2014. Njeuhmeli E, Forsythe S, Reed J, et al. Voluntary medical male circumcision: modeling the impact and cost of expanding male circumcision for HIV prevention in eastern and southern Africa. PLoS Med. 2011;8(11):1–15. Wamai RG, Morris BJ, Waskett JH, et al. Criticisms of African trials fail to withstand scrutiny: male circumcision does prevent HIV infection. J Law Med. 2012;20(1):93–123. World Health Organization (WHO).World Health Organization and Joint United Nations Programme on HIV/AIDS. UN resources on male circumcision for HIV prevention. 〈http:// www.who.int/hiv/pub/malecircumcision/MC_inventory.pdf〉; 2010;1-48. Accessed November 23, 2014. Ruth. Setlhatlhanyo, Kanye, Botswana Tribal Wedding Tour Guide Communication; 2012. Garenne M. Age at marriage and modernization in sub-saharan Africa. S Afr J Demogr. 2004;9(2):59–79. Holy Bible. Luke 10:25-37. Nashville, TN: Thomas Nelson Publishers; 1991. Lincoln Balandin S, Sen M, Wilkins R, Trembath D. Twelve tips for effective international clinical placements. Med Teach. 2007;29(9):872–877. Meeting abstracts 114th Annual Meeting of the American Association of Colleges of Pharmacy, Chicago, Il, July 13-17,
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