For this written assignment, select one recent (within the past two years) evidence-based article from a peer reviewed nursing j

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Journal of Professional Nursing

journal homepage: www.elsevier.com/locate/jpnu

Transforming nursing curricula for a global community

Jennifer Dohrn⁎, Karen Desjardins, Judy Honig, Heidi Hahn-Schroeder, Yu-hui Ferng, Elaine Larson Columbia University School of Nursing, 617 West 168th Street, New York, NY 10032, USA

A R T I C L E I N F O

Keywords: Global Health Nursing education Clinical education

A B S T R A C T

With nurses and midwives providing the majority of health care globally, nursing education in all countries must prepare students for broader responsibilities to move the agenda forward for equitable care and universal health coverage. Columbia University School of Nursing developed and implemented a vibrant approach to curriculum transformation that included a new didactic course followed by a program of global clinical experiences to expand students' learning environments in global health. Program planning included defining learning objec- tives, mobilizing support within the school, establishing new sites, recruiting and preparing students, overseeing of students with host institutions, and evaluating the program. A total of twenty-four students were placed over five sites for a six-week credit-bearing global clinical experience. Students had varied clinical experiences with new understandings of the reality of health disparities. Host sites expressed a commitment to have students return in the next year, and all students stated that they would chose a global experience again. This innovation provides a transformative addition to nursing education with a deepened understanding of health disparities and nursing roles in different health systems. It strengthens the school's network of nursing and midwifery educators and opens doors for new exchanges.

Introduction

Nurses and midwives provide the majority of clinical care around the world. Their roles and responsibilities are substantial in advancing the global mandate to provide health care for all and universal health coverage. The health care environment has rapidly moved from a na- tional to global focus, influenced by increased technological advances, record migrations of people and increased disparities, necessitating a framework for global equity. Nursing and midwifery education needs to prepare students to assume broader roles in the global environment with competencies that include a rigorous understanding of the orga- nization of health systems and access to resources, leadership skills, and advocacy for the most marginalized populations to ensure equitable health care as a fundamental human right (Wilson et al., 2016). The Global Strategic Directions for Nursing and Midwifery 2016–2020, re- cently released by the World Health Organization, states: “Nurses… are critical in achieving global mandates such as universal health coverage and the Sustainable Development Goals. The mandates provide a challenge as well as an opportunity for making improvements in nur- sing and midwifery education …in a comprehensive way” (World Health Organization, 2016, p.3). The aim of this paper is to describe the transformation of a traditional community health curriculum to focus

on global health at both the didactic and clinical levels, and to re- commend to other nursing schools in the U.S.

Background

Global encounters place the nursing student directly within various countries' health systems and infrastructures, offering first-hand ex- perience of the meaning of social determinants of health, the impact of burden of disease and limited resources by global health care workers. Such experiences reduce the gap between theory and clinical practice, a serious concern in current global nursing education (Dadgaran, Parvizy, & Peyrovi, 2012). The student learns how nurses in host health facilities acclimate to these challenges, bearing witness to the daily clinical realities, sharing experiences and knowledge and completing projects designed by the host nursing school. For example, a nursing educator can provide curricular content regarding the global burden of disease with regards to malaria and childhood morbidity and mortality in Malawi in a classroom. However, it is a very different experience to work in a pediatric ward in Lilongwe, Malawi, and see four to five children die in their mother's arms daily. It is challenging to work with nurses and doctors trying to provide acute care to infected children in overcrowded wards with scarce resources, and return day after day. The

https://doi.org/10.1016/j.profnurs.2018.02.001 Received 28 November 2016; Received in revised form 13 February 2018; Accepted 21 February 2018

⁎ Corresponding author. E-mail addresses: [email protected] (J. Dohrn), [email protected] (K. Desjardins), [email protected] (J. Honig),

[email protected] (H. Hahn-Schroeder), [email protected] (Y.-h. Ferng), [email protected] (E. Larson).

Journal of Professional Nursing 34 (2018) 449–453

8755-7223/ © 2018 Elsevier Inc. All rights reserved.

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development of global clinical experiences in nursing and midwifery education must function concurrently with new didactic knowledge on global health issues that include cultural competencies such as respect, dignity, and inclusiveness. This expands competency-based curricula by “taking into account quantity, quality and relevance of the nursing and midwifery workforce to meet local and national changing health needs.” (WHO, 2016, p. 17). Upon return from their global experiences students share these experiences with faculty and other students, which expand the lessons of the learning experience.

Although Columbia University School of Nursing and its faculty, like many schools, has had a long history of international involvement and has been a WHO Collaborating Center for Columbia University School of Nursing for several decades, its global activities were siloed, with faculty often working independently on global projects. There was no shared vision for the work nor was there any coordinated involvement of students. Hence, the Office of Columbia University School of Nursing was established in 2012 to centralize and expand its global health priorities as a strong pillar of the education, practice, and research of future nurses (Kulage, Hickey, Honig, Johnson, & Larson, 2014). A re- vised strategic plan (2015–2020) clarified its vision: “to contribute to global health equity by addressing health disparities through service, practice, education, research, and leadership.” (Office of Columbia University School of Nursing Strategic Plan, 2015). One of the objec- tives of this strategic plan was to provide education for students to acquire ‘global health-specific competencies’ (Jogerst et al., 2015).

Methods

The current course on community health was reviewed and replaced by a new didactic course with a focus on global health. The final six- week practicum was expanded with the development of global clinical practicum experiences for nursing students.

Didactic course on global health equity

A new didactic course, Assessing Population Health Needs on a Global Scale, for entering students in the accelerated master's program was developed and implemented in 2014. It recognizes the changing needs and global demands for healthcare and replaced the former Community Health, with the goal of addressing current critical issues of global health equity and nursing models that provide solutions. Topics in- clude: Global Health Equity; Global Burden of Disease: Health Determinants, Measurements, Trends; Ethical and Human Rights Concerns in Global Health; Prioritizing Child and Youth Health; Environment and Health; Nutrition and Health; Communicable and Noncommunicable Diseases; Women's Health (Maternal Health and Reproductive Health and Rights); Well-Being and Mental Health; Living Longer, Living Healthily; Natural Disaster and Complex Humanitarian Emergencies; Unintentional injuries; Working Together to Improve Global Health: Nursing Profession as Global Provider.

The enrolled students are divided into five groups for the first year didactic learning, with this new course being taught in five-week in- tensive sessions to each group over the fall-winter-spring semesters. Course requirements include a community assessment and a poster presentation of an abstract on an assigned major global health issue and nursing's role. Students have local clinical assignments during this time, based at community sites, which allow them to learn nursing's role at the community level; class discussions tie these experiences into the issues that face communities around the world.

The course objectives remain constant, with annual updates to ex- amine current global health crises or emerging issues. Because pro- viding ‘real’ examples can enhance learning, the course builds its con- tent and discussions of the clinical, sociologic, ethical, and political issues around a specific crisis or issue. Themes have included, for ex- ample, the Ebola crisis, refugee health issues, and the Zika virus out- break. During the Ebola outbreak, students in the course developed

health literacy pamphlets on Ebola and provided short talks in the waiting area at their clinical sites about the Ebola virus. Several doc- toral students, moved by the outreach efforts of students in the course, created an independent project, Gloves4Gloves, 2014 (http://nursing. XXX.edu/gloves4gloves-doctoral-students-campaign-help-ebola- treatment) to raise money selling winter gloves locally and then pur- chasing thousands of protective gloves for nurses in Sierra Leone.

Clinical and field experiences

At the completion of didactic coursework with local clinical ex- periences, all students have a final clinical practicum that lasts for six weeks, usually within the larger Columbia University School of Nursing area. The new program has expanded these clinical sites to include global clinical experiences. The syllabus is the same for sites here as well as for global sites. Students can decide to apply for the global sites to fulfill this requirement.

Establishing criteria Crucial to our responsibility to prepare students to advance global

health (Wilson et al., 2012), it is important to complement the ex- panded didactic course with a hands-on global clinical program. Ob- jectives were developed and criteria were defined for potential clinical sites: 1) sites located in low-income countries with high burden of disease; 2) host schools of nursing and/or health care staff supportive to working with students from Columbia University School of Nursing; 3) reciprocal opportunities available, including exchanges, curriculum development or research opportunities. The rationale for these criteria focused on achieving experiences for the students that provide an op- portunity to collaborate in reducing health disparities, minimize being a burden to the staff as well as ensure a learning environment for the students, facilitate sustainability, and assure an on-going win-win for the host and Columbia University School of Nursing. The aims of the global clinical practicum include immersion in cultures and learning how they impact people's approach to their well-being and disease processes; exposure to different healthcare systems with challenged/ fragile infrastructure and nurses' roles and responsibilities and adap- tations to manage care when access and resources are minimal; first- hand learning of burden of disease and social determinants of health; increased capacities of students to contribute within the nursing student context; broadened understanding amongst faculty and student body through sharing of experiences. The experiences are designed to open the door for meaningful exchange with the host nursing faculty and students. They also promote the understanding that a partnership means reciprocity and contributing to addressing the health needs that nurses face daily in the host country as identified by them (Visovsky, McGhee, Jordan, Dominic, & Morrison-Beedy, 2016).

Identifying appropriate sites The first six-week clinical practicum with a primary health care

clinic for Spanish-speaking students in the Dominican Republic has been offered since 2010 and provided a model as new international sites were identified Columbia University School of Nursing second degree and masters students have participated in this experience and two PhD students are conducting their doctoral research in the clinic. In 2015 a second collaboration with a nursing school in Spain began with four students with fluency in Spanish participating in a 6-week clinical practicum and four students from that university spending four weeks of clinical observation here. Follow-up focus sessions with groups of students returning from these two sites confirmed the valuable learning experiences for creating nurses of the future.

Four additional sites that meet our criteria above (in low-income country with staff supportive to working with students and desiring a reciprocal relationship with Columbia University School of Nursing) have been identified to date through contacts at national and interna- tional conferences/meetings, through communication with nursing

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schools, and other established programs within the University. When there is interest from the host nursing school, discussions via calls, emails and direct talks explore the strategies for successful placement during clinical integration. A Memorandum of Understanding (MOU) is then prepared and signed. When possible, a site visit is conducted to discuss the opportunities for clinical experiences and tour the facilities. Key people at both the potential site and School of Nursing have regular communications over several months prior to the arrival of students. The number of sites is based on the need for student placement sites during the final capstone clinical experience referred to as integration, student interest in global experiences, and capacity to manage students and sites successfully. Each site generally hosts 4–6 students so that they have a supportive cohort with which to work, share experiences, and network.

Mobilizing support within the school's community It is important to assure that faculty, staff, administration, and

students within the School of Nursing here are well informed about these global activities and to garner their support and suggestions. Various venues are used to ‘spread the word’, including presentations at quarterly faculty and staff meetings, meetings with program directors whose students would be candidates, and with offices/departments that handle administrative student affairs. Discussions included the ratio- nale for expanding a traditional community health course to a global framework that included issues within the U.S. During the new course students continued clinical placements at sites throughout the area engaged in community health. Faculty rallied to accept this when they understood its relevance to the expanding definition of community. Once support is garnered, strategic meetings are held to develop a co- ordinated plan. Departmental responsibility is clarified to accomplish a successful program; overall responsibility and coordination for the de- velopment of sites, student recruitment and placement, and commu- nication with the students and the host schools resides within the Office of Columbia University School of Nursing while other offices within the School play supportive roles as students moved through integration. With support of the dean who is strongly committed to this transfor- mation and the development office, a ‘Global Fellows Fund’ was es- tablished specifically designed to help students participate in global clinical experiences. Alumni contribute annually to the funds, which cover student airfare and fees at the sites. The Office of Columbia University School of Nursing budget was increased to cover faculty and staff time to manage this program.

Recruitment of students: selection process for participation An informational meeting is held each fall semester for spring pla-

cements of students interested in global sites for their 6-week clinical practicum (integration). Staff provide an overview of the sites and students who had a global practicum the previous year describe their experiences and the impact on their nursing education. An application with site-specific information on cost, types of clinical experiences of- fered, and language requirements is disseminated in which students include a brief essay on their desire and rationale for a global experi- ence. Applications are reviewed by the program department and in- terviews for each student applicant with at least two members of faculty are scheduled. Interviews focus on student reasons for wanting a global experience, flexibility, understanding of health disparities and limited resources, and previous experience doing global work (such as Peace Corps). Where specific language competency is required, interviews are conducted in the required language.

The team reviews each applicant, reaches consensus, and an effort is made to match the student with her/his first request. For sites where more students apply than spaces, efforts are made to increase the number of students accepted by the host institution.

All participating students receive a small scholarship from a fund designated for global work to travel and student fees that might be incurred during the practicum. Arrangements are made with the

Financial Aid Department if additional loans were needed.

Orientation Students are required to attend an orientation for general travel

plans and information specific to each site. This session covers required vaccinations and health concerns; enrollment in the University's student emergency health services and waiver of liability; expected expenses and accommodations; and discussion on the general environment of the site, culture, and health system. Emphasis is placed on the fact that students are under the leadership of the host site and are expected to learn as well as contribute to the site via designated projects and in- terchange with host students.

Overseeing students while at sites A faculty member is designated as liaison for students at each site.

That person is responsible for weekly communication (usually via Skype) with case presentations, individual student support and com- munication with the identified preceptor at the host site, and trouble- shooting or helping students manage challenges as they occur. Host sites also designate faculty to work with students during their prac- ticum; the host faculty preceptor and the Columbia University School of Nursing liaison decide on final grades together upon completion of the syllabus. Each new site has a visit prior to the student clinical experi- ence as well as a visit by one of our School's faculty members during the time the students are present to facilitate collaboration, increase direct knowledge about the site and conditions for nursing, promote direct communication and support with the site and help the students as they adapted to new and challenging circumstances.

Debriefing Debriefing sessions for each site-specific group are held within a

week after the students return from the six-week experience. Each student speaks about the experience in terms of the clinical nursing rotation, interaction with nurses and nursing students, exposure to burden of diseases (e.g., HIV in sub-Saharan Africa; sickle cell disease in Jamaica; high infant and maternal morbidity), and health system or- ganization and function. Students are also asked to assess their ac- commodations and overall experience, how the group functioned and provide recommendations for future rotations at the site. In addition, students write a narrative work on their experience which is reviewed during the debriefing process. An annual timeline for program im- plementation is shown in Table 1.

Results

Between 2014 and 2016 (2 full years), 415 students completed the new course Assessing Population Health Needs on a Global Scale and 40 students have participated in the global clinical integration in one of six countries. Having administrative and faculty buy-in within the SON was critical at each step and provided a framework for problem-solving, and global sites welcomed the collaboration and our delivery of individual student projects, curricular development and exchange student pro- grams. Building reciprocity is central to the principle of equity and was repeatedly verified at each site.

Students at different sites had varied clinical experiences. Students experienced deaths of patients at all sites, though as expected it was highest in countries with the least resources. Students in Malawi, for example, experienced deaths of children from malaria every day, and sometimes several an hour. Global health disparities take on a new reality for the students as well as daily reminders of how nurses give care with minimal resources. Every student stated they would choose such a global experience again.

Central to the evaluation process were the student debriefing ses- sions which were highly informative, in describing the richness of the experiences, increasing understanding of global health issues, and ex- periencing the role of nurses in varied practices. Concrete suggestions

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by the students were sought and offered on what would be helpful going forward. It became evident that the students who experienced the most difficult circumstances might benefit from having mental health counseling services available after the rotation, which is now offered to them. Several students availed themselves for this opportunity to help process their experiences.

All students participating in these global placements report in their narratives written upon returning the importance of learning in practice the new framework that community health is global health, and the resourcefulness of nurses to meet patient needs with minimal resources. Some examples from their essays of the experiences include:

“I have seen things here that I will never forget…I am better pre- pared to handle life and death and I can be thankful for this ex- perience.”

“I was struck by how varied a health care setting can be and still provide amazing care for those it serves. I am grateful for the ex- perience and know that it will impact me as a provider.”

“This experience reminded me of my purpose and gave me that boost of self-esteem that I needed. My global experience helped me understand that I have the courage to succeed.”

“Why did I go there? Because of the nurses. Because of their wisdom, strength, their ability to improvise when faced with limited resources….Because of the time they take to teach me. Because of the way I learn to give care when I am with them. Because the person I am now is different than the person I was before.”

Evaluation includes feedback from the host sites, and each site is also asked to evaluate their experience with the students, including a checklist of expected learning accomplishments, which is part of the

syllabus for the course. Calls to each site focus on qualitative in- formation from the site, including their suggestions for areas of im- provement for the upcoming year. Letters are also sent to each pre- ceptor at the host sites to acknowledge their work and thank them.

Next steps and recommendations

The transformation of curricula at our school to prepare students for the global reality and challenges that await their entry into the pro- fession is dynamic. The required course has generated a new perspec- tive on how to approach nursing care in an environment where global and community health are part of an engaged continuum that impacts health outcomes across and within countries. The number of sites are developed in response to student interest and commitment to partici- pate.

Those students with direct clinical participation express deepened understanding of health disparities and nursing roles in countries with challenged health infrastructures and an increased commitment to nursing's responsibility to advocate for health justice. With these stu- dents as ambassadors for this global approach – speaking with other students, writing articles for the School newsletter and other media – we expect participation in this program will increase.

New protocols from the next year's initiatives have been developed to systemize the program as it goes forward. One delineates criteria for sites, with specified roles for our school and the host site; another de- scribes the rationale and frequency site visits are conducted. A protocol was also developed for roles, responsibilities and timelines within the School's offices. We have established a Student Advisory Committee to provide input to the process and preparation for students. Access to mental health services is now available from a counselor who worked with health care providers during the Ebola crisis in western Africa.

Table 1 Annual timeline for global program implementation following implementation of new didactic course.

Program planning Summer Fall Winter Spring

Defining the objectives

• Project number of sites • Identify criteria for sites

X X

Mobilizing support within the school

• Organize strategic meetings amongst the various departments for buy-in of program • Develop coordinated plan with tasks and responsibilities for each department • Establish scholarship fund for student travel support

X X

Exploring and identifying clinical sites

• Establish contact and dialogue with potential sites • Develop memorandum of understanding when consensus on site • Conduct site visit when possible by faculty

X X

Recruiting and preparing students prior to departure

• Hold informational session on global clinical sites for students • Develop and send application materials • Conduct interviews of applicants • Review and final selection of students by faculty and staff • Hold preparatory orientation sessions prior to departure. This includes completion of university and host requirements and forms

X X X

Overseeing students during practicum

• Support and oversee participating students by designated faculty and staff at host institution and Columbia University School of Nursing on a weekly basis

• Conduct site-visit by Columbia University School of Nursing faculty during student practicum whenever possible

X

Debriefing upon return

• Hold debriefing sessions with students upon their return • Require students to provide narrative on their experience

X

Evaluating of program

• Communicate with host institution about program for feedback of students and program improvement • Obtain feedback from students for next year's practicum and sites • Adjust program for next year based on evaluations

X

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Improved data collection includes pre- and post-surveys of student ex- periences in addition to evaluation by debriefing sessions.

With more students prepared to engage in an expanded global role, faculty are more involved in how their curriculum responds to global needs. These experiences are deepening the School's network of nursing and midwifery educators through on-the-ground knowledge. We are now moving forward to consolidate and deepen these relationships. We recommend that

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