Creating an Innovative Global Health Clinical Experience During the COVID-19 Pandemic

Abstract

When the COVID-19 pandemic hit and international travel was halted, nursing faculty were challenged to transform the in-person global health clinical experience with travel to a new virtual format. The virtual experience would need to meet the learning objectives and provide a global health perspective. This article describes the process of transforming the in-person clinical experience to a virtual format to provide a rich global learning opportunity for the students without travel to the host country. Virtual global health experiences can successfully help students understand the health of populations with a global perspective.

Introduction

Global health community health experiences for nursing students have become more common to provide educational opportunities to expand the learning of population and community-based healthcare principles that impact the health and wellness of the individual, community, and global populations. Evidence shows that designing clinical experiences to engage the student in using public health frameworks and social determinants of health to partner with global communities enhances the student's self-awareness, increases commitment to care for the medically underserved, and development of global mindfulness (Litzelman et al., 2017). While globalization has increased the need and demand for global health clinical experiences in medical education, without proper planning, supervision, preparation, and focus, these experiences become nothing more than “voluntourism” and can do more harm than good to the communities they are trying to serve (Wilson et al., 2012; Andrews, 2020; Lasker, 2016). A School of Nursing in the southeastern United States (US) provides global health experiences to the students through a community health nursing course. Interested students complete a short application discussing why they want to participate, any previous global health experience and how the experience will help them in their future career goals. Though language fluency is not required, students are also required to complete an online Spanish proficiency exam. After faculty review of the applications, 6 students are selected to participate in the clinical experience to partner with a school in San Eduardo, Ecuador. The students participate in a 3-semester course series working with the host partner in Ecuador to develop and implement a quality improvement project. Students then travel to Ecuador during spring break for project implementation. However, when the COVID-19 pandemic hit, international travel was halted. Faculty were challenged to develop a new virtual curriculum to develop a clinical experience that would meet the learning objectives as well as provide support and services to the global partners. This article describes the process of transforming the in-person clinical experience to a virtual format to provide successful project completion and a rich learning experience for the students.

Prepandemic Experiences

For 6 years before the COVID-19 pandemic, a faculty member traveled annually to Ecuador to participate in a 3-day medical clinic provided on-site at Escuela Ann Stevens (EAS) in San Eduardo, Ecuador. During these trips a nursing student would accompany the faculty and travel with the group to participate in the global health experience. EAS houses approximately 80 students and is supported by the Center for Contemplative Justice (CCJ) in Nashville, Tennessee. The CCJ has a 22-year relationship with the school and sends a group of healthcare providers and community members annually to participate in a medical clinic and capital improvement projects. Over the years the medical clinic has shifted from a focus on curative care to a preventive health and education model. In the fall of 2019, the decision was made to create a Global Health clinical opportunity at the School of Nursing to allow a group of 6 students to work collaboratively with EAS and travel to Ecuador for project implementation during spring break as part of their Community Health Nursing Course. In the Spring of 2020, the COVID-19 pandemic hit, and international travel ceased. Faculty were challenged to pivot and revise the curriculum to create a virtual clinical experience. In creating a virtual community health experience, efforts were made to provide learning opportunities congruent with the course objectives and effective communication with the host partner to establish a collaborative relationship.

Community Assessment

Traditionally if the students traveled to the clinical site, they would complete a community assessment and windshield or walking survey in person (University of Kansas, n.d.) (see Table 1 ). This was not feasible due to the pandemic. For the virtual experience, the students were provided with a variety of resources to develop a better understanding of the social, political, educational, and healthcare climate in the country. Online maps were utilized to focus on the geography of the area. Students were placed in pairs and assigned a topic (politics, healthcare, or education) to research and present information to the group. Internet searches were used on sites such as the World Health Organization (WHO) and the Pan American Health Organization (PANHO) to gather data on morbidity and mortality rates, life expectancy, vaccination rates, and illness. The faculty were able to share personal experiences traveling to Ecuador the along with photographs of the school, students and surrounding community. Results from a community assessment completed in 2008, as well as evidence on guidelines for short-term medical missions, were presented with PowerPoint presentations. Online folders were created to house medical Spanish resources and current articles on global health travel. Faculty had developed relationships with key stakeholders including the trip coordinator, school administrators, community leaders, and teachers during the past 6 years of traveling to the site. Synchronous interviews were conducted via Zoom with the various stakeholders, facilitated by a student interpreter and the faculty. After the data were collected, the students analyzed the information identifying strengths and weaknesses and the needs of the community.

Table 1.

What is a Windshield or Walking Survey

•A systematic method of achieving an overview of a community

•Conducted by either walking or driving through an area

•Used to understand the physical or geographical aspects of a community and/or how people use the community

•Allow one to see the assets of a community and provides a comparison of various neighborhoods or areas

•Use a checklist to ensure all questions and observations that are needed are made

•Take notes along the way

•Work in groups and be mindful of safety

•Analyze what you see and how the information will be used

Adapted from The Community Toolbox, 2014, https://ctb.ku.edu/en.

Quality Improvement Project

After completion of the Community Assessment, the students presented project ideas to the school administration and teachers via a virtual meeting. The host partners and the students mutually agreed upon the development of 2 different projects. The students split into 2 groups and would develop informational websites on CPR/First Aid and Reproductive Health. The development of the websites would provide resources to the teachers, parents, and students on the identified topics. As the projects developed the faculty coordinated additional resources for the students to help facilitate project development. A small grant from a local chapter of a professional organization was secured to provide a medical Spanish class for the students. A visiting professor from Ecuador met for 2 hours with the students to answer questions relevant to the cultural influences on health education. A faculty member, a native Spanish speaker volunteered to review all content and provided editing of both websites.

The students presented their websites virtually to the administration and teachers at the school on 2 separate days. Additional community members and students were not involved because the school was closed due to COVID-19. Presurveys and postsurveys administered demonstrated a 33% increase in knowledge and confidence in the information presented. The end of the 3-semester course cumulated with the development of a poster that was presented to 150 students and faculty to highlight the students' scholarly work. Both groups submitted written abstracts and were selected for a poster presentation of their project at the state nurses’ association annual conference. The next team of students is now prepared to continue the work that has been laid by the previous group and build on the training and resources that have been developed.

Post-COVID-19 Preparation for Future Travel

As the ban on international travel has been lifted the faculty is again challenged to prepare the next round of students to travel to the clinical site in Ecuador during 2023. The pandemic has had a direct effect on how students are prepared and supported during travel abroad. An Incident Response for Travel team (IRT), a team dedicated to providing safety-related guidance and assistance for all members of the University community who plan to be away from campus on university-related travel has been developed. IRT provides critical, personal, and time-sensitive guidance to travelers facing emergency situations while away from campus. IRT coordinates with overseas partners, campus offices, and connects travelers to the appropriate insurance policies. IRT supports all university travelers with health, safety, and emergencies throughout their travel experience.

The faculty coordinator registers all travel with the IRT and coordinates the students' completion of all required steps before travel to ensure the safety and security of all travelers (see Table 2 ).

Table 2.

Steps for preparing faculty and students for safe travel abroad

•Complete the International Travel Questionnaire provided by the IRT (Name, passport #/expiration date, emergency contacts, verification of travel and health insurance)

•Complete the Safety and Security Checklist with Covid-19 considerations

•Confirm all travelers have a valid passport for 6-months after they plan to arrive at their destination

•Register all travel information with IRT (flights, housing, transportation etc.)

•Review the CDC's list of recommendations and requirements for the destination

•Obtain a travel consultation with a healthcare provider and receive all recommended vaccines before travel

•Enroll in an international medical and evacuation insurance program

•Register with the US Department of State Steps Program Travel Registration https://step.state.gov/step/

•Travelers should be aware of entry and exit requirements for the U.S. and their destination. Reference the CDC and U.S. Department of State for guidance.

Conclusion

The Covid-19 pandemic disrupted teaching and learning across the globe overnight. Faculty and educators had to pivot and develop innovative strategies to continue providing meaningful global health experiences for students without the ability to travel to the partner country. The faculty have an ethical responsibility to oversee the students' work to focus on locally identified needs, build local capacity and sustainability, and prevent harm to the communities served. The use of technology paired with selected resources can effectively facilitate a collaborative and successful global health learning experience for both students and global host partners (Bowen et al., 2021). Future research could focus on the impact of global health experiences on students’ future plans to engage in global health after graduation. Additional research is needed that focuses on the use of virtual study abroad experiences to create more opportunities for students to experience a global health perspective on health and illness without travel.