Promoting social justice through experiential learning at an interprofessional refugee clinic

1. Introduction

The COVID-19 pandemic shed light on stark health disparities plaguing the global community, most recently, with the inequitable distribution of COVID-19 vaccines (Hyder et al., 2021). In many countries, including the United States [US], poor health outcomes related to COVID-19 disproportionally affected lower income and communities of color (Centers for Disease Control and Prevention, 2021). The National Academies of Sciences, Engineering and Medicine recently released a report to guide the next decade of the nursing profession. The report emphasized the need for health professionals to work across disciplines as a critical step in promoting health equity (Dzau, 2021). Integrating meaningful interprofessional education (IPE) into health professionals' curricula is a key strategy to impact the future of healthcare. Promoting health equity, social justice, and evidence-based quality care can be difficult when broad healthcare policies often limit resources for the poor. However, interprofessional care that is grounded in ethics and values can serve as an important venue for advocating for systemic change, while fulfilling a real need in the community (IPEC, 2016).

In 2021, the American Association of Colleges of Nursing (AACN) released new Essentials for Professional Nursing Education (AACN, 2021). The principles of health equity, diversity, and inclusion are intertwined throughout the entire document. With the advent of the new Essentials, nursing educators need to adapt their approach to include the measurement of student competency rather than a traditional time-based approach. This article details a longstanding interprofessional academic-community partnership that exists to provide basic health services for resettled refugees, while nurturing health professional students' commitment to social justice.

One of the most effective ways to impact students' commitment to social justice and health equity is through guided experiential learning (Leaune et al., 2021). The premise of Kolb's Experiential Learning Theory (ELT) is that transformative learning is a cyclical, holistic process occurring through experience. Kolb (1984) described four stages of experiential learning that are essential for acquiring new knowledge, skills, or attitudes: 1) concrete experience; 2) reflective observation; 3) abstract conceptualization; and 4) active experimentation (p. 30). The following sections will demonstrate how ELT was utilized to enhance student learning at an interprofessional refugee clinic.

2. Concrete experience at the refugee clinic

Kolb's ELT cycle begins with the concrete experiences stage. Students engage with resettled refugees each week at a student-faculty collaborative clinic. The clinic is an academic-community partnership located in a large US city with a mission to provide free, culturally appropriate medical and dental care to refugees in a welcoming environment that advances interprofessional health education and inspires students to pursue lifelong service. Refugees resettled through the Office of Refugee Resettlement are usually provided Medicaid for the first eight months after arrival into the United States. However, after the eight-month grace period, many do not qualify for Medicaid and cannot afford any of the alternative options for health insurance. This clinic has served as a healthcare safety net for refugees for more than ten years, evaluating and treating around 500 medical and 400 dental patients each year. The clinic increased from biweekly to weekly sessions in 2016 and is currently evaluating the feasibility of further expansion. The demographics of patients at the clinic changes based on the global political climate (Table 1).

Table 1.

Patient case vignettes.

An Afghani woman presented to the free refugee clinic with tooth pain after a local dentist had extracted her wisdom tooth. After assessment by the nursing, medical and dental students and faculty, it was determined that the swelling was lending to upper left eye cellulitis. Since her husband was assisting the US border staff in another state, the clinic team called him for interpretation and consent to transfer her to the local teaching hospital. Because the faculty physician at the refugee clinic also worked at the hospital emergency department, he was able to facilitate a seamless coordination of care. A medical student fluent in her language was able to explain the treatment protocol and assisted with transportation. The interprofessional team of students and faculty worked together to provide “just in time” healthcare for this woman.

An Afghani woman presented to the refugee clinic with her husband because they had just arrived to the city and she was pregnant with her first child. She had not had any prenatal care and did not have health insurance. Upon assessment, it was noted that she had a prosthetic left lower extremity. She explained to the student-faculty team, that as a six-year-old child, she lost her leg when a bomb exploded outside her home. As the team marveled at her endurance and resilience through unspeakable horrors, they committed to ensuring her access to quality prenatal care. Through networking with the university's obstetric department and the county health safety net program administrators, the team was able to facilitate her access to prenatal care.

In August of 2021 after 20 years of war, the US withdrew from Afghanistan and thousands of Afghan refugees were evacuated from Kabul. Throughout the months following the abrupt evacuation, thousands of Afghans lived on military bases in the US while waiting for placement. With the federally supported resettlement organizations lacking the capacity and resources to assist such a high number of families in a short amount of time, community-based organizations had to fill the gap and assist with basics of shelter, food, and healthcare (Christenson, 2021). Our clinic was one of the resources that responded to the sudden need for free, culturally sensitive health services for this community.

The genesis of the clinic was the result of a 2009 collaboration between the university and a church whose pastor was a refugee from Poland and felt called to reach out to the nearby refugee community. What started as a nursing student population health clinical experience to provide basic healthcare services at one of the nearby refugee apartment complexes evolved into a student-faculty collaborative clinic. In 2011, the Schools of Nursing, Dentistry and Medicine formally established the refugee health clinic whose basic tenets focus on social justice, cultural humility, patient advocacy, and compassionate care. The School of Medicine has a center dedicated to teaching ethics and nurturing humanitarian values. The center provides the clinic with administrative support and funding for supplies, medications, and laboratory services. All three schools provide faculty support to the clinic through patient care supervision, research mentorship, and community collaboration.

There are two key community partners who support the clinic. The first partner for the clinic is a non-profit volunteer-based organization that provides social services for refugees. Their staff address many social determinants of health barriers to successful resettlement, including access to care, transportation, and language. They assist with healthcare system navigation, insurance enrollment, and recruiting interpreters for the clinic. The interpreters are also leaders in their community and play a key role in fostering trusting relationships between patients and the healthcare team.

The second community partner is the church, which opens its campus for clinic use every Wednesday evening. Their members are committed to the mission of the clinic and the wellbeing of the community. The church location is optimal because it is within walking distance of many of the apartment complexes where refugees reside.

Three to four student leaders from each of the schools serve one year-terms to manage clinic operations, including the website, pre-clinic orientation, oversight of supplies, and patient flow of clinic sessions. Students from all three schools can sign-up to volunteer at the clinic through a registration portal. There are eight medical, four nursing, and four dental student volunteer slots each clinic session. Volunteers receive an orientation, form an IPE team, complete a patient assessment, then report to the faculty physician, nurse practitioner, and/or dentist. The team identifies a diagnosis and creates a plan of care that includes addressing social determinants of health factors in collaboration with the social service staff member and the interpreter. In addition to student volunteers, the clinic continues to serve as a clinical site for undergraduate nursing students who are completing their population health clinical rotation. An average of 15 patients are assessed during each clinic session.

In this setting, students learn to work in an interprofessional team and navigate assessments with an interpreter all while considering the cultural implications of their actions. This concrete experience provides students the opportunity for peer-to-peer interprofessional education, to develop attributes such as advocacy and leadership, and participate in community service.

3. Reflective observation

The second stage of Kolb's ELT is reflective observation. The students are consistently assessed for learning outcomes through huddles, faculty facilitated debriefings, and reflections. For example, the undergraduate nursing students in their population health clinical rotation use reflective journaling to apply course concepts and principles. These reflections provide a method to better understand students' critical thinking. Over the past decade, there has been a consistent theme from the students' reflections that demonstrates how assumptions can be challenged and replaced with cultural awareness.

“The refugees taught me more than they will know through their stories. They spoke about their struggles they endured getting to America and the violence that uprooted them out of their home. I realize that this isn't just a story I hear on the news, these are people right here in my community. I found myself sympathetic and in awe of the horrific detail he shared. Yet, I found hope in their new beginning. The Refugee Clinic allowed the opportunity to make an impact and deliver care these individuals need. Public health grew a different meaning for me”

(BSN Student Reflection, 2021).

The authentic experiences students have at the refugee clinic impacts their understanding and actualization of compassionate care, social justice, and health equity. These observations and reflections contribute to the next stage of Kolb's ELT.

4. Abstract conceptualization & active experimentation

After IPE students engage in concrete experience with time to reflect both individually and as a group, they draw conclusions and adapt their approach to patient care thereby increasing their knowledge and skills. Recently, the students realized that Afghan women were uncomfortable when a male (other than her husband) was in the exam room during their health encounter (including a male telephone interpreter). With a male present, women were likely to limit their responses and leave the clinic without their chief complaint being adequately addressed. After identifying this abstract concept, the students were able to transition to the active experimentation stage of ELT, whereby they adjusted the triage check-in process so that female Afghan patients were matched with an all-female student team, including the faculty member, and the interpreter.

There have been several research and quality improvement projects conducted at the refugee clinic over the years. Funding for the projects is usually acquired through the medical school’s community service-learning grant program. Studies have ranged from chart reviews of common conditions, diagnoses, and demographics of the patient population to qualitative interviews and focus groups with refugee patients to solicit their perceptions, preferences, and healthcare needs. During the COVID-19 pandemic, the dental team led an IPE telehealth strategy for triaging oral health complaints so they could deliver dental care to these patients when all community dental clinics were closed. Future research related to the educational impact will focus on evaluating interprofessional skills and attitudes, growth in cultural sensitivity, and long-term impact on professional career trajectories relating to health equity.

5. Conclusion

As academia moves toward competency-based education, it is paramount for educators to use innovative methods to incorporate the concepts of social justice and health equity. This will require action-based strategies that support meaningful experiences and contribute to tangible learning outcomes. The success of the refugee clinic as an experiential learning venue demonstrates how academic-community partnerships paired with interprofessional collaboration expands healthcare access for vulnerable, culturally diverse populations. Nursing schools will need to examine their own structures to evaluate whether they are actualizing their professed values related to health equity. Although a seemingly monumental endeavor, it is possible. Investment in meeting the needs of the local community and providing opportunities for students to walk alongside patients and families from diverse backgrounds as they navigate the complexities of the healthcare system, instills an experiential connection that inspires students to tackle the health disparities plaguing the world today.

Funding

This manuscript did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of competing interest

No conflict of interest has been declared by the authors.