Healthcare reform demands, including the aligning of nursing education to meet the needs of the healthcare delivery system, is on every stakeholder's mind at every level of engagement (Josiah Macy Jr. Foundation, 2018). An innovative learning environment in the framework of a medical mission, designed to strengthen undergraduate nursing students' rapport building and communication skills while delivering primary healthcare in a rural village in Kenya, Africa, is described. The medical mission endeavor aligns elements of the African environment with the components of a learning environment using Irby's Conceptual Framework for Learning Environments (2018).
Although the challenges for the nursing profession are many, nursing faculty face some of the highest challenges. Nurse educators must create learning environments that meet public demand and simultaneously redesign curricula to provide graduate nurses who are culturally sensitive.
Various factors require the curricula to change. One factor is the increasing ethnic diversity in the United States. Another factor is technological dependence that can overlap care for the person. Today's nursing students differ from earlier generations as 82% report that technology enhances their learning (National League for Nursing, 2015). Today's students are confident, technology savvy, easily distracted, and learn differently than earlier generations.
Although nursing students are technologically astute, they often lack the ability to communicate with patients, to build rapport and trust for better communication and nursing care. A 2016 study reported that 48% of patients who reported clinicians' high computer use during their visit experienced lower rapport building with providers and reduced patient satisfaction, whereas 83% of patients whose providers had low computer use reported high rapport with their clinician and higher satisfaction (Ratanawongsa et al., 2016). This evidence contradicts the notion that technology as a standalone teaching method adequately prepares students to communicate effectively in meeting patient needs.
A KENYAN VILLAGE LEARNING ENVIRONMENT
Nola Schrum, a nurse educator, began work in Kenya in 2011 during a nonprofit mission trip. She brought years of experience as a critical care nurse; her teaching philosophy of “See one, do one, teach one” during the immersion experience profoundly affected her. This philosophy is a primary teaching method in medical education, specifically in surgery (Benzil, 2018).
The following year, Schrum invited nursing students to join the mission trip and two students accepted. Four meetings were held before departure to introduce the concept of cultural awareness and discuss the environment in which they would be learning and working. Knowing that no technology was available in the village, students understood they would have just their stethoscopes, their senses, their hands, and most importantly, their minds and basic assessment skills; the students were forced to use the assessment and communication skills learned in nursing school. This hands-on, human-to-human interaction with villagers allowed the students to develop the art of listening, compassion and sincerity in care, and genuine concern.
Since that trip, this learning environment, known as “A Kenyan Village,” has been designed for nursing students who are technologically sound, but lack the skill to build rapport with diverse patients seeking care. This African immersion experience is outlined using the Learning Environments Framework and includes quotes from participating learners and teachers.
Before departure, students participate in planning and training; cultural competency and customs specific to Kenya are discussed. Activities include planning and buying clinic supplies. The lead faculty member instructs the teams to anticipate their clinic supplies based on the number of patients seen in previous years. During the final meeting, the nursing students inventory and pack the supplies.
LEARNING ENVIRONMENT CONCEPTUAL FRAMEWORK
A learning environment (LE) is defined by the “social interactions, organizational cultures and structures and physical and virtual spaces that surround and shape participants' experiences, perceptions, and learning” (Irby, 2018, p. 36).
This framework for innovative LEs has four components (Figure 1):
- personal: the learner interacts with the environment, engages in personal growth, and develops professional identity and autonomy.
- social: learners engage with others peer to peer, learner to faculty/staff, and learner to patient, as these relationships influence the content and means by which students learn.
- organizational: provides the structure, guidance, and support of learning, from curriculum to geographic locations, and incorporating organizational practices and culture.
- physical and virtual: learning occurs in physical spaces of educational and practice settings, whereas virtually learners use informational infrastructure such as online resources and electronic health records to foster learning.
The personal component develops an immersion philosophy where the learner and instructor engage in activities characterized by meaningful learning and exchanges, allowing the learner to develop a professional identity with increasing autonomy throughout the learning experience. Innovative LE experiences reach students at a deeper level than do typical classroom instruction techniques, promoting the qualities of professional identity and autonomy (Gruppen et al., 2018).
While in Kenya, students had opportunities to engage in activities aside from hands-on nursing care. For example, students could tour a boarding school and interact with high school girls who lived there. The boarding school professor explained that the mission organization sought out U.S. donors to support 4 years of high school education for girls who otherwise would be denied an education. The girls normally are laborers at home, working in fields to provide food for the family and caring for smaller children. The girls often are sold into marriage at age 14 to 15. To attend the boarding school, villagers turn in applications to the sponsoring organization; students are chosen based on scholastic achievements and their aspirations, including nursing, engineering, and teaching.
A junior nursing student acknowledged how the immersive LE impacted her personal growth:
I am so grateful to have been able to experience the medical mission trip to Kenya. I have gone through tremendous growth from the constant learning that surrounded us daily. Being faced with the opportunity to understand and appreciate the vast culture that is found in Kenya was a large part of the journey. It is important to be immersed in different cultures to gain a different perspective of the world and the individuals in it. Combining new experiences with old to deliver care to the less fortunate was difficult at first but it has granted me with a greater purpose. It is critical to be proficient in assessment and pathophysiology to understand the afflictions one may be going through in any culture. The challenge of actualizing the knowledge that we have gained from nursing school in a foreign land with diseases particular to the area was a learning experience unlike any other.
This student's experience demonstrates a holistic view of people with needs as students realize how an education, which seems basic in the United States, is not so for all.
As the nursing students formulate a new personal identity as learners, they realize how fortunate many are to come from supportive backgrounds and fulfill their dreams of a college education. They often see themselves and their families differently, strengthen their autonomy, and build resilience traits, which are often accessed during future difficult times.
Regarding how this LE promotes interpersonal communication, a faculty team leader stated,
[The learning experience] promotes [students'] development in ways I can't begin to describe, but I certainly recognize it objectively and they tell me subjectively after the mission and sometimes years later when they visit me. The richness and value of the patient/nurse relationship has been demonstrated for the nursing students through this immersion experience.
The social component of the high-functioning LE is undulating, dynamic, purposeful, and meaningful (Gruppen et al., 2018). During weekdays in Kenya, students work in clinics, paired with a registered nurse. In the evenings, students relax and eat communally. On some occasions, the students eat with members of the clinic staff, church leaders, and interpreters.
The Mothers Union, a group of Kenyan church women, teaches young girls in the village how to maintain a home, be a “Christian wife,” and be a productive community member. During mission experiences, these women build an open fire outside the kitchen and prepare lunch for the students. This is a time of bonding and cultural education. During lunch, the women often teach the nursing students how to prepare and cook local foods safely over the open fire.
A daily staffing schedule allows the students to work with various preceptors, exposing students to different styles and approaches to patient care. The nurse preceptors are from different settings and backgrounds as well as specialty areas. This model supports the students in the field and provides opportunity for collaboration with the nurses while assessing patients. As students' confidence grows, they begin to assume more responsibility for decisions and learn to become more flexible and better prepared for nursing roles postgraduation.
The reality of living in a different culture, smelling the smells, seeing life lived firsthand, and interacting with people in need provide a learning experience which is difficult to articulate. By living and working immersively in a different culture, students' perspectives of the world are broadened. They see the rural villagers as people with similar needs, desires, and goals as their own families have. As students begin to identify with the villagers, the students' understanding of the holistic needs of their patients increases exponentially. Maslow's hierarchy of needs (1943) becomes real as students view people in a developing country who often do not eat for an entire day or longer. Seeing patients come to clinic with clothes literally falling off their bodies and rubber tire shoes crumbling apart is a humbling experience.
A senior nursing student stated,
I know it sounds cliché, but my trip to Africa taught me so many things I could not possibly include them all in one sitting. It impacted my life in more ways than I could have ever imagined. I preface that what I am about to write in no way fully encompasses the richness of the knowledge, love, encouragement, and meaningfulness that was poured into me during my stay in Africa. So, with that said, one of the things that I learned on my trip was that I had taken for granted many (what I thought) menial things in my life—toilet paper, shelter, air conditioning, smooth paved roads, vehicles, washer and dryer, eating utensils, WATER, deodorant, medication, food, clothing, and the list could seriously take up this whole page.
All of these things have been at my disposal since I have been born so I can honestly say I did not know any better. My mom used to always tell me, “You should be thankful for what you have, there are kids in this world that don't get to eat today.” I never grasped the depth of what that meant and unfortunately, I don't think she ever did either. Yeah, it made me take a couple extra bites of my dinner, but I went on about my day not thinking twice about it. This trip changed it all for me. It gave me something tangible physically, emotionally, and spiritually. I got to see firsthand, feel firsthand, and hear firsthand what lacking really looks like. I came home and of course shared so many of these rich stories to family and friends and yes, I think they heard me and were happy for me. What breaks my heart though, is that they will never fully understand until they are there in it.
Over time, learners begin to mentor and lead each other by combining their didactic education with their experiential education. As Irby (2018) explained, “Exemplary learning environments prepare, support, and inspire all involved in health professions education and health care to work toward optimal health of individuals, populations, and communities” (p 106). All nurses are teachers, whether for patients, families, colleagues, or community members. By promoting this mindset early in a nursing student's learning, this framework is fostered and promoted.
One faculty team leader helped express this:
I have seen the art of nursing get further and further away from current nursing students because it is rarely taught or addressed as the “art of nursing” in the classroom. This experience allows the students to gain a much more concrete understanding of how the art of nursing, combined with the science of nursing, affects outcomes in a very positive way for both the patient and the nurse. It is a way to preserve “the art of nursing.”
Physical and Virtual Component
The physical and virtual component of the LE includes opportunities for intraprofessional development and training, virtual communities, credit for clinical hours in communities, disaster relief, health prevention and promotion initiatives in high-risk populations, locally, statewide and in Third-World countries, social and cultural immersions with diverse learners and faculty, venues for succession planning, sustained by electronic health records, resources, and online learning responsive in every way to the learner (Gruppen et al., 2018).
Although nursing students generally have keen technology skills, their personal communication skills often are lacking, limiting them to only a basic level of communication with patients. Students lack a general understanding of holistic care and don't realize that psychosocial and spiritual impacts of patients' lives often directly correlate with physical health. In Kenya, as students worked in the clinic, they began to realize that even as diseases were being identified, no easy solutions existed due to the hardships of rural life. This experience provided a better perspective of why some patients are labeled as “noncompliant” when, in fact, often other factors are involved that the patients cannot alter.
The absence of technology in rural Kenyan villages causes students to rely on and use their education rather than using technology to obtain data. One nursing professor explained that, as technology advanced, it became captivating for Americans young and old, and the “old” skill of face-to-face interaction became passé and is looked upon as a negative trait.
The first day of clinic, students and staff arrange the clinic rooms with chairs and a table where the teams will see patients. Patients arrive, register, recieve a number, and proceed into the church to wait for their numbers to be called. The teams include nurse practitioners, registered nurses, and nursing students, and the students rotate rooms daily.
Over time, the LE teams have expanded to include social workers, nurse managers, emergency room nurses, and construction crews. Screening for HIV, anemia, urinary tract infection, malaria, and glucose as well as providing pregnancy tests lends a degree of objective testing to the students' experience and their interpretation of data. Documentation of patient visits is done on paper and includes the students' interpretation of the patients' concerns and the treatment plan. Medications are offered free of charge as are toothbrushes and hygiene supplies such as soap, emery boards, and lotion.
One example of students applying communication skills to their assessment knowledge was their work related to the prevalence of Helicobacter pylori (H. pylori), a bacteria that can cause infection in the stomach. Infection with H. pylori was prevalent in the area, and clinic workers heard many patients describe complaints related to this infection. The students educated patients on methods to decrease gastroesophageal reflux disease symptoms and provided antacids that could be obtained at a local pharmacy without a prescription. Most individuals can manage their symptoms with over-the-counter medications, such as antacids, and lifestyle changes (Mayo Clinic, 2020).
Schrum continues to teach students and now employs minimal objective testing and screening materials, reinforcing basic assessment skills and critical thinking which are the most important skills nurses possess. Some students receive clinical credit for this immersion experience, and course evaluations provide evidence for modifications for the next mission.
A senior nursing student reflected on her experience:
It became apparent to me that I had not truly valued how other people live their lives and this trip helped open my eyes to see that I should never assume that people are going to make decisions like I do. I think that these experiences will translate over into my nursing practice and will help me be more empathetic and understanding.
“Organizations provide structure, guidance, and support for learning, including curriculum resources, geographic placements, accreditation rules, as well as organizational culture, practices, and policies.” (Gruppen et al., 2018, p. 38).
In village life in rural Kenya, the church is a focal point and the priest is the key informant for his congregation. Accordingly, lead LE faculty consulted with the priest on medical or social problems that female patients brought to the nurses at the clinic. The nurses considered his input during the patient assessment; later the priest would provide follow-up and support for these patients. Most diseases were chronic, but on occasion a very ill patient came in, usually a child or infant, and the students were involved with a quick, focused assessment.
The frontline clinic staff of registered nurses and student nurses produced improved flow and efficiency in care. In these nurse–student teams, the student took a health history and measured vital signs and the nurse assessed the patient. Students were responsible for health prevention and promotion for each patient. The nursing students received credit for the community health course they were enrolled in for this education component of clinical time. In 2019, the teams saw 530 patients in 3 days of clinics.
As the innovative LE program continued, students consistently reported an intense learning experience not only in nursing but in holistic care. A faculty team member observed that the program was modified, with the students being assigned at the forefront of the clinic. She stated,
The students engaged in not only taking vital signs, but in administrative duties such as registration of patients to be seen by providers. While the students met face to face with villagers and their families, they began to understand the family units and this was the beginning of the students' role expanding from the interview process to patient flow, introduction to triage, and focused assessment.
COMMUNICATING AS JESUS DID
From a faith-based viewpoint, an LE such as a Kenya village is a rich and fruitful atmosphere for students to add to their understanding of serving people with whom they seem to have little in common, but who are identical as creations made in the image of God and for his glory. Students can gain more motivation for developing their face-to-face communication skills when they remember that Jesus taught face to face and person to person. His interactions were holistic and provide a positive model for student learning.
Faculty leading a faith-based school or student group can include Scripture study and discussion that depicts Jesus' interactions with people; these small group times can enrich and inform students as they anticipate future patient encounters. Scripture passages such as Mark 10:46-52 where Jesus' interaction showed his awareness of a blind man's need; Matthew 8:1-4 that describes Jesus using touch with his words to communicate with a leprous man; and in Luke 19:1-10 where Jesus communicated his willingness to become involved with individuals who were in need of acceptance and redemption.
LEARNING ASSESSMENT AND DEBRIEFING
Daily debriefing is a valuable aspect of learning. All Kenya village nursing students are encouraged to complete post-trip evaluations; faculty team leaders review the evaluations and consider potential changes for future experiences. Debriefing is helpful in addressing the psychological impact of this type of learning for the whole team. A faculty team member who is a mental health educator was vital in the debriefing process.
One common debriefing discussion has centered on how Kenyan village people chose to spend their $1.00/day income. Identification of critical decisions on whether to buy coal to cook food versus buying bleach to clean eating utensils or purchasing soap for handwashing aided in a more holistic view of the patients' needs.
As part of the post-trip evaluations, students reflected on their experiences based on questions presented by the faculty members. When students were asked how the experiential learning mission activity helped them with their student nursing education and future career, one student shared,
I think that this experience helped me with my education and future career because it gave me hands-on experience not only with patients, but patients of a different culture. It taught me how to ask questions in an algorithm-like fashion so that I could come to a diagnosis of how to treat the patient. There were multiple situations where I had to critically think about how I was going to best treat my patients. It also allowed me the opportunity to work with amazing translators. I was not prepared for what was the great difficulty of having a language barrier between my patients and me.
Also, I think that working with a culture different from my own has given me invaluable experience to understand that we all have different needs, and we all do life differently. It became apparent to me that I had not truly valued how other people live their lives and this trip helped open my eyes to see that I should never assume that people are going to make decisions like I do. I think that these experiences will translate over into my nursing practice and will help me be more empathetic and understanding.
To the question about what the students thought was the most important nursing skill set necessary to care for people in other cultures, one student answered,
For those in need and especially of different cultures is genuine empathy and care. I think this rare quality is easily overlooked in the nursing field because it is not a tangible skill. It is hard to measure and results of this particular skill set can be obscure. Of course, practicing safe nursing care is critical, but I think that compassion for patients is a very valuable quality to have as a nurse and I think it is easily lost when we start focusing on the wrong aspects of our care of the patient.
Since 2011, 87 individuals, including social workers, information technology personnel, project managers, contractors, registered nurses, nurse practitioners, priests, and chief financial officers, have served on teams in the Kenya village LE along with nursing students who comprise the majority of the teams.
Nursing educators are committed to innovation and learning. In order to prepare nursing students for the future, faculty and administrators need a willingness to embrace LEs in settings outside of hospitals where nursing students can develop communication and assessment skills while experiencing cultures and communities locally and across the globe.
This Africa-based clinic program continues to deliver holistic nursing care in a Kenyan village. To succeed, this LE mission experience requires thinking outside the box, the ability to award clinical hour credit, and recruiting willing faculty. Nursing students with this kind of rich cultural immersion experience will be better prepared to provide culturally competent assessment and communication skills early in their nursing practice.