Study abroad learning has been found to be a rich, life-changing experience for students. Most universities support and encourage this type of learning environment.1 During the past decade, there has been exponential growth and interest in international education among undergraduate nursing students.2
According to Sealey and Hathorn,3 nursing study abroad prepares students to work more effectively in international environments, as well as at home with culturally diverse clients. Study abroad makes it possible for students to spend considerable time immersed in a different culture and allows them to work with clients who hold different health beliefs and values.3 Dawson et al4 addressed the importance of educating all health care professionals for a globalized world. Nursing students need to be prepared to address emerging global health challenges and be competent in global health.4 Wilson et al5 suggested that "nurse educators have a responsibility to ensure that students are prepared to assume their role as global citizens to address emerging global health challenges" and "provide care in a clinically competent, safe, and culturally appropriate manner."
International nursing education is enhanced by exchanges between nurses of different countries in clinical and academic settings. Mkandawire-Valhmu and Doering6 indicated that many study abroad programs have their destinations in Third World countries, with a goal of promoting transcultural awareness. Faculty need to be prepared to plan study abroad programs that meet specific learning objectives.7
Our university had the unique opportunity of providing both theory and clinical nursing courses during an entire semester of study for nursing students in Uganda. We believed that the experience would be more valuable if students spent the full semester there rather than a brief study abroad experience. This would allow them to have a deeper appreciation for the culture and develop cultural skills that would better prepare them for their nursing practice.6
Benefits of a Nursing Semester Abroad
One of the goals of our university is to have most students participate in a cross-cultural experience. Some students, however, find it difficult to participate for a variety of reasons, including lack of finances and difficult and complicated coursework found in a nursing major. These reasons, among others, prompted nursing faculty and administration from a midwestern university to design and implement a senior-year nursing semester abroad. This article describes the preplanning, implementation, and postsemester experience of a nursing study abroad program.
Setting and Goals
Uganda was selected as the country for the nursing semester study abroad for a variety of reasons. Faculty knew the country well and had long-standing, well-established relationships with the Ugandan people, as well as with a supportive Ugandan university and number of health care agencies. Another important factor in choosing Uganda was that English is the national language, thus allowing for better communication. The faculty had taken groups of nursing students to Uganda for over 10 years, as part of a 4-week course: Cultural Diversity in Nursing.
The major goals of a nursing program are to provide students with strong academic and clinical learning. Other goals include providing opportunities to develop in nursing roles related to team work, communication and critical thinking skills, as well as growth in clinical competence. Some of these goals were met easily during the semester abroad, whereas others were more difficult.
Preplanning Phase
Before the semester abroad, faculty spent many months developing a proposal to meet department of nursing and university expectations. The International and Off-Campus Studies Committee required a fully developed semester plan including budget, accommodations, and student life activities, as well as syllabi of the 4 nursing courses to be taught during the semester. The nursing department decided that the courses taught in Uganda would be identical to their US counterparts, differing only in regard to the clinical environments and timeframe to accomplish the clinical goals. This decision was made in part because, as stated by Wright,1 faculty had concerns that nursing students would not acquire the necessary preparation for the licensure examination.
For the selection process, students were ranked by grade point average, and each student submitted an essay explaining past experiences with other cultures, their specific expectations for the semester and their interpretation of anticipated hardships. Each student was also interviewed by one of the study abroad faculty members. The interview focused on the reality of spending 4 months in a developing country away from friends and family, possible academic challenges while being away from the university, and ability to remain cohesive with a limited number of peers for 4 months in a potentially challenging environment. After completion of this process, 16 students were selected for the semester abroad in Uganda.
Planning meetings were scheduled regularly to discuss expectations and preparations, and a signed agreement was completed to confirm the student's understanding related to the food and technology challenges they would encounter during the semester abroad. Students were asked to read a book about the Ugandan culture in hopes of preparing them in a small way for the immersion experience. A parent picnic was held 6 weeks before the departure date as a way to allay fears and concerns and answer any last-minute questions.
Cost is often a barrier to study abroad experiences because students may be paying high tuition payments and generally do not have extra money to spend. After working on the budget, we were able to allow our students to exchange their regular semester tuition for the semester abroad tuition. Their room and board allotment on the US campus covered the remainder of the costs, including travel, as the cost of living in Uganda is significantly less than in the United States. Students needed no extra funds for the semester. In years past, students spent an additional $3000 to $3500 on a short-term study abroad trip. With the semester experience, all students were able to consider this experience as an option.
To accommodate teaching assignments back in the United States and meet the requirements of the Ugandan university, the decision was made to have 1 faculty member at a time with the students in Uganda, concentrating on their area of expertise. Faculty overlapped in Uganda for a few days to help with the academic and clinical flow of the semester and ensure that there was always a faculty member present. This plan worked well, and a total of 3 nursing faculty taught students in Uganda during the semester abroad.
Implementation Phase
Arrival
When all the planning and preparations were complete and the university approved our final plans and budget, the 16 students and 1 faculty member arrived in Uganda before the semester began. Each student was given a Ugandan-based cell phone and minutes to use on these phones. An orientation week was initiated to ease the students' adjustment to Uganda before beginning the academic coursework.
Semester Study Abroad Courses
The faculty had anticipated challenges to a semester of nursing study abroad, and one of the greatest challenges was in the academic area. One of the courses, Population-Focused Nursing Care, is an exploration of nursing care with an emphasis on culturally diverse and underserved populations. This course was an entirely online course and was managed in the same way for students on both Uganda and US campuses. One faculty member who taught this course not only had a leadership role in the nursing department but also took responsibility for working with the students in Uganda and served as a liaison between those students and the university. She helped with academic and nonacademic issues.
Another course, Family Health Issues, is an overview of theoretical frameworks and practice applications for family health nursing. It was taught similarly with both groups, with students in Uganda using videoconferencing to attend the lectures. Faculty who were teaching on the US campus had students both on campus and in Uganda. These faculty members spent extensive time before and during the semester working with Uganda faculty and students.
Nursing Practicum III is a course with a focus on evidence-based nursing practice, analysis of societal issues, and an understanding of cross-cultural relationships to improve nursing care. Students had the opportunity in Uganda to synthesize nursing roles in the care of individuals, families, and communities through clinical application in various community settings.
Nursing Skills III is a course in which students develop nursing skills used in specialty areas of nursing with a focus on children, families, and populations, as well as informatics skills to improve the quality and safety of health care delivery. Both of the clinical courses were taught entirely by nursing faculty who were with the students during the semester in Uganda.
The clinical experiences in Uganda were phenomenal, both in the amount of time students spent in clinical settings as well as the types of rich, clinical, and cultural experiences in which they participated. At the clinical sites they were embraced, versus tolerated, as students sometimes are in the United States. The main challenge with the clinical courses centered on the standard of care delivery and how to find a balance between respecting the cultural norms of nursing care in a developing country and maintaining the standard of care found in the United States. In addition to this, medical and simulation equipment was at a minimum in Uganda.
The students also attended community health clinical experiences alongside Ugandan nursing students. This provided a wonderful opportunity to engage not only with Ugandans but also with Ugandan nurses. It is important to keep in mind the impact that the program and students have on the Ugandan community. The nurses expressed gratitude for assisting them with patient care and providing them with educational opportunities.
The faculty members from the United States spent extensive time with the study abroad students in both academic and student life settings in activities such as orchestrating class video conferencing sessions, administering examinations for all courses, dealing with students' dietary concerns, and facilitating integration on the Uganda campus. Faculty worked with technology failures, communicated with faculty in the United States, and acted as the nursing program liaisons. All of this created a heavy workload for the faculty in Uganda. Some courses were taught by faculty on the US campus, but students needed guidance and direction from faculty who were with them in Uganda. Palmer et al8 agree with this reflection on our experience: "study abroad is time and labor intensive throughout the entire academic year."
Postsemester Experience
Our students were met with challenges that commonly occur in study abroad programs in developing countries. Many of the challenges required ongoing faculty attention, such as adjusting to food and living with unreliable electricity and Internet service.6 The students' environment while on the Uganda campus was anticipated but difficult. The dorm rooms, as well as the bathing and toileting facilities, were unlike those students were used to, and the food selection and variety of meals were different from what most students experience on a college campus. Throughout the semester, the lack of food choice remained a source of stress for the students even though they were taken out to dinner weekly and were given a small amount of money to purchase fruit and other treats as needed.
After the semester abroad experience, faculty concluded that simulation and class assignments did not need to be identical in both settings. As long as course objectives and competencies were met and courses maintained integrity, there should be freedom to meet the objectives in different ways. In the future, this change in approach would help decrease faculty workload. It also would help with the lack of Internet access and allow for country-appropriate teaching and learning strategies. Faculty determined that the lack of medical technology and equipment did not hinder students' learning and, in fact, seemed to aid their critical thinking skills and confidence in the clinical setting upon their return to the United States.
One of the obvious goals of the semester was one of a cultural immersion experience. There were victories in this area, with students stating that they were forever changed by the people they met and patients they cared for. A few joined sports teams, and students made Ugandan friends and became involved in the Uganda university campus activities. Many of our students, however, did not fully immerse themselves on the Uganda campus as much as we had hoped. They remained together as a group, eating and spending their evenings together while remaining connected to family and friends in the United States via the Internet. We believe that physical and emotional exhaustion played a part in this, as well as a lack of planning on the part of faculty to formally engage students in the international student groups available on campus.
Another challenge, although planned for, was the lack of infrastructure regarding electricity and Internet access. The Internet, when working, was extremely slow and became a frustration for students. Many times there was no power, which limited their ability to study and complete coursework. This problem was worse than anticipated and complicated the academic aspects of the semester abroad.
As with all experiences, there were also unanticipated challenges. Our host country's expectations were different from ours and had an impact on our semester. The nursing faculty from the Ugandan university desired more collaboration and joint activities than our courses allowed. This had not been clearly communicated and led to some misunderstanding. Wright1 described a similar situation as a potential barrier. She found that despite the misunderstandings, the benefit in working together became a wonderful learning opportunity for everyone.1 We agree and have a similar hope for a future semester of study in Uganda.
Wright1 also emphasized that the safety of students and faculty must be of primary importance. There were a number of security threats during our time in Uganda, which led to both faculty and parental concern. The Study Abroad Office at our university was in contact with government officials and helped make decisions relating to student safety. The Ugandan university also assisted us to make plans and preparations when these issues arose. This, however, remained a stressful and challenging situation for faculty.
From a clinical standpoint, faculty noticed an increased confidence and ability to think critically among the students when they returned from Uganda. Evanson and Zust9 found that the experience of providing hands-on nursing care during an international experience strengthened students' ability to provide effective, culturally sensitive care and become patient advocates. Our faculty also noted, as did students, an increased comfort level when caring for clients from different cultures.
Student Responses
In a follow-up questionnaire given to the students 10 months after they returned, students reported that their clinical experiences in Uganda were the highlight of their semester abroad. Many students said the experience increased their comfort level when working with patients of different cultures, and they understand how it feels to be the "odd one out" when in a strange place. Many students cited personal growth as a positive result of the semester abroad.
Students also acknowledged the difficulties of living in a different culture while studying nursing. Additional time was needed for research and online classes during power outages and slow Internet service. They noted that it was hard to use the US syllabus while in Uganda as "we were experiencing 2 different worlds at 2 different times." Findings from the study of Edmonds10 suggest that there are vast benefits of study abroad programs for nursing students, including increased personal growth, awareness of diverse cultures, adapting despite an unfamiliar environment, and increased self-efficacy. We believe that our students' comments reflect these findings. Our experience also supports the findings of Carpenter and Garcia11 that study abroad experiences provide deeply personal learning opportunities that can result in increased self-awareness, sensitivity, knowledge, and skills that are helpful when addressing cultural differences. We believe that a nursing study abroad is a beneficial experience as we prepare students for global endeavors.
Conclusion
The students and faculty learned much from their semester in Uganda. The semester abroad provided a way of incorporating a cultural immersion experience in our nursing program, a value we all share. We evaluated the strengths and challenges of the semester and realize that changes should be made in future endeavors.
We believe that the coursework has to be designed differently between the US and Uganda campuses. Assignments and syllabi should reflect technology challenges. With better planning on the part of faculty to formally engage students into the numerous international student groups on campus, we believe that students' cultural immersion experience could be enhanced. Lastly, the clinical experiences were a highlight, both academically and personally for students; therefore we would repeat them in the same manner.
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