Post master's and post baccalaureate Doctor of Nursing Practice (DNP) students encounter steep learning curves to achieve competence in diagnostic reasoning and critical thinking while they simultaneously strive to develop a scholarly approach to implement evidence-based practice interventions. Service-learning programs are consistent with the American Association of Colleges of Nursing's (2006)The Essentials of Doctoral Education for Advanced Nursing Practice recommendation for students to collaborate interprofessionally, practice evidence-based nursing, and increase awareness of social determinants of health (SDoH). Faculty and students experience cultural humility with service learning, which requires self-reflection about attitudes, thoughts, and actions that cannot be learned in a solely didactic format. Improving cultural humility skills of health professionals is an essential component to decreasing racial and ethnic health disparities (U.S. Department of Health and Human Services, 2011). Although cultural competency and cultural humility in simulation are supported as an effort to eliminate health disparities (Foronda, et al., 2018), immersion in a practical service learning experience allows for a deeper and more meaningful understanding of cultural humility and SDoH (Bryne, Collins, & Martelly, 2014).

Haiti is plagued by a lack of human resources, political unrest, and economic turmoil, and SDoH in Haiti are the worst in the western hemisphere. A faith-based Haitian coalition was established 26 years ago through grassroots efforts of Americans and Haitians to share knowledge and resources to improve residents' quality of life. A Haitian doctor, who returned to Haiti after practicing in the United States (US), guided the health care efforts of the coalition to serve his own people. The coalition received support from individuals, churches, organizations, businesses, and academic institutions across the US to open a school, orphanage, and medical clinic. Although the 2010 earthquake devastated Haiti and its residents and many organizations left the country, the coalition remains dedicated to serve Haiti and its residents, making it a unique service opportunity for postmaster's and postbaccalaureate DNP students to work with diverse professions to transform residents' lives.

Recent literature reflects concern about the ethics of international medical volunteering (Bauer, 2017). The coalition follows ethical guidelines for Haitians and Americans to improve residents' health within the context of their societal infrastructure. Consistent with many aspects of ethical frameworks for volunteer tourism to optimize experiences of host communities and team members (Hartman, Paris, & Blache-Cohen, 2014), the coalition's health care aim is to encourage Haitians to promote health initiatives that are reasonable and sustainable. Two years ago, the medical clinic was renovated and expanded to include a physical therapy and rehabilitation clinic, pharmacy, and new operating center. The coalition strives to improve community wellness through partnerships in education and community development. The local community benefits through ongoing professional development of Haitian educators and partnered development of sustainable small businesses, such as beekeeping.

Students' recommendation letters and applications to participate in the week-long service experience are reviewed by the coalition board of directors. The medical director makes recommendations to team members for pretravel immunizations and shares scheduling and travel information months before the departure date. Universities and individuals consider current US State Department travel advisories for the region. The coalition provides basic safety travel recommendations to participants, who travel as a team. Many team members obtain donated medical and surgical supplies to transport with their luggage. Team members reside in housing used only by American team members and Haitian and American coalition employees. Haitian coalition employees are residents who transport team members and provide food, bedding, and security; the clinic coalition employees reside in their own homes and travel to the clinic daily. American team members include internists, surgeons, residents, nurses, nurse practitioners (NPs), nursing students, anesthesiologists, physician assistants, physical therapists, and technicians, and equipment and simulation specialist.

The clinic employs a Haitian coordinator, pharmacist, physicians, interpreters, nurse anesthetists, medical assistants, nurses, physical therapists, and transporters. The Haitian physicians and therapists provide primary care and rehabilitation service, supplemented with the coalition's visiting clinicians. Nurse practitioner students can work in the surgical pre- and postoperative area, observe a surgical case, or see preoperative and same-day patients in the medical clinic. Medical patient encounters may include the student, a faculty or physician/NP mentor, the patient/family, and an interpreter. Patients drive or travel by foot for hours to seek treatment, and patient acuity is high. Students' experience includes patients of all ages who often present with multiple symptoms, such as nausea, headaches, musculoskeletal injuries or pain, rashes, or lumps. Students can palpate large thyroids, not seen in the US, and learn the posterior approach to assess for malignancy and compression on the trachea. They have opportunities to palpate large subcutaneous cysts, liposarcomas, and advanced breast lumps; assess thigh and sacral pitting edema in the context of end-stage heart failure; and formulate differential diagnoses for dermatological conditions and abdominal concerns. Students may examine children with failure to thrive and grow to understand the socioeconomic context and challenges in which such a condition occurs. Students are exposed to multiple medical and surgical conditions while working with a clinician mentor and interpreter to educate patients and families about reasonable, sustainable, evidence-based interventions.

Clinical decisions are made with minimal available point-of-care diagnostic tests. Most diagnoses are syndromic, meaning symptoms occur as a syndrome or part of a syndrome. Without radiologic or diagnostic aids, students learn that the stethoscope, often underused with advanced technological and diagnostic tools available in the western world, is essential to diagnostic reasoning. Egophony and tactile fremitus assist in diagnosing pneumonia, teaching students how to avoid ordering unnecessary radiographic imaging. Students collaborate with pharmacists to choose medications and appreciate the complexities of pharmacological prescribing practice. The pharmacist interprets for patients and their families about medication administration, dosage, adverse effects, follow-up treatment, or referral to other medical or surgical teams.

When students or professionals are first exposed to the realities of poverty in the developing world, they encounter the real ethical and moral challenge of deeper understanding of their own wealth and privilege in contrast to the poverty-stricken conditions overseas. Resilience and perseverance are comfortably challenged when exposed to international SDoH, and serving an international, underserved population promotes awareness and self-reflection on issues of dignity and justice. The effect of spirituality among Haitians is almost palpable. Students appreciate the effect of spirituality on Haitian patients' health and how spirituality can improve health outcomes. If students choose to participate, they can hold hands with patients and the staff to recite a daily morning prayer before clinic. The American and Haitian team members also gather each morning in the preoperative room to hold hands, share, and reflect on the prior day's work and pray for blessings for the work ahead. Team members, whether spiritual or nonspiritual, learn to balance their emotions to best serve patients. At the conclusion of the trip, the coalition offers methods for unstructured reflection and sharing of thoughts. Faculty may consider providing students with structured reflection related to their experiences (Hartman et al., 2014).

The challenge for NP students to improve patient health requires them to develop critical thinking and advanced clinical skills in the context of SDoH. International service-learning experiences allow students to experience different environmental, socioeconomic, and cultural contexts and improve clinical and pharmacological skills. Many NP students are required to complete one semester of pharmacology despite the number of prescribing agents that have exponentially increased in the past few decades. Mundinger and Carter (2019) add the limited number of faculty who are prepared for teaching DNP students advanced clinical practice skills, causing concern for students and new graduates. Academic institutions can consider incorporating immersion short-term service-learning trips for students and faculty and align goals of service with competency-based, curricular learning objectives. Reevaluating current learning modalities to meet curricular objectives for content, including spirituality, cultural humility, and diversity, is recommended. Foronda et al. (2018) add the importance of reevaluating our current simulation programs to prepare better learners and improve clinician-patient communication and outcomes. Nursing, as an art and science, encourages us to experience service learning and to serve others as competent NPs with advanced clinical skills, emphasizing the art of caring, compassion, and cultural humility with NP students.

Acknowledgments:The authors acknowledge Dr. Wayne Reichman, medical director, and the Community Coalition of Haiti staff for their work in Jacmel, Haiti.

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