International short-term immersion service-learning (SL) experiences are high-impact educational opportunities that expand deep learning and personal and professional development (Kelleher, 2013; Knecht et al., 2019). A school of nursing in a public midwestern university has utilized short-term immersion experiences in Kenya as an undergraduate community health nursing clinical option since 2013. A Kenya trip was scheduled for May 2020 with 15 students. Seven students elected the course as a community health clinical experience and completed required didactic coursework during the winter term. When international travel was halted because of the COVID-19 pandemic, an alternative clinical to meet the learning objectives of the course was required. Faculty were challenged to develop a virtual clinical experience that would meet the same deep understanding of concepts and connections that previous students gained from travel abroad. Two faculty who previously accompanied students to Kenya led the clinical activities; both had significant experience/expertise teaching in the online environment.

Using course objectives as a guide for alternate clinical activities, assignments were designed with previously associated projects and SL experiences in Kenya serving the foundation for planning. This article reports on the process of transforming the in-person, short-term immersion clinical to a virtual format that would provide robust experiences mirroring the actual study abroad clinical.

ONSITE SERVICE-LEARNING FORMAT

Prior to COVID-19, the SL community health clinical included assignments that students completed prior to travel. These consisted of presentations on select sectors of the country of Kenya (economy, health care, indigenous tribes, geography, environment, and education) and the development of several health teaching projects identified by Kenyan community stakeholders. While in Kenya, students spent their days working alongside community health partners in clinics, hospitals, and schools. At the conclusion of each day, students and faculty leaders came together to discuss and debrief the students' experiences to develop an in-depth understanding of the communities, resources, and the Kenyan people. Students also completed daily reflective journaling. After returning home, students evaluated the delivery of the community health teaching activities and the learning outcomes of the intended audience. A final social gathering two weeks later allowed students and faculty to discuss their experiences with reimmersion into the US culture in a debrief format.

In creating a virtual community health experience, efforts were made to replicate as much of the short-term immersion as possible. Assignments were created and mapped to the course objectives. Faculty used previous knowledge from Kenya trips to identify two possible communities of interest to be used in the community assessment assignment and as the geographic focus for the community health teaching project. Participation was required for all students as part of their graded course work for the semester. Voluntary pre- and post-course surveys about the experience were administered with approval from the university's institutional review board.

Community Assessment

The community assessment assignment was divided into sections, culminating in the submission of a PowerPoint presentation. To define the community, students selected the geographic area surrounding a high school situated in Nairobi on the outskirts of Kibera, the largest urban informal settlement in Africa, which students visit as part of the SL immersion experience. The high school student population includes orphans of the AIDS epidemic. Traditionally, an in-person windshield survey and stakeholder survey would be embedded in the community assessment, and students would collect and analyze secondary data to identify leading health indicators. For the virtual immersion, Google Earth was utilized as part of the windshield survey to focus on the geography surrounding the high school. Students could see the area virtually and identify available community resources by satellite. This was used to develop a better understanding of the area's strengths and weaknesses. Internet searches were also used to identify needs, explore resources, and gather information on Kibera's demographics. Appropriate maps and photos supporting the results of the searches were embedded in the PowerPoint.

Faculty developed strong relationships with several key stakeholders in Kenya during the years of in-person experiences, including health care workers, community members and leaders, and school and hospital administrators. For the virtual experience, students participated in arranged synchronous interviews with these same stakeholders via Zoom with faculty present in an observational capacity.

Case Studies and Teaching Project

Drawing upon events and experiences from previous trips, case studies were developed for students to read and discuss as a group using the Zoom platform. Students then wrote independent reflections on the case studies. The assignment was developed to mirror situations students might have experienced during a clinical immersion, with debriefing. Individual reflections on the case studies proved to be impactful, with comments including the following: 1) "I will never fully understand the perspective of these health care workers because I have not been in their shoes, but I have a new/better understanding and respect for how they view life and death." 2) "This case study is painful to read and magnifies the disparities in health care around the world." 3) "This case discussion made me think about the pandemic we are currently living through. At certain points, the US experienced what it is like to have a scarcity of supplies and protective equipment. This[horizontal ellipsis]gave us a glimpse of what other countries have to deal with on a day-to-day basis." 4) "As we have discussed in previous case studies, the attitudes around health care and death are vastly different in Kenya from what we in the US are accustomed to. We expect to be fixed when a health issue arises."

As a group, students selected a UN sustainable development goal (United Nations General Assembly, 2015) and produced a teaching project on gender inequality. The project was meant to be portable and usable by faculty at the high school. Because the school was closed because of COVID-19, the project was presented to clinical faculty in lieu of Kenyan high school students.

Despite concerns that student disappointment regarding their inability to travel would overshadow any course adaptation efforts, reflective statements from students indicated that the course and content were beneficial. Student comments included: 1) "I was worried about how we would be able to still learn if we had to stay in the US for this course. I think our teachers[horizontal ellipsis]gave us the right tools for us to still be able to learn all about their culture in Kenya and how medicine is practiced there. For being the first time having to do this online, I believe this class taught me a lot and has me wanting to go to Kenya in the future." 2) "I anticipate that this course will make me more sensitive and compassionate as a registered nurse[horizontal ellipsis]. I have been able to learn a lot and have taken away many ideas. Talking to someone from Kenya and realizing how different they live has humbled me and I know this will help me be a better and more caring nurse." 3) "This course affected my personal growth by teaching me how important it is to really get to know and understand people, especially before making judgments."

CONCLUSION

There is a paucity of research on creating virtual community health clinical courses with a global emphasis. This article adds to the current body of knowledge about designing virtual clinicals that focus on a population in another country. Even in the absence of international travel, experiences can be created that allow students to learn about and reflect on cultures other than their own (Phillips & Young, 2018). Procter et al. (2017) found that social media platforms assisted in developing an understanding of another country's culture without leaving home. Todhunter et al. (2013) expressed that a virtual "study-elsewhere" experience supported nursing students' understanding of health care around the world. Increasing the number of participating students in future virtual course offerings with a global population focus will provide a more robust data set, allowing for deeper understanding of the topic. Virtual community health SL courses are a viable option for experiencing a global health perspective without travel.

Study abroad experiences contribute significantly to nursing students' personal growth and professional development and increase cultural sensitivity and competence (Kelleher, 2013). The development of a virtual study abroad experience provides opportunities for more students to thoroughly and thoughtfully study a global community and better understand the culture and impact of health indicators on a population. Faculty were concerned that the urgency in creating this replacement course would not allow for the transformative thinking that often takes place in a true study abroad experience; however, student surveys supported that not only was the experience transformative but had the potential to impact future practice. Further development of course content could allow for the offering of future virtual study abroad courses, giving more students the opportunity to experience a global health care perspective.

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