Marking a Decade of Nursing Students Immersed in Global Clinical Experiences

Abstract

Background

Ten years ago, Columbia University School of Nursing (CUSON) started to transform its nursing curriculum to include global health equity to prepare future nurses for escalating rates of health problems caused by wars, forced migration, and climate change.

Method

A course for entering students examines health disparities worldwide and within the United States with nursing intervention examples. Global Students Clinical Program offers students 6 weeks to learn and practice under the leadership of nurses and midwives in primarily Global South sites, engaging with 20 sites worldwide. With reciprocity as the foundation, host institutions determine collaborations to build, such as simulation learning, research, and curriculum development.

Results

Evaluations from host sites and participating students confirm increased knowledge, skills, and understanding of global health issues.

Conclusion

CUSON urges other nursing institutions to expand their programs didactically and clinically within a global health equity framework for future nurses to provide care and leadership that these challenging times demand.

In 2014, Columbia University School of Nursing (CUSON) examined its nursing education program and boldly began to transform the preparation of future nurses to include global health equity as a focus. From this review, the school initiated a program, the Global Students Clinical Program (GSCP), where for 6 weeks nursing students completing the prelicensure accelerated bachelor and Master of Nursing degree program are selected to learn and practice under the faculty leadership of nurses and midwives at clinical sites in primarily Global South countries (Dohrn et al., 2018). Now marking a decade of experience, CUSON is celebrating and reflecting on where we are toward meeting our goal of graduating students with a strong understanding of the global responsibility of nursing professionals to see themselves as advocates for health justice and equity in active solidarity with nurses everywhere.

We live in a world confronting many crises that include the reality of deadly infectious diseases with the potential to spread from one country to another with rapid speed; the escalating numbers of people in forced migration, fueled by wars, famine, and violence; and the increasing effects of human-made climate change making many lands uninhabitable. All of these issues affect people's health, and nursing, as the largest cadre of the health professions and on the frontline, can provide high-quality care if it is recognized at leadership and policy levels. Nurses globally provide the connections to the communities they serve and provide the knowledge of what people see as their health problems in the context of cultural and spiritual values; they provide evidence-based care and adhere to the ethical principle that everyone is entitled to the highest level of health care as a human right. Nurses need to be poised and empowered to provide and model health solutions for countries, regions, and the globe (^{World Health Organization, 2021}).

The coronavirus disease 2019 (COVID-19) pandemic exposed vividly the sizeable inequities between Global North and Global South countries. Essential resources, such as access to clean water, gloves, and oxygen, were scarce for the majority of people; protective vaccines initially were the privilege solely for Global North citizens (^{The Lancet, 2023}). Once vaccines were more widely distributed, many countries with strong public health systems responded with mandated vaccination drives with effective results. We learned once again that communicable diseases have no borders and can only be contained by an effective and well-implemented global strategy. These world events continue to push CUSON to expand its focus on global health in its curriculum, clinical, and research platforms.

Method

Starting in 2014, CUSON established a department called the Office of Global Initiatives (OGI) as the home to build hands-on global clinical experiences for students with nursing institutions in other countries. The essential foundational principles for the program were articulated and defined (Table A; available in the online version of this article).

Table A

Foundational Principles for the Global Students Clinical Program

Essential Foundational Principles	Clarification and Examples
Global Health Equity	Collaborations are built with nursing institutions in areas of the world most challenged for resources, primarily in the Global South (e.g., in Kenya and The Gambia).
	Collaborations are built with countries with public health systems and universal health care that approach primary health care from community to tertiary levels (e.g., with partnership in an institution in rural India).
Leadership begins with the country and its nursing leadership, who have the final authority for this initiative	The site itself provides the overall leadership for this program; we are their guests, and this is their country and their health system. Example: The nursing school director with the chief matron at the main hospital develop the students' schedule, provide evaluation of the students' clinical skills, and ensures that the students are performing under nursing supervision as defined by their regulatory body.
Reciprocity	A balanced collaboration means that it is beneficial and significant to all involved. Although CUSON students gain an understanding of how nurses practice under extremely different conditions, the program also has expanded to involve collaborations important to the host. CUSON asks each partner what the nursing institution wants CUSON to engage in to meet that school's priorities. Reciprocity is central to building and maintaining a healthy balanced relationship. Examples: Some site partners request specific input on curriculum development; some seek joint research projects; several schools want support to implement simulation learning; and some schools request faculty and student exchanges.

Ten years ago, the program started with a faculty member who has extensive nursing work in Global South Countries and with the World Health Organization, the International Council of Nurses, the International Confederation of Midwives, and the Global Network of World Health Organization Collaborating Centers reaching out to colleagues' nursing schools to determine potential interest in hosting student clinical learning. Response from these nursing schools was positive, and the program expanded from 4 to 20 sites during the past 10 years. These include nursing institutions in Nepal, China, Thailand, Jordan, Israel, India, Kenya, Zambia, Malawi, Ghana, The Gambia, Ethiopia, Italy, Spain, Dominican Republic, Mexico, Jamaica, and Trinidad and Tobago. This expansion paralleled growing student interest and commitment to becoming a “global nurse” through this unique preparation, with a range of two to eight students per site participating each year in a global clinical practicum.

In 2020, with COVID-19 sweeping the world, CUSON changed the program to a virtual one; the university, in partnership with the sites, determined it was critically important to continue this exchange, even if students could not travel to the sites. Students from the host school and OGI developed case studies, and students were paired to explore and present how nurses would address care from each country's perspective within nursing guidelines. When war developed in northern Ethiopia, travel was postponed until conditions might allow returning for direct experiences. Each year, the team carefully reviews what sites will be involved; this is done in discussion with the host schools as they consider their staffing availability. Currently, there are 10 countries where students can participate in the clinical practicum. This program exists in the changing and fluctuating global and regional world and has survived by responding and adapting to what is needed while creatively finding ways for students to be immersed in learning and experiencing how consequences of disparities and inequities affect people's health in different countries and the innovative ways that nurses find solutions to provide ongoing care.

With the full support of CUSON's dean and leadership, OGI put into place effective systems to manage and ensure sustainability for this initiative. This expanded to all CUSON departments and has become an “all-hands-on-board” approach. In 2022, the dean formed a Global Health Division as the larger home for global research and education where OGI is now situated. The OGI team consists of an assistant dean who is a professor of nursing and three staff members with backgrounds in higher education, administration, and public health. CUSON's Masters Direct Entry (MDE) program, an accelerated prelicensure baccalaureate nursing and Master of Nursing program for nursing students who have another bachelor's degree, collaborates with OGI on student selection. Faculty members within the MDE program are selected to be “faculty liaisons” to connect directly with each of the host sites to mentor and guide the participating students.

Course Description

As this initiative grew, CUSON determined that the overall nursing curriculum needed to expand to include didactic teaching about global health issues (^{Walton et al., 2022}). A new course, Global Health Equity and the Responsibility of the Nursing Profession (²⁰²⁵), was developed. The course, which is required for incoming MDE students, provides an overview of the major health issues and disparities around the world and within countries. The course description states:

The pursuit of health equity for all in the 21st century is a global mandate and responsibility. This course is designed to provide an overview of critical health disparities within the global community between Global North and Global South countries and racialization and exclusion within the U.S., and provide the student with a systematic approach to understanding them within the framework of human rights and social justice. The course will also explore the role and responsibility of the nursing profession to address these with both individual and cooperative strategies.

Course Objectives

The following course objectives are included in the syllabus (^{Global Health Equity and the Responsibility of the Nursing Profession Masters Directly Course N6010 Syllabus, 2025}):

Upon completion of the course, the student will (1) recognize human rights and ethical issues in global health; (2) define global health equity concepts, including universal health coverage; structural racism in the current health system; and the ethical mandate for health justice in the nursing profession; (3) analyze major challenges to resolve health inequities and burden of disease, and how cooperative and multidisciplinary solutions can be developed in sustainable ways; (4) describe the major organizational forces that lead global health policy; and (5) identify new models for the delivery of health care that move towards global health equity; examine the role of nursing as a major health provider.

Each week, a topic of major concern is addressed, such as maternal health, noncommunicable diseases, complex humanitarian crises, environmental justice, and ethical and human rights concerns in global health. Students are assigned to groups to research these critical issues and present examples of nursing solutions to these problems. This connects didactic learning to global nursing clinical practice. Since 2016, more than 200 students each year have completed this course. Their course evaluations support the importance of nursing students to understand nurses' central role in providing communities' health needs around the world. After taking the course, many of the students apply to the Global Student Clinical Program.

CUSON developed a syllabus for the global clinical program to define the objectives, methodology, and evaluation for the host institution. The syllabus and its skills list provide a checklist for the host institution to mark for each student, showing that the student has completed what is necessary for the final MDE clinical practicum. The primary faculty liaison reviews the evaluation with students and oversees the final grading.

In the past decade, a system for accountability and program flow has been developed. This begins with the selection of a faculty liaison from the sending school assigned to each host site. Responsibilities for this faculty liaison include the development of a working relationship with a lead faculty mentor at each host site to ensure consistent communication between the site and OGI. The faculty liaison helps orient students to the site and conducts a group virtual meeting with the host leadership prior to the students' departure. The faculty also meets each week with students virtually during the 6 weeks that the students are at the host site, reviewing cases and clinical issues as well as the emotional well-being of the students in their new environment. The faculty liaison also may travel to visit the site, usually during the second to third week of the program. This opens the door to meet the nurses on the units where the students are placed, experience the direct clinical challenges, and build the relationship with the host faculty and institution. The next level of student support is the site preceptor or mentor who represents the host leadership and works directly with the nurses and midwives on the wards for clinical supervision. Building and sustaining this direct communication is the foundation for this program. This is overseen by the lead of the OGI who is in regular communication with the head of the nursing or midwifery institution.

The OGI additionally has built a strong emotional well-being component to the program. Mental and emotional support are available through close partnership within CUSON and the university health professionals to meet with individual students and the group as needed. Students often experience challenging clinical experiences at the host site, such as the death of a mother in labor, newborn deaths, and deaths of adults from noncommunicable diseases due to lack of access to timely treatment. The marking of births and deaths is unique to different cultures and a learning process for students to accept and respect. Over the past 10 years, OGI has given more attention to this level of support to absorb the results of what health inequity means on a daily level; this includes predeparture discussions and timely meetings as soon as students return to CUSON. It also includes meeting weekly with the students describing the victories of daily nursing work as they witness them and reflect on new models. Before finishing the MDE program, a celebration of the “global students” happens to acknowledge their courage and commitment and includes the new class of students who then can learn and talk with those who have participated to prepare for the upcoming year.

Persistence and flexibility help build a genuine reciprocal relationship with the sites. From the beginning dialogue with a site, it is a central issue of how to make this a partnership. It has its unique growth and process of concretizing specific to what the site wants to focus on with CUSON. In India, the partnership with the institution is centered on building a simulation learning center for the school and surrounding area, in harmony with the Indian Nursing Council's strategic plan. In Zambia, the collaboration focuses on strengthening its Doctor of Philosophy Program through curricular development, mentorship, and engagement with student theses. In The Gambia, it is an exchange of webinars on central issues in midwifery care, and in midwifery education and practice. Faculty at CUSON are recruited for each of these initiatives and report the change in their own teaching from these programs as they gain new perspectives.

Results

The effectiveness of meeting our objectives for this program is examined on many levels. Evaluations have been a continuous process since the program began. Clinically, the host site preceptor evaluates the students on a CUSON skills evaluation form to verify that students are meeting the competencies necessary for this practicum (^{Kelly & Lazenby, 2019}). The students themselves write narratives about their experiences and impressions while at the site. These narratives are a form of lived experiences and a rich source of evidence that students are changed from this experience. They write that they see inequities and struggle with the realization that with more resources, many lives would be saved. They also describe how nurses create solutions and have victories as well as resilience. Some examples from students over the past 10 years include:

“I have seen things here that I will never forgetI'm better prepared to handle life and death, and I can be thankful for this experience.”

“I was struck by how varied a health care setting can be and still provide amazing care for those it serves. I am grateful for the experience and know that it will help [me] as a provider.”

“This experience reminded me of my purpose and gave me that boost of self-esteem that I needed. My global experience helped me understand that I have courage to succeed.”

“Why did I go there? Because of the nurses. Because of their wisdom, strength, their ability to improvise when faced with limited resourcesBecause of the people who stayed, because they had no choiceBecause of the time they take to teach me. Because of the way I feel when I teach them. Because the person I am now is different than the person I was before.”

The narratives also repeat new understandings of the global foundation of the nursing profession and the students' commitment to take this forward as they enter the nursing workforce. The students also complete an evaluation online and meet with the OGI team after they have returned for a comprehensive look at what worked and what was challenging. OGI meets with the faculty liaisons for their evaluations. The composite picture is then shared with the site, providing CUSON feedback to the host site, and most importantly, getting feedback from the site. OGI then holds strategy sessions to examine the initiative from specific sites to the overall program, which results in the development of a plan for the upcoming year that addresses challenges and builds on the successes. Overall systems review promotes improvement and sustainability to manage the many levels necessary for the operation of the program and are then mapped out on the upcoming year timeline. Quality of the experiences at the sites as well as factors affecting the sites (e.g., war, security, and local situations such as health workers' strikes at hospitals) will guide the selection of sites for the upcoming year, with direct input from the site partners themselves.

In the past decade, OGI continuously examined the cost and resources required to expand and sustain the GSCP. For example, in the beginning, students in the GSCP received a small stipend of $500 towards their travel-related costs. However, in recent years, students now have their travel-related costs such as airfare and visa applications covered by generous donations of CUSON alums. CUSON leadership is committed to the growth and sustainability of the GSCP by allocating time and effort for the faculty liaisons to oversee the students; work on the reciprocal requests (e.g., curriculum development and review, joint research projects, assistance in the implementation of simulation learning, and oversight of student exchanges). Faculty liaisons are encouraged to apply for small grants in CUSON and at the larger Columbia University to conduct pilot research projects and initiatives with the collaborators. These pilot grants have produced preliminary data for CUSON and the collaborators to seek additional funding, manuscript publications, and program building for the collaborators. Both the CUSON faculty liaisons and the collaborating faculty are encouraged to apply for external opportunities, such as Fulbright awards, to sustain reciprocity requests when mutual interests are aligned. When faculty liaisons conduct site visits, once every 1 to 3 years, the travel-related costs (airfare, accommodation, ground transportation, and meals) for the 3- to 5-day visit is fully covered by CUSON. Preliminary work and follow-up are completed by videoconferencing, calls, and emails.

Conclusion

Global clinical student experiences are now embedded in the approach to comprehensive nursing education at CUSON. The past decade has involved collaborations with 20 nursing schools in 18 countries resulting in more than 280 MDE students who have graduated with direct experience being on the frontlines as nurses globally face the challenges of war, pandemics, and increasing amounts of noncommunicable diseases. Faculty have direct contact through this Global Student Clinical Program with their peers at the host nursing institutions and engage in long-term curricular, clinical, and research initiatives. The host schools engage in determining how the program grows and how they can benefit as they expand their nursing education strategies. It is a step-by step approach, starting with small programs and exchanges that can be grown over the next several years and resourced effectively within CUSON's strategic and fiscal plans.

Going forward, CUSON wants to embed this initiative more solidly within the Doctor of Nursing Practice program, with initial steps and small numbers of students already opening the doors for residency experience in Global South countries. The OGI team also is examining the changes in students' understanding of cultures, belief systems, and nursing practices before and after their participation that will yield important data to quantify the effects of the program.

Ways to measure longer effects for students who have graduated and are now practicing will be examined. Another consideration is the development of a network amongst the nursing institutions in this program for the direct exchange of their examples that transform nursing education for a global community.

A decade of experiences for graduating students to be advocates for global health equity is being marked and celebrated in 2024–2025 as CUSON prepares for the next 10 years. We call on other nursing education institutions to develop and expand their programs within the framework of global health equity as essential and critical to uphold the ethics of the nursing profession that every human being has the right to the highest level of health. This will enable future nurses, wherever they practice, to work to implement this.

References

Dohrn, J., Desjardins, K., Honig, J., Hahn-Schroeder, H., Ferng, Y. H., & Larson, E. (2018). Transforming nursing curricula foraglobal community. Journal of Professional Nursing, 34(6), 449–453. 10.1016/j.profnurs.2018.02.001 PMID: 30527692

Global Health Equity and the Responsibility of the Nursing Profession Masters Directly Course N6010 Syllabus. (2025). Columbia University School of Nursing. https://doc.sis.columbia.edu/subj/NURS/N6010-20252-001/

Kelly, T., & Lazenby, M. (2019). Developing and validating learning domains, competencies, and evaluation items for global health clinical immersion practicums for graduate-level nursing programs. Journal of Advanced Nursing, 75(1), 234–252. 10.1111/jan.13851 PMID: 30209814

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