Should short term missions projects be used as service learning opportunities for students in the healthcare professions?
As the world moves into a global society, increasingly there is a desire on the part of academic institutions to provide educational opportunities for students to experience what it means to be a global citizen. Students are also seeking to have experiences in other countries. For institutions and students involved in healthcare, this has included service learning opportunities in healthcare outside of the United States. How these service learning programs are arranged and evaluated varies greatly. At times the student initiates receiving academic credit for a short term healthcare missions trip. More formal service learning programs will have dedicated faculty who are responsible to plan, implement, and evaluate the student experience. The focus for service learning programs tends to be on the learning objectives for the healthcare student. How the student service learning experience impacts the health or the healthcare delivery system of the people and healthcare systems of the host country is often not taken into consideration.
It has been noted that there are no guidelines for service learning programs for healthcare students. (Leffers, 2011) There are guidelines for study abroad programs published by the Forum on Education Abroad and available at http://www.forumea.org/documents/ForumEA-StandardsGoodPractice2011-4thEdition.pdf
and for short-term study abroad, http://www.forumea.org/documents/ForumEAStandardsShortTermProg.pdf
. Most of the guidelines focus on the US based educational institutions that are engaged in study abroad programming and are geared to guiding and protecting those institutions and students. The guidelines are a good starting point for anyone interested in service learning programs abroad. (Forum on Education Abroad, 2014)
Within healthcare education, the topic of cultural competence increasingly is taking on importance as the United States becomes a more culturally diverse society. Faculties are looking for global service learning opportunities for their students. However, Cathleen M. Shultz notes that “most educators agree that service-learning is an experiential learning pedagogy that balances student and community needs (emphasis mine), uses reflective processes, and is directed toward aspects of student development; each element must be present. Typically, volunteerism and nonreflective efforts which are offered by an increasing number of colleges and universities do not belong under the service learning umbrella.” (Shultz, 2011)
Recently, questions have been asked about the ethics of using short term missions for service learning experiences. Matthew Decamp writes, “Ethical issues in medical outreach are often left to individuals’ professional guidelines. We reject this approach for clinical trials in developing countries; we should also reject it for outreach.” (Decamp, 2007). In the end, he acknowledges that there are differences between clinical trials and service learning programs but concludes “The comparison merely highlights our failure to consider the ethical issues of medical outreach. What matters is that we can make progress on these issues, just as we did with clinical trials, and that progress is necessary for better global health work. We are more likely to cause lasting harm when we fail to critically evaluate our actions.”
In 2011, the Nurses Christian Fellowship missions staff conducted a survey of Christian nursing schools who had global nursing education offerings. (Jarlsberg, 2011) Faculty members were asked about planning, leading, types of experience, language preparation, and partnerships related to service learning programs abroad. 94% of the 18 schools included in the survey indicated that they gave academic credit for experiences outside of the US. 50% of the faculty had some missions experience. 27% of the faculty indicated they had no international experience. Only four faculty members were licensed in the country where the service learning program was conducted. Experiences varied from observational and teaching to direct provision of care. Two faculty members indicated that they were proficient in host country language and only one school required students to have a level II language proficiency. Half of the schools had a partnership agreement. Of them, four schools had partnership agreements with overseas academic institutions; seven schools had agreements with non-government or mission organizations. Nine schools had no partnership agreements.
The Working Group on Ethics Guidelines for Global Health Training (WEIGHT) published some guidelines for ethics in global health training in 2010. The guidelines were aimed at sending and host institutions, trainees, and sponsors. The guidelines were derived from the experience of the working group members. They noted that they had no data related to the potential benefits and harms on which to base the guidelines and encouraged further assessment and refinement of the guidelines based on data as it became available. The WEIGHT guidelines “address the need for structured programs between partners; the importance of a comprehensive accounting for costs associated with programs; the goal of mutual and reciprocal benefit; the value of long-term partnership for mitigating some adverse consequences of short-term experiences; characteristics of suitable trainees; the need to have adequate mentorship and supervision for trainees; preparation of trainees; trainee attitudes and behavior; trainee safety; and characteristics of programs that merit support by sponsors.” (Crump, 2010)
Several articles have sought to look at the student outcomes in international service learning programs. In 2010, Chavez, Bender, Hardie, and Gastaldo published an article on the lessons learned from a course evaluation of the Critical Perspectives in Global Health course. Their findings comprised of the student’s sense of lack of preparedness with suggestions for more preparation prior to departure including what their role was to be and what they would be doing. Students were assigned preceptors and some students thought that course instructors should have better evaluated the suitability of the preceptors. Students also felt that upon return their reflection and debriefing could have had more structure and over a longer period of time for them to process the experience. Some students questioned the benefit to the local community and what they had actually contributed to their welfare (emphasis mine). (Chavez, 2010) One article compared an international service learning program with a service learning program in a local multicultural setting. The authors found that students were able to achieve their learning objectives in either setting; but felt that the international setting provided the opportunity to experience a role in international collaboration. (Wros, 2010)
A recent systematic review of the literature, spanning 20 years January 1, 1993 – May 15, 2013, related to short-term medical service trips identified 67 articles that included data with the report. These articles were then analyzed for common characteristics. Of interest to short-term missions, the review found a decreasing number of publications reporting the work of faith-based organizations with only 18% of the publications identifying a faith connection. The reason for this was unknown. This could be because 1) the type of work done by faith-based organizations is not reported, 2) faith-based organizations do not include, collect or report data, or 3) faith-based organizations are not reporting their work in indexed journals. The author also questioned the current cultural discomfort with discussion of religion as a possible consideration. The study found that most of the data focused on process outputs, I.e. numbers of surgeries, patient visits, etc. The review questioned the ethics of just reporting outputs as opposed to reporting health outcomes. The author suggested that the rigors of evidence based practice should be in place for short-term medical service trips as well. The lack of outcomes also made it difficult to evaluate the cost-effectiveness of the medical service trips. The study noted a lack of data to support claims of education in the area of cultural competency or career trajectory. The study concluded that data collection and outcome assessment was necessary to evaluate the medical service trips. Instruments designed for this purpose would be a first step in beginning this effort. (Sykes, 2014).
Within nursing education, faculties have looked to service learning programs abroad, to meet other learning objectives. Johanson (Johanson, 2009) suggested that such experiences deepen nursing students’ commitment to service. Others see this as an opportunity for nursing students to learn more about missionary and global nursing. Wright has written articles that describe the planning process for a study abroad experience (Wright, 2010) and described the program she has developed. (Wright D. , 2011) Similarly, Hawkins and Vialet, (Hawkins, 2012) describe a short-term missions experience from a student and a faculty perspective.
Ideally the following basics for service learning programs and/ or for short term missions programs which include student learning objectives would be in place:
1. There would be a partnership between the sending institution/organization and the host institution/organization. This partnership would:
a. Identify a project that would be mutually beneficial to the students engaged in the program and the recipients of their efforts.
b. Spell out the goals and objectives for the project.
c. Identify responsibilities of both sending and receiving institutions/organizations for the implementation of the project.
d. Include a plan for the evaluation of the project.
e. Include a budget for the project that clearly spells out who is responsible for the income and expenses related to each aspect of the project.
2. A faculty member who is both familiar with the language and culture of the host country and hold professional healthcare credentials in the host country would oversee the project.
3. Students participating in service learning programs would:
a. Receive adequate preparation in culture, language, and prerequisite professional knowledge before leaving for the service learning program,
b. Respect cultural mores of the host country and institution/organization.
c. Have access to professional supervision and instruction during the service learning project,
d. Have reflection assignments that would be part of the service learning experience, and
e. Debrief the experience upon completion of the service learning program.
4. The service learning program would contribute in some measureable and documented way to improving the health outcomes of the host country.
5. The service learning programs would follow legal and ethical standards in both the sending and receiving countries.
Recognizing that not many short-term missions programs or service learning programs are currently achieving this ideal, the guidelines should serve as a goal nonetheless.
As the next generation of healthcare professionals practice as global citizens in a global society, it is critical that their learning experiences model excellence in global health practice. As Christian healthcare professionals we need to model ethical principles founded in a Biblical worldview. We need to respect all people as created in God’s image. That means that those we serve in limited resource countries receive care with dignity and respect afforded to people in our country. It means that we also respect the laws and standards of care dictated by the governments and professional organizations present in host countries. As Christ’s ambassadors, it means that we follow Jesus’ example of love and compassion toward those in need of physical and spiritual healing. As participants in God’s Kingdom building activities, we seek to bring shalom, health and wholeness, to the people we serve wherever that may be.
Anything less than our best communicates disrespect and can potentially harm the health of the people we have gone to serve and discredit the gospel of Jesus Christ. Short term missions projects can provide a base for service learning if both the sending organization and the receiving organizations in the host country assess, plan, implement and evaluate the project from both the student learning and the receiving community’s perspective.
Chavez, F. B. (2010). Becoming a Global Citizen through Nursing Education: Lessons Learned in Developing Evaluation Tools. International Journal of Nursing Education Scholarship, 7(1), article 44,1-22. doi: 10.2202/1548-923X.1974
Crump, J. A. & Sugarman, J. (2010). Global Health Training: Ethics and Best Practice Guidelines for Training Experiences in Global Health. American Journal of Tropical Medicine and Hygiene, 83(6).1178-1182. doi: 10.4269/ajtmh.2010.10-0527
Decamp, M. (2007). Scrutinizing Global Short-Term Medical Outreach. Hastings Center Report 37(6), 21-23. Retrieved from http://www.jstor.org/stable/4625794 on July 7, 2012.
Forum on Education Abroad. (2014, August 1). Forum on Education Abroad. Retrieved from Forum on Education Abroad: http://www.forumea.org/.
Hawkins, J. E. (2012). Service-Learning Abroad: A life-Changing Experience for Nursing Students. Journal of Christian Nursing, 29(3), 173-177. doi: 10.1097/CNJ.0b013e31823fabf2
Jarlsberg, C. (2011). Global Nursing Education Survey. Madison, WI: Nurses Christian Fellowship.
Johanson, L. S. (2009). Service-Learning: Deeping Students' Commitment to Serve. Journal of Christian Nursing, 26(2), 95-98.
Leffers, J. &. (2011). Volunteering at Home and Abroad: The Essential Guide for Nurses. Indianapolis, IN: Sigma Theta Tau.
Shultz, C. M. (2011). Global Service-Learning and Nursing Education. Nursing Education Perspectives, 32(2), 73. doi: http://dx.doi.org/10.5480/1536-32.2.73
Sykes, K. J. (2014). Short-Term Medical Service Trips: A systematic Review of the Evidence. American Journal of Public Health, 104(7), e38-348. doi:10.2105/AJPH.2014.301983
Wright, D. (2011). Service-Learning: Educatio with a Missions Focus. Journal of Christian Nursing, 28(4), 212-217. doi: 10.1097/CNJ.0b013e.31822b-4550
Wright, D. J. (2010). Planning a Study Abroad Clinical Experience. Journal of Nursing Education, 49(5), 280-286. doi: 10.3928/01484834-20100115-05
Wros, P. a. (2010). Comparing Learning Outcomes of International and Local Community Partnerships for Undergraduate Nursing Students. Journal of Community Health Nursing, 27, 216-225. doi: 10.1080/07370016.2010.515461