I spent years running around the globe seeking to create academic collaborations and meaningful cultural immersion activities for students and partners. Earlier this year, COVID-19 pulled the emergency cord, and we were stopped in our tracks. In reality it was a slow halt. We hoped the coronavirus would be short-lived and we could get back to the business of study abroad by the end of summer. Eventually, the true scope of the pandemic emerged, and our provost’s office shared that all official travel, whether domestic or international, was cancelled. The students’ disappointment was palpable—so was that of our global academic partners as well as partners on the ground who rely on us for income during our stays. Ah, 2020.
But then we were quickly dealt another reality. In May, the unnecessary deaths of Black Americans at the hands of police and vigilantes tore at the fabric of society. It brought systemic and structural racism to the forefront, so often ignored after prior episodes of police brutality or other social injustices. This time—whether because the crimes were too heinous, or we had more time on our hands due to the pandemic—people started paying more attention. We began to examine our history as a country. Having time for reflection can be a wonderful gift and being grounded from study abroad gave me time to consider what we do and what we stand for with our cultural immersion programs.
Creating study abroad experiences for our students requires understanding our roles once on the ground, practicing within our scope, and not letting opportunity outweigh professional ethics. I began really thinking about this when I was living and teaching at a university in Tanzania. I saw students on a gap year or an organized voluntourism experience “working” in healthcare and being asked to perform skills and assessments (or volunteering to do them) that they had no training to do, such as suturing, wound care, and delivering babies—the list goes on and on.
When I returned from my year away, I met with some graduate nursing students interested in global health back in the states. The first questions from them were, “How many babies did you deliver?” and “What kind of surgeries did you perform?”
I’ll admit I was confused by their questions, having spent time abroad as a researcher, then as an educator. I fielded the first question, with a resounding “None.” Her question made me curious though, so I asked her if she had delivered a baby. Our conversation went something like this.
Student: “When I was an undergraduate student, I went to Tanzania and had the opportunity to deliver a baby!”
Me: “Do you feel like you had the knowledge to do so?”
Student: “No, but there were nurses there to watch me.”
Me: “Would you be comfortable with a Tanzanian nursing student delivering your sister’s baby or your baby?”
Student: “No, probably not.”
Me: “Do you know if the patient had given consent for you to deliver her baby?”
Student: “I don’t know.”
Me: “Do you think the delivering mom knew that you didn’t have the training to be a midwife?”
Again, she did not know. The second student had just returned from a medical mission trip and had observed medical students getting hands-on experience in surgeries, which was the impetus behind her question. I assured her that I’m not a surgeon, and that as a family nurse practitioner, the closest thing to cutting into a patient is if I’m lancing a boil.
I posed the same questions to her about whether she thought that the patients knew that people cutting on them were practicing outside of their scope. She doubted that there was any informed consent for an untrained (although supervised) student to be cutting on them.
The principle guiding my line of questioning and thought is autonomy. We learn about autonomy early in nursing school, yet sometimes this principle is not applied when travelling abroad to low-income countries.
What I took away from these conversations (and many others since) is that there is a lot of work to do to change the mindset of students who see study abroad trips as opportunities to help people who can’t help themselves. They might feel that they could also gain experiences that they can’t have in the US. In addition, there can be a feeling that having a student from the US as a “nurse/midwife” or a “surgeon” must be better than having someone from the host country provide healthcare services. Students may feel that even though they are not fully trained, they likely possess more knowledge than local healthcare providers. That is a red flag and should make anyone stand back and take inventory of their colonial beliefs of superiority.
The same holds true for patient autonomy and the choice of whether to have a student deliver their baby or make the first cut during surgery. Whether the patient is consenting to this or not, do they know that this person doesn’t possess the same contextual knowledge or skills as the local provider? Is it culturally accepted that because the person is white or from the global north that they must have more knowledge? Are they conditioned to think that the color of someone’s skin or the English language is associated with superior nursing or medical skills and better health outcomes?
So how can you distance your study abroad experience from the situations listed above and keep safe from perpetuating these ethical and cultural missteps? For us, we strive to recognize our colonial past and remove ourselves from situations where we might visualize ourselves as saviors. Instead, we work to create lasting partnerships that have powerful effects on our nursing students and those of our collaborating institutions. We develop and grow global nurses who:
- Recognize the forms of healthcare that exist in the communities we visit.
- Think about their global experiences as culturally immersive learning opportunities.
- Go back to their friends and families and share with them about life in a different culture in a meaningful and nonjudgmental way.
We want our students to report what they learned, not who they helped or what they did for a community. We want them to feel fortunate to be able to get an inside look at another culture vastly different from their own in many ways, yet similar in terms of family, values, and hopes for the future. Our students live with host-country nursing students, learning to care for that community. The students cook for each other. They share experiences and knowledge. They compare their countries, their education, their families, their dreams for life after nursing school. They share contact information so they can stay in touch years after their experience together. They take care of one another. Our students’ experiences help them develop empathy and cultural humility, translating into cultural sensitivity and interest in caring for diverse populations.
As this reflection comes to a close, it is prudent to say that not everything works out the way we intend. We want to blend in, hoping not to cause too much disruption. But by the very nature of being a guest, we are treated differently— kindly and as respected visitors. We cannot always claim that same treatment of guests in our country, or those who have made the US their new home. We’ll save that reflection for another time.
Kate York, PhD, RN is the Director of Global Health Nursing and Assistant Professor of Clinical Nursing at the University of Cincinnati College of Nursing in Cincinnati, Ohio, USA. She is a member of Sigma’s Beta Iota Chapter at the University of Cincinnati College of Nursing.