Mutual Trust and Respect

Partnerships are voluntary collaborative agreements wherein parties agree to work together, sharing benefits and risks as well as competencies and responsibilities. Wheeler (2012) compares trust to trusting relationships. Trust is defined as “a psychological state in which positive expectations are held regarding the motives and intentions of another actor” (Ruzicka & Wheeler, 2010, p. 70). A trusting relationship involves acting on that trust and has been defined as “one into which actors enter in order to realize benefits which would otherwise not be available to them. They do so in the knowledge that this increases their vulnerability to other actors whose behavior they do not control, with potentially negative consequences for themselves” (as cited in Wheeler, 2012). Although it is important that nurses maintain professional roles, trusting relationships with host partners are key to successful partnerships.

Communication

Good communication is essential to successful partnerships. According to Ross (in Kanani, 2012), “Partnership failures can usually be linked to some level of miscommunication. This can range from misperceptions about the objectives, expected results, operating approaches and/or roles and responsibilities” (p. 2). Clearly, communication means more than just language. Diversity in language, cultures, and perspectives is to be expected when working globally. And as diversity increases, so do the communication challenges.

Working with partners from other cultures requires cultural humility and fluency, as explained elsewhere in this book. Culture can have a powerful effect on communication. Anthropologist Edward T. Hall’s theory of high- and low-context culture can help anticipate challenges in communication (Hall, 1976). Although we are all individuals, we are acculturated from a very young age. Hall’s theory of intercultural communication can help when used as a general approach for communication. For example, high-context cultures (Latin American, African, Asian, Mediterranean, Slav, Native American) are generally cultures of few words. Much is left in between the lines, to be understood through context and nonverbal clues. People from high-context cultures generally are collectivist, intuitive, and relational, valuing interpersonal relationships. Low-context cultures (North America and Western Europe) value communication that is straightforward and direct. People from these cultures are individualistic, logical, and action-oriented (Fussell, Zhang, & Setlock, 2008; Goman, 2011). Views on time can also affect communication. Cultures that have a sequential approach to time speak of it almost as money (“waste time,” “spend time,” “save time,” even “buy time”). Synchronistic cultures do not see time as something to be bargained for, but rather as something to be experienced. The work of Triandis (1995) added the dimension of task versus relationship orientation (whether people focus on accomplishing tasks or on establishing rapport). The additional challenge of computer-mediated communication (CMC) can potentiate these challenges. Fussell, Zhang, and Setlock (2008) show that cultural background affects CMC. This reinforces the need for face-to-face encounters in developing partnerships. Studies on partnerships point to the need for open and free communication (Beal et al., 2012; Bosworth et al., 2006; Breslin et al., 2011; Everett et al., 2012; MacPhee, 2009). This can be more complicated when relying on CMC but is worth the extra effort.

Shared Vision

Commitment

After the initial work is done and the partnership is developed, the hard work of sustaining commitment to the partnership begins. During this time it will be necessary to “check in” with partners. It is particularly important to be aware of power inequities that can develop (Green-Moton, Palermo, Flicker, & Travers, 2006; Tierney et al., 2013). As partnerships evolve, it may be necessary to restate the mission and revise policies, procedures, and processes. There may even be an opportunity for expanding or contracting the partnership itself. It is always important to remain inclusive even at the risk of expedience—it is at this point that the trusting relationship gets further reinforced through open communication and sustained commitment.

Over time, partnerships can be expected to evolve. The evaluation process can be used to strategize and plan for sustainability. Process evaluation is normally done to monitor a program (e.g., number of immunizations given, number of patients served, number of students taking part in an exchange program). In addition, process evaluation offers the opportunity to revisit the mission and policies and to monitor the health of the partnership. Resources for developing process evaluation questions can be found through the various websites of the Centers for Disease Control and Prevention (www.cdc.gov/healthyyouth/evaluation/pdf/brief4.pdf) and the CCPH (http://depts.washington.edu/ccph/cbpr/index.php).

Process evaluation can determine whether goals and objectives are well aligned. Anonymous surveys or reflective discussions can help identify areas of strength and for growth. However, threats and weaknesses will also be identified and should not be ignored.

When problems arise in partnership, it is important to address them. Conflict resolution is rarely simple. Add a cultural dimension, and things are further complicated. The process of team development is well known to nurses (forming, storming, norming, and performing). Research on teams indicates that successful teams are comfortable dealing with conflict and are committed to, and learn from, resolution.

Unfortunately, that research was done on mostly North American organizations. For some cultures, the group is more important than the individual. Harmony and group conformity is sought, sometimes at the expense of personal interests. Although everyone may seek to avoid conflict to some degree, persons from individualistic societies may be more direct in dealing with conflict (“meet it head on”; “take the bull by the horns”). In fact, culture may determine whether conflict even exists. An elderly Chinese man in Canada denied having had any conflict at all in the past 40 years. Consistent with his Confucian upbringing, he saw the world with a vision of harmony rather than of conflict (LeBaron & Grundison, 1993).

In her essay “Culture and Conflict,” Michelle LeBaron speaks of cultural fluency as “a key for disentangling and managing multilayered, cultural conflicts” (LeBaron, 2003, para. 25). In addition to awareness of distinctions in communication as articulated by Hall, cultures have different ways of “naming, framing, and taming” conflict. It is important to understand the context of a perceived conflict. Cultures have different ways of meaning-making, and not knowing these may make it easier to attribute negative motives to a behavior.

Working to develop partnerships across cultures can be rewarding and challenging. How we approach the partnership and whether the inevitable changes involves “recognizing and acting respectfully from the knowledge that communication, ways of naming, framing, and taming conflict, approaches to meaning-making, and identities and roles vary across cultures” (LeBaron, 2003, para. 25).

As stated above, partnerships are voluntary collaborative agreements wherein parties agree to work together, sharing benefits and risks as well as competencies and responsibilities. This voluntary nature of relationships does not mean, however, that partnerships are self-sustaining. The steps toward negotiating and maintaining a relationship are succinctly elaborated by Ross (2012). Through a literature review and interviews with NGOs and business leaders, Ross has identified 10 elements of a partnership agreement that include everything from creating a shared vision and maintaining communication to deciding to end a partnership.

International Student Experiences

All the elements for developing a partnership are necessary for a successful international student experience. However, as these types of experiences become more common, special attention should be given to promoting true partnerships among students and faculty. Kulbok, Mitchell, Glick, and Greiner (2012) reviewed the literature on student international experiences from 2003 to 2010. Their findings highlight the need for published reports that discuss two-way exchanges between students of higher and lower income countries. Too often emphasis is placed on the student from the high-income country going to another country with a high UN development index rating (e.g., European countries, Australia, Japan, Norway) rather than countries considered low-income that are struggling with the issues of poverty and other social determinants of health. Second, published reports of the student experience should include authorship from the country hosting the international student. Including authors from all countries involved in the partnership can increase the capacity for conducting research and developing scholarship. Third, all students, including those from the host country, should receive additional education addressing the cultural differences among all the partners. Finally, experiences that extend beyond the university setting should be considered partnership opportunities for students. Students can benefit from working with NGOs and other agencies active in low-income countries. There is tremendous opportunity for international student partnerships that challenge students to extend themselves beyond providing basic clinical procedures, moving them away from “us and them” to true partnerships.

Three case studies follow that highlight the processes of selecting and maintaining partnerships. The first case study provides the perspective of an NGO, Health Volunteers Overseas (HVO), in developing relationships with partners outside of the borders of the United States. Practical information on the process of volunteering is shared, including the role of volunteers and dealing with the challenge of continuity.

The second case study offers the perceptions of an international student pursuing a doctoral degree in the United States. Having a dream, facing the reality of living and studying in a land completely different from her home country, and wondering how her life will be changed when she returns home are all discussed in a spirit of openness and honesty. Themes from this case study can be compared to the research of the Arab/Muslim international student experience from entry to the United States to reentry in the home country by McDermott-Levy (2011, 2013).

The final case study focuses on a community partnership in existence for over 20 years. Although this partnership has evolved over the years, some of the pioneering individuals are still involved, as are some of the original institutional partners—but the program itself has expanded.

References

Context

It is generally recognized that one of the most serious systemic problems in the delivery of health services in developing countries is the lack of appropriately trained health care providers. The World Health Organization focused on this problem in its 2006 World Health Report, Working Together for Health, and Health Volunteers Overseas (HVO), a private nonprofit organization dedicated to improving the availability and quality of health care in developing countries through the training and education of local health care providers, is actively addressing this concern (wwww.hvousa.org/whoWeAre/mission.shtml). By investing in education and training, HVO is focusing on building local capacity and empowering local health personnel. A key concept underlying the implementation of all of HVO’s projects is that of sustainability.

HVO has developed a series of dynamic institutional partnerships with a wide variety of nongovernmental organizations, government ministries, and teaching institutions around the world (for a list of these partnerships, visit www.hvousa.org/whereWeWork/institutions.shtml). These partnerships are the result of years of relationship building and provide HVO with the opportunity to develop and sustain its educational programs. The initiation of a new partnership may come from one of several sources—a HVO volunteer may recommend pursuing an opportunity with a new organization, or HVO may receive a request from an organization that has heard of HVO’s work in other settings. It is not uncommon for a facility to seek additional projects in other program areas after a project has been successfully established and the value of the educational input has been demonstrated. For example, HVO recently established a series of new projects (nursing education, physical therapy, and orthopedics) at a hospital in Bolivia. The request came from a contact who had previously worked with HVO at a hospital in Cambodia. Her familiarity with HVO’s mission and her understanding of HVO’s methods were critical factors in her decision to ask HVO to consider this new partnership.

HVO depends on the commitment and skills of dedicated volunteers to accomplish its goals. These volunteers bring different backgrounds, experiences, and perspectives to their assignments but all share a commonality: HVO volunteers understand that the long-term solution to the health care problems found in developing countries depends on the training and education of the health professionals in those countries. Faced with serious resource constraints, as well as an immense burden of disease, developing countries must deal with enormous needs in the health care sector but have limited ability to educate and support the workforce needed.

HVO operates under the premise that only through the development of local expertise and institutional capacities will countries be able to handle the health care challenges they face. Countries must develop the expertise to identify and address their own health care problems and to create their own appropriate solutions. The training and education of health professionals is the critical component in this process. Projects must be carefully planned from the outset. Resources in developing countries—whether human, financial, or technological—are extremely limited, and demands for basic services go unmet. Planners thus must rationally, practically, and efficiently allocate these scarce resources based upon realistic objectives and sensible priorities.

The Hvo Model

Unlike many organizations involved in international development and relief efforts, HVO relies almost exclusively on short-term volunteers to staff its projects. The short time frame of the assignments (generally 1 month) facilitates the participation of many medical, dental, and health professionals who would otherwise be unable to share their knowledge and skills overseas.

What are the fundamental components of the HVO model?

Conclusion

HVO has developed a reputation for designing strong, effective clinical education programs in developing countries that successfully use short-term volunteers. It must be acknowledged, however, that there are some serious limitations to the HVO model, including issues related to continuity of volunteer coverage and coordination between volunteers. There can be problems with volunteers adjusting to the challenges at a site—both on personal and professional levels. Proper vetting and briefing of volunteers is an essential component of this process, and most issues are related to inappropriate expectations or misplaced assumptions.

There are limited resources in developing countries to support the training and education of health care professionals. Educational materials that are taken for granted in the West (textbooks, journals, access to the Internet, models, charts, slides, and the like) are usually not available or are woefully out of date. There are few, if any, opportunities for continuing education for clinicians in the field, nor any real opportunities for faculty development. Health care providers often work in professional isolation, unable to network or communicate with other professionals in nearby countries faced with similar problems and constraints.

Against this backdrop of significant need sometimes comes a tendency to think that input from any organization or well-meaning (and qualified) health care professional is of value. After all, resources are so scarce that surely something is better than nothing. There is ample evidence in the literature and plenty of anecdotal evidence from well-meaning but flawed projects that have been in fact a barrier to progress (Easterly, 2007; Maren, 1997; Moyo, 2009; Riddell, 2008).

Reflective Questions

References

Context: Nursing in Egypt

Challenges to Egyptian Health Care Within the Context of Culture

There are many challenges within any health care system, and cultural context always plays a role regardless of country. In Egypt some of the factors influencing health and the nursing profession include:

• Female patients prefer to be examined by a female physician, especially for gynecological or obstetric purposes. Women feel shy and embarrassed talking about private issues like sexual issues with a male physician, so they prefer female doctors.

• Egyptian patients like to hear good news about their health, but if they have a serious illness, it is better to report the seriousness of illness and its consequences to a selected member of the family.

• Most Egyptian people don’t seek medical care unless they are in need. They don’t like routine checkups, lest they discover a disease—though the educated people have regular checkups.

• Herbal medicine use is a common precursor to seeking medical advice.

Critical care nursing training lab in the Faculty of Nursing, Alexandria University.

Credit: N. Elcokany

The Dream: Studying Nursing Abroad

In light of the challenges to nursing in Egypt, as a nursing educator, I was looking for new information that I could apply in my field. I wanted to develop my career, expand my nursing skills, and learn more about conducting nursing research. My story began 5 years ago when I started to think of studying nursing abroad. These years were spent comparing nursing in my country (Egypt) and nursing in Western countries. I had many ideas about nursing abroad from the media as I watched the television series Grey’s Anatomy and ER. They motivated me to practice nursing in my country and I noticed in these series that the nurse has an important role in the medical team. Essentially, the media and Internet were the instigators of my search.

Awareness and Search for International Programs of Study

My first problem was to find a university for study. To do this, I contacted many universities to find a professor who matched my area of research. A second problem was to find a way (grant or scholarship) to cover my study and living expenses. The Internet was the only way to look for a professor who matched my specialty in critical care nursing with an emphasis on pulmonary problems. In Egypt, I was a student in the PhD program at the University of Alexandria and had completed the coursework and data collection for my dissertation. The studies I envisioned would add to what I had learned and enable me to take this information back to my country.

I contacted many schools of nursing in the United States, and each school suggested another school for me. I was surprised to find that they read e-mails from people abroad. I felt that the nursing professors were helpful and willing to attract international students and help them succeed. After I found a professor (Dr. Leslie Hoffman) at the University of Pittsburgh, I was in contact with her for more than 18 months before receiving my scholarship. My dream then was not just to come to the United States as a visiting scholar, but to earn a degree in the United States. The value and quality of studying in the United States is well known and includes exposure to advanced technology in research, teaching, and nursing practice.

At our university, located in Alexandria, Egypt, we usually receive many announcements about scholarships, grants, and exchange programs between our university and other univer sities. The scholarship that I applied for was offered by the mission sector, which was managed by the ministry of higher education and scientific research. Major requirements for receiving support included being an assistant lecturer at the university, being younger than 30 years old, obtaining professor acceptance from a foreign university, having an acceptable TOEFL score, and completing the PhD coursework, along with other requirements. I learned that prior successful applicants were primarily from the medical field and other majors, such as engineering, agriculture, and veterinary medicine. Undeterred, I submitted my application. I was finally accepted during the revolution of January 25, 2011, 10 months after I applied. The scholarship provided me a small stipend to cover my living expenses.

Next came the process of obtaining a visa, and for that, I needed to journey to Cairo from my hometown of Alexandria, a 135-mile trip (3 hours by car or train). I had to leave at 5 a.m. each morning to arrive at the visa office at 8 a.m., but I persisted through all the paperwork and the required interview process.

Expectations and Feelings Associated with Studying Nursing in the United States

When first arriving in the United States, I had mixed feelings that included happiness and worry. I was happy because it was one of my dreams to go abroad, but at the same time I was worried about the language. In Egypt, we study nursing in English, but we do not use English when speaking with each other. Therefore, we learn a more formal way of speaking that does not include slang or common expressions used with each other. I was worried that I would be misunderstood by the people around me, including my advisor, if I didn’t catch the correct meanings of words. In addition, I worried about being away from my family and was concerned about the weather in a different climate. Before traveling to Pittsburgh, I had not been in a country with four distinct seasons, and I had never experienced snow.

Reflections on Immersion in a New Culture

Conclusion

In nursing education, students learn about differences between cultures and religions, so the teachers, students, and classmates probably knew a little bit about my traditions. I remember when I attended a clinical session with the undergraduate students in the simulation center and the teacher gave them many scenarios about different cultures and religions and how to deal with these differences. These activities help nurses deal with humanity with extra care and inspire others to serve without discrimination. I will always remember when I was in my undergraduate class on nursing ethics. The first rule I learned in the code of ethics was to accept the patient as he or she is, regardless of race, religion, and culture.

I like Americans, and yet I know that during my stay I was touched by only a few sides of America—in particular, academic and professional life. My perspectives are subjective, and I know I cannot uncover everything about the United States during my brief stay of 18 months.

I have seen a number of things I would like to take back with me as goals for change in Egypt:

Finally, I’m thinking seriously about how I can be helpful in my country when I return, and about how I will adjust when I go back. Can I be effective in changing something in the curricula? Can I be a factor of change in the nursing profession in general? If so, how? I have a lot of plans and ideas, but I will need strong support from the administrative level and the decision makers in my home institution. I don’t know if the people around me will motivate or frustrate me (probably both at times), but I’m hoping I can be a force for change.

Reflective Questions

References

Context: Farmworker Family Health Program, United States

Global health practice does not always require a passport. The United States is a remarkably diverse nation, where over 300 languages are spoken. In fact, over 55 million people speak a language other than English at home (Shin & Komanski, 2010). It is essential that health care workers be prepared to work with diverse cultures. This case study describes a “domestic as global” academic–community partnership that has been in existence for longer than 20 years. Clients of this partnership are largely migrant workers and their family members from Mexico, who are not necessarily working in the United States with appropriate documentation. They primarily speak Spanish, but some speak indigenous dialects. These workers harvest fruits and vegetables by hand, grueling work. We ask no questions of clients regarding documentation status during our 2-week summer rotation. However, for the sites where care is provided, migrant status is virtually 100% assured. Federally funded migrant health clinics can only treat clients who meet their definition for migrant status. Because of the fluidity of this population, there is little collaboration between these clinics.

The initial Farmworker Family Health Program (FWFHP) partnership, which began with one small group of undergraduate public health nursing students and one faculty member from a single school who engaged with a single south Georgia farmworker clinic, has evolved to encompass over 100 students and faculty members from five different universities along with community partners. The number of community partners has expanded to include not only the initiating federally funded migrant farm clinic, but also a summer school program, day care centers, two area health education centers (AHECs), businesses, faith communities, and, of course, the farmers and growers. Dental hygiene, nursing, pharmacy, psychology, and physical therapy students, volunteers, and faculty travel to a rural area of a southeastern state as part of a 2-week service learning cultural immersion experience, each adding to the overall scope of services.

Program Overview

The FWFHP is a collaboration of the federally funded Ellenton Health Clinic (hereinafter referred to as the Ellenton Clinic), located in Ellenton, Georgia, and five Georgia universities: Emory University (lead university), Georgia State University, Clayton College and State University, Darton College, and the University of Georgia. Other partners include the Colquitt County Health Department, the Colquitt County Board of Education, the Southern Pine Migrant Education Agency, and the owners of farms and packing houses in the Colquitt County area. Additional budget-relieving in-kind support comes from churches and community organizations in the area. The FWFHP, coordinated by the Lillian Carter Center for Global Health and Social Responsibility in the Nell Hodgson Woodruff School of Nursing at Emory University, has served over 13,000 individuals in its 20-year history. Using students and faculty in the health professions, preventive and episodic health care is delivered over a 2-week period each summer in an intensive outreach setting that also serves as part of the clinical training programs of the universities. Each participating university pays the salaries of its faculty and makes some arrangement with its students regarding housing costs. Although the program is intermittently funded by small grants, no single current funding source covers all program expenses.

The team provides care for farmworker families to live, work, and go to school. In the mornings the team sees children enrolled in a migrant summer program at a local elementary school and day care. In the evenings the team caravans to various locations, including packing sheds, farmworker camps, and local neighborhoods. While the Ellenton Clinic is responsible for communication with and arranging for the various locations for our nightly schedule, the faculty is responsible for making sure students arrive at the farms or service sites together and on time. Participants meet in the parking lot of the hotel where we are housed at a designated time and all leave together for our destination. The leader of the caravan knows the directions to each farm, and a “caboose” faculty car also follows with the directions. Country roads are extremely dark, and the farms and their entrances are spread over four very rural counties. Earlier years without cell phone service posed a challenge, but improvements in technology have helped significantly.

Services provided at the migrant summer school program in the morning are structured around comprehensive physical examinations of children and adolescents. Parental permission is required for a child to be seen. Outreach workers from the Southern Pine Migrant Education Agency work alongside the Colquitt County Board of Education to sign children up for the summer school, and the Ellenton Clinic provides existing charts from their files and makes new charts for children without records. All records are property of the Ellenton Clinic, and all HIPAA regulations are observed. Undergraduate nursing students (BSNs) complete screenings of height, weight (body mass index [BMI]), blood pressure, hemoglobin, vision, and hearing. Nurse practitioner (NP) students do full physical examinations. Developmental assessments are carried out by physical therapy (PT) students. Dental services, including application of sealants and fluoride, are provided by dental hygiene (DH) students. Pharmacy (PharmD) students provide health education in the classrooms. Meanwhile, a small team of students and faculty work at the partnering farmworker clinic seeing patients and preparing the pharmacy. If health-related problems are detected, children who do not have a Medicaid provider listed on their permission form are referred to the Ellenton Clinic for follow-up. Health status letters in both Spanish and English are sent home to the parents of each child seen, whether a referral is necessary or not. Ellenton Clinic outreach workers handle emergent problems on an as-needed basis.

In the evenings BSN students complete height, weight, blood pressure, BMI, hemoglobin, and blood glucose screenings. A foot care station is staffed primarily by BSNs but also with other team members’ participation. DH, NP, and PT students have separate stations for their respective practices. The evening focus of care is acute complaints rather than comprehensive examinations. NPs can prescribe with collaborative practice protocols, and PharmD students operate a pharmacy dispensary on site out of the clinic’s mobile unit. Patients with chronic conditions are referred to the clinic for follow-up, with on-site clinic outreach workers arranging appointments and transportation. The clinic staff has provided interpretation services subsidized by one of the AHECs at the evening clinics. The need for more interpreters has led to inclusion of an additional team partner, the Emory Volunteer Medical Interpretation Services. This is a student-run organization made up of bilingual students formally trained as medical interpreters. The team starts seeing patients in the evening clinics before sunset, often staying out past midnight. All members wait until the last patient and provider are done. Then we caravan home together, and in the morning we get up and do it again.

Program History of Developing Trust and a Shared Mission

The executive director of the clinic and the lead faculty came to trust each other through a shared vision of improving access to health care for migrant farmworkers and their families. The FWFHP extends the work of the clinic and adds to the numbers of new annual visits they need to continue their federal funding. As the need for additional expertise became obvious, they jointly decided to invite other disciplines to join the nursing students, thus expanding the program’s services. The grueling work and conditions of farm labor result in multiple musculoskeletal complaints, and the benefit of having PT students on site became apparent. The nursing faculty reached out to the physical therapy department. A similar situation occurred with psychology, where an identified need carved out a role for an additional discipline.

A good exemplar of dovetailing interests is the example of dental hygiene. Dental disease is among the top five health problems in this population (Lombardi, 2001). Both the clinic executive director and nurses saw a great need for dental services for both the children and the migrant workers. About the same time, many of the dental hygiene programs in the state were transitioning to bachelor-level programs, needing sites for community rotations. These needs allowed for great synergy. Even more importantly, the application of dental sealants and fluoride has probably been the most positive measurable outcome of the program.

Mutual trust and respect has grown over the years. The program’s collaboration with the churches each summer has done much to raise community awareness regarding the plight of the farmworker. Because farmworkers are basically an “invisible” population working and living in these outlying rural areas, citizens of the four focal counties rarely see the labor or living conditions of these workers up close.

Two of the individuals who were founding partners have either retired or moved on, but leadership has not been lacking. The strong foundation built by years of work has fostered embedded trust between the involved institutions and has in fact led to a web of new personal relationships that have spun off to additional partnerships in different locations. For example, a member of the FWFHP nursing faculty runs a clinic caring for the uninsured and underinsured population of Atlanta. A member of the PT faculty now brings students to this clinic.

After 20 years of working together, even the site visits have evolved. Initially program faculty drove to the rural area for a day meeting a few months before the annual event. Then all participants (including all students) had a full-day orientation in Atlanta. Communication in preparation for the event now includes e-mails and conference calls and occasional “off-season” site visits. Medical records (the point of which is, after all, good communication) are developed by the Ellenton Clinic to meet their reporting requirements, with interstation transit front sheets developed in collaboration by all partners.

The 20 years together have not been without conflict. Working with partners requires compromise and negotiation. For example, the school system at the partner site determines the dates of the program. These may not always coincide with the best times for academic faculty and students, but as their guests and partners, it is imperative that we work with them based on their needs. In fact, one year the funding for the program was cut, and at the end of the first week we were told the last day would be the following Monday. We took this as an opportunity to look for new partners, which is when we began working with child care centers. This conflict thus turned into a benefit as NP students were able to complete physical examinations on children age 6 months to 3 years at a migrant Headstart program.

An ongoing conflict exists in the broader context of the program. We ask ourselves whether a program that provides care for migrant farmworkers perpetuates the inequities and conditions that put them at risk. Health care is rarely neutral or innocent. Placing care in its full context is an important consideration for all health care providers. The act of delivering health care, like providing assistance in complex humanitarian emergencies, isn’t that complicated. It’s the operational context in which the assistance is provided that is the complicated part. In caring for farmworkers with health problems exacerbated by the working conditions, are we doing all we can to solve the problem? This question is put to students and faculty and provide for self-reflection and ethical discussion. The FWFHP objective is to care for as many people as possible. As we work through this conflict, it may lead to a review of our vision.

Evening activities from the Farmworker Family Health Program.

Credit: J. Wold

The program is evaluated by each student and faculty member every summer. Undergraduate student nurses use this course as the clinical component of their public health nursing course and are evaluated on both didactic and clinical standards used by the Emory School of Nursing. Reflection journals are kept by undergraduate student nurses, and interprofessional reflection groups meet each morning prior to beginning the day covering various questions reflecting on the previous day’s experiences. Other students’ clinical expertise is evaluated by their respective faculty and credit allocated accordingly. Annual student and faculty evaluations through a questionnaire combining Likert scale and open-ended responses are tallied at Emory School of Nursing. The results are distributed to the other participating schools and considered as a whole by the program faculty. The operations of the program are enriched by suggestions from both seasoned faculty and staff and fresh student participants. We seek continued improvement in the efficacy and efficiency of this important work. Other evaluation comes in the form of thesis or dissertation projects of students from varying disciplines that request use of our anonymous clinical data collected each year on all clients.

Unforeseen collateral benefits include the interprofessional education. Continuity of faculty from year to year fosters faculty role modeling of interprofessional teamwork and partnership. Through the FWFHP, students from the various disciplines collaborate and consult with each other on all sorts of patient conditions. This interprofessional program predates the calls from the World Health Organization (2010) and the Institute of Medicine (Greiner, 2003) for increased interprofessional education.

Conclusion

The FWFHP is a unique interprofessional service-learning program that promotes student learning, improves knowledge and skills, and impacts students’ attitudes. By partnering with a local clinic to support and expand its capacity at peak harvest season, health care professional students provide care for a vulnerable population. Students learn with, from, and about each other and the community they serve. The FWFHP is an example of a successful academic–community partnership.

Reflective Questions

References