Abstract
Background
Nepal is a small country in the central Himalayas, with approximately 26.5 million inhabitants. Student Volunteer Placements International (SVPI) organise volunteer experiences with the Children’s Welfare Organisation in Nepal (CWON) in the Chitwan region of Nepal. These programs focus on the health of communities of this region. This research was undertaken to uncover the experiences of student nurses (participants) who volunteered as health care workers in Nepal. More specifically, the research explores the effect that the experience of delivering health care within the context of a low socio-economic setting had on the participant’s perceptions of nursing.
Objectives
To gain an insight into how (if at all) the professional identity of student nurses had been impacted through volunteering as health care workers in Nepal.
Method
The research used the phenomenological paradigm. Five student nurses, who had volunteered in Nepal as healthcare workers and participated in the CWON/SVPI program for three week intervals, were interviewed. These semi-structured one on one interviews were recorded, the audio was transcribed and analysed using thematic analysis.
Results
From the research five emergent themes were derived from the participant’s experiences. Participants reported that the experience of delivering healthcare in the context of a developing country forced them to get creative and ‘think outside the box’.
Conclusion
Engaging in overseas volunteering assisted student nurses to reconnect with their empathy and compassion, and explore the humanistic and interpersonal nature of nursing rather than the technical skill based components of nursing identity. Additionally, the participants were forced to enact their nursing skills to the very boundaries of their capabilities and to be more innovative.
Keywords
1. Introduction
For many nurses, including students, their focus has primarily been directed toward responding to disease and injury. According to the
Australian Government Department of Health and Ageing, 2009
, training and education of health professionals has traditionally been structured around the illness model and has therefore been mostly dependent on acute care facilities for clinical training. Additionally, there is still a heavy focus on preparing nursing students to work in hospitals, which could be argued, does not reflect the breadth of nursing practice and hence nursing identities.Frank et al., 2005
suggest that nursing students fail to professionally identify with performing community based health roles and consequently prioritise hospital based professional identities; believing the skills they acquire in these settings have more relevance to nursing. Furthermore, the authors point out that most nursing programs place students in acute care settings, despite an increasing policy emphasis toward health care being provided in the community. In contrast, Erickson, 2004
and Lashley, 2007
concur that a positive, long-term clinical experience in the community is vital to increasing the likelihood that nursing students will choose to practice in community health care settings. Nies and McEwen, 2007
contend that preventative care, health promotion and restorative care are necessary to combat escalating rates of chronic disease, again suggesting that a crowded undergraduate nurse curriculum may be struggling to prepare a workforce ready for future community needs. Indeed, the significance of promoting primary and public health care and health promotion and illness prevention has strong congruence with the aims of the Health Workforce Australia (HWA) plan to reform the future health care workforce of Australia to meet the current and emerging needs of the population (HWA, 2011
). Of interest is whether the population needs identified by HWA, 2011
is focusing more on the location of care rather than the skills underpinning that care. Maben and Griffiths, 2008
in their patient based study identified that empathy and compassion were prioritized as underpinning good nursing care.1.1 Background of the research
Nepal is a small country in the central Himalayas, with a population of 26.5 million (
Government of Nepal, Ministry of Health and Population, Central Bureau of Statistics National Planning Commission Secretariat, 2011
). According to WHO, 2004
, 38% of the Nepalese population live below the poverty line, and 90% of the poor are living within rural areas. Nepal is still a very traditional country, with strong religious, social and family ties. They uphold a caste system, with the poorest people belonging to the lowest caste group living in the mountainous regions of Nepal (WHO, 2004
). These issues need to be addressed more effectively with a view to accelerating policies into action to improve health outcomes for all in rural and urban areas in an equitable and sustainable manner (WHO, 2007
). Addressing the determinants of health is necessary to improve the health of a population. Ways of doing this include through nutrition, water and sanitation, maternal and childcare, family planning and the treatment and control of disease through immunisation programs as outlined in the Alma Ata Declaration NGOs and INGOs are of central importance to meeting the Nepalese Government’s goal to improve health within marginalised populations. Nurses with competence in health education and promotion would be of great value in developing countries such as Nepal, as such skills play a large role in improving the health of disadvantaged individuals and communities.1.2 Student volunteer placements international
Student Volunteer Placements International (SVPI) organise volunteer experiences with the Children’s Welfare Organisation in Nepal (CWON) in the Chitwan region of Nepal. Volunteer programs focus on the health of communities in this region, including health promotion and education of women and children. Emails are sent to students within several leading Australian universities explaining the program. Information sessions are then delivered to prospective volunteers by SVPI explaining the program; students subsequently make enquiries and volunteer of their own volition.
1.3 Volunteering
Health professionals and students perceive volunteer experiences abroad not only as an opportunity for them to expand their career options, but also as an opportunity for them to act as a direct agent for change in communities of the world that need help most (
Barbeau, 2003
). , a registered nurse from the UK maintains there are many ways that nurses can support international development by participating in projects ranging from responding in humanitarian emergencies to working with planned programs.Despite the professional development opportunities that lay within volunteering there is a deficiency in information when searching for international experiences of Australian nursing students within the literature. However, the findings from a qualitative exploratory study in which eight undergraduate nursing students undertook a clinical placement in Surin, Thailand suggest that international clinical placements may impact on the personal as well as professional development of participants (
Reid-Searl et al., 2011
). It has also been suggested that international placements of the immersion type are valuable in providing a unique learning experience by enhancing cross-cultural competence (Reid-Searl et al., 2011
).1.4 Cultural competence
Cultural competency has been defined in the literature as the ability to function with a thorough knowledge of the beliefs, traditions and practices of another culture (
Levi, 2009
). The dramatic increase in ‘global migration’ has contributed to a need for an international dimension to the health sciences curriculum to prepare students for providing culturally appropriate care to migrants and immigrants (- Levi A.
The ethics of nursing student international clinical experiences.
Journal of Obstetric, Gynecologic, & Neonatal Nursing. 2009; 38 (Retrieved from:): 94-99https://doi.org/10.1111/j.1552-6909.2008.00314.x
www.jognn.awahonn.org
Levi, 2009
). - Levi A.
The ethics of nursing student international clinical experiences.
Journal of Obstetric, Gynecologic, & Neonatal Nursing. 2009; 38 (Retrieved from:): 94-99https://doi.org/10.1111/j.1552-6909.2008.00314.x
www.jognn.awahonn.org
Nursing and Midwifery Board of Australia, 2010
in the National Competency Standards for the Registered Nurse state that Registered Nurses should practice ‘in a way that acknowledges the dignity, culture, values, beliefs and rights of individuals/groups’ and furthermore that nurses should accept ‘individuals/groups to whom care is provided regardless of race, culture, religion, age, gender, sexual preference, physical or mental state’ (Nursing and Midwifery Board of Australia, 2010
).The opportunity to develop cultural, spiritual and physical nursing skills in a third world environment was described as inspiring by a third year nursing student from New Zealand who spent time volunteering in north western Thailand. The student explained the time spent in Thailand taught how to approach difficult situations in a more creative, flexible way and the experience boosted confidence and ability to think on ones feet (
Blockey and Moore, 2006
).It would appear from the literature that the experience of delivering health care whilst being immersed in a different culture can provide an opportunity to develop the skills required to interact with culturally diverse populations. According to the Australian Institute of Health and Welfare (
AIHW, 2013
) in 2011, 27% of the Australian population was born overseas. Given this information, volunteering in a country such as Nepal where there is not only language and cultural differences but also political unrest may have a positive effect on attitudes towards refugees that nurses may deal with whilst delivering health care in Australia.1.5 Theoretical framework
The research employed an interpretive phenomenological method of research in the style of van Manen, seeking to better understand peoples’ lived experiences and individual truths (). This focus on the in-depth lived experience is characteristic of phenomenology and is best suited for an identity-focused research such as this.
1.6 Ethical considerations
Ethics permission was obtained and granted for this research.
1.7 Research design
The research design was based on the phenomenological paradigm according to
van Manen, 1990
. The design was specifically chosen so as the individual and unique experiences of the participants could be heard without bias from the primary researcher and her own experiences. By adopting this methodology, the emerging meanings of the volunteer student nurses’ lived experience relating to their time spent in Nepal was explored in depth. This methodology is additionally appropriate for this topic of investigation as there is minimal research exploring volunteering nurses partially reconstructing their professional identity through volunteering.1.8 Research population or sample
As phenomenology is an exploratory approach, it does not seek to achieve either reliability or validity to wide population groups, typically using small samples (
Polit and Hungler, 2004
). Therefore the research population consisted of five student nurses who volunteered in Nepal as health care workers and participated in the SVPI/CWON program for a three-week interval. These volunteers were all female, aged between eighteen and thirty and were all Australian citizens and spoke fluent English.1.9 Specific procedures and instrumentation
To establish a position of genuineness rather than a false one of neutrality, the primary author acknowledges their own position in relation to this research and its context in relation to their personal experiences and their effect on their identity as a nurse. This has created a greater ease of relating, engaging in narratives and partnership within data collection. Given the primary task of the interview was to gain an understanding from another of her or his truth, such empathic foundations would appear crucial to generating rich text (
Hurley, 2009
).MP3 audio files of the interviews were listened to and transcribed into text. Sections of this text were highlighted and assigned to recurring subjects or themes that arose from the participants’ voices. After grouping the text in this manner, these themes were critically re-examined to ensure compatibility with the unique descriptor and the consideration of alternate explanations. These initial themes were then placed under major themes that reflected the differences of participants’ experiences. Many initial themes were not included as informing themes, and new themes were added throughout the analysis process. Throughout this entire process, every stage of the data analysis was documented and filed, from the original transcription of the interviews, which were numbered according to the participant through to the final results.
1.10 Data collection and data analysis
Nursing students who volunteered in Nepal were contacted via email and interest in participation in the study was sought. Five participants expressed an interest and were sent permission forms to sign and return to the researcher. An appointment was made for an interview, which was conducted in a nursing research room, with Mp3 audio recordings of the conversation being taken at the time. Semi- structured interviews were conducted with between twelve and fifteen questions asked at each interview. The number and wording of questions was dependent on the individual being interviewed at the time. Interviews were transcribed verbatim with the transcripts being read and re-read for emergent themes and meanings, allowing the experience to be understood more widely.
1.11 Thematic interpretations
Thematic analysis is a flexible, useful research tool that can provide a rich but detailed, complex account of the data (
Vaismoradi et al., 2013
). Thematic analysis involves the identification of common threads of lived experiences that reach across a group of interviews and is widely used with variation across phenomenological studies. It has been used to analyse the interview data in this study. Each recorded transcript was repeatedly read; to search for those common threads of the participants lived experience.The following five emergent themes were derived from the participants’ experiences of volunteering as health workers in Nepal, with each one being individually discussed.
1.11.1 Theme 1: student nurses experienced growth of their nursing capabilities
The experience of volunteering in a developing country appears to have significantly drawn upon and expanded many of the participants’ capabilities as nurses. At times the participants were required to ‘think on their feet’, drawing on their knowledge and decision making skills when assessing patients and delivering health care.
Participant two described her time spent volunteering in Nepal as being a “learning experience” that made her feel more like a nurse and less like a student, and challenged her to “step up,” assess and refer patients using her own skills and knowledge. “I think you value your nursing skills then, you’re being able to assess and refer patients to doctors and pharmacists. You realise how much you’ve learnt.”
Witnessing the health conditions suffered by the Nepalese and the underlying causes encouraged participant five to look to “more than just the common cause” for people experiencing ill health and disease, stating that “it (the experience) may even make you think why someone might be getting asthma.”
Volunteering as a health care worker in a developing country in the formative years of nursing was “highly recommended” by participant two, describing it as a great opportunity and a way to “make you a much better nurse” being able “to step out into an environment like this. It’s going to boost your confidence. It forces you to use your skills and makes you aware of what you don’t know and when you do need to turn for help.”
Participant two further authenticated the experience, stating that “For the most part it really validates your decision to become a nurse and it also emphasises that you do have things to learn and you do start to get a better idea that yes I do need to get better assessing skills and better ideas of how to work in a situation if I’m really going to do something valid here.”
The volunteering experience in Nepal had an entirely diverse effect on participant one in relation to this theme, who felt the skills they had an opportunity to utilise in this environment were not “specific nursing skills.” In fact, the health promotion, education and first aid programs participated in were seemingly insignificant to this participant as they voiced their concerns of them being unrelated to nursing identity, when they explained “I don’t necessarily think that I’m going to stick with nursing. I feel as nurses, there’s not enough scope of practice. As a GP or doctor or medical officer I think that you have the ability to make change and you can do more than you really can as a nurse. And that’s what being over there kind of showed me. As a nurse we don’t really do a lot. We can educate, and inform but when it comes down to purely just medical issues, we don’t really do much, we just follow the orders of someone else.”
1.11.2 Theme 2: student nurses experienced volunteering as building empathy, compassion and caring
Being exposed to the way of life of the people in rural Nepal had a humbling effect on the participants. During their time spent with the Nepalese people, the participants expressed an increased appreciation for the plight of individuals who came from undeveloped nations, as well as insight into the reciprocal learning. Participant one described their experience as having “made me feel like I’m incredibly lucky to live in Australia” as it “kind of tore your heart out seeing the conditions that people live in.” They further went on to explain that, “You think you know something, but until you really see it and experience it you don’t really have a depth or level of understanding.” Participant two described their experience as challenging. For them, it illustrated moments such as when the volunteers spent a day in the hospitals seeing patients in palliative care with only a concrete bed, and very limited pain relief. Thereby finding it hard to “just come back and sit, just knowing that was occurring.”
For participant five, the experience of Nepal “broadened their (nursing) philosophy, and increased the depth of caring I have and how I treat people.” The same participant described the interaction they had with the Nepalese people and culture as “Inspiring. Even though the people over there have got illnesses or injuries that are impacting on their lives they’re still as happy as can be. Nothing stops them from doing anything. They have limbs missing and they’re still like ‘yes we’re fine, would you like something?’ They’d offer you the world even though they didn’t have it.”
1.11.3 Theme 3: student nurses’ experienced education and health promotion within their nursing identity
For the participants, the experience of volunteering in Nepal strengthened the importance of patient education and promotion of health within their identity as nurses. Participant three maintained they “feel like the importance of health promotion is much greater” since being in Nepal. Prior to the Nepal experience they “wouldn’t have thought to educate someone on their diet”. They described feeling as if they would previously have taken the “biomedical approach”, however after being in Nepal it’s easier for them to now educate people on “basic stuff that could have an impact” and may prevent an admission to hospital. The role of a nurse, as educator, was clarified for participant two, maintaining that they are “a little bit more confident in what I can do, and obviously what I know.” Further they credit their experience as highlighting the need to work on their “educating skills.” Prior to the experience in Nepal, the prospect of educating patients was daunting for participant three. They maintain that the responses from Nepalese people, coupled with how they enjoyed the experience that they “would be more willing and open to spreading and giving (my) knowledge to other people.”
The opportunity to share information with Nepalese women in a group context was an enlightening experience for participant two, where she was able to perceive nursing care as being something more than only medical interventions, additionally being able to identify the role that nurses play in effecting change.
The challenging nature of providing health care to women with whom there was no common language, was highlighted by participant four. Participant four made reference to their struggle with cultural diversity in general. They further described the difficulty adjusting to differences in both “the way someone else thinks” and what people “perceive to be important” compared to the attitudes and perceptions of the Australian culture. Moreover they commented on the need for cultural respect, agreeing that “you can’t just go in (to another country) and go ‘you can’t do that, this is the way we do it in Australia’.”
1.11.4 Theme 4: student nurses experienced the need to use creativity in overcoming barriers to delivering health care effectively
There were a number of barriers to health care delivery that were identified by the participants during the interview process. However, the participants found ways in being creative, overcoming challenges and learning invaluable lessons in patient care from their experience.
Participation in health camps proved to be a challenging experience for the participants. Participant one describes some issues that she felt were insurmountable as far as remote areas were concerned. For participant two, the process of delivering health care in rural remote communities of Nepal, instigated a situation where they had to think outside of the box, outside of the normal parameters of nursing guidelines to be able to safely and successfully deliver care to the presenting patients.
“I’m used to having supplies set up and ready and being able to get what you need and go. There was a lot more makeshift care than I typically think of with nursing. Especially when we were up on the mountain in the village and your resources were a bit limited.”
1.11.5 Theme 5: student nurses experienced gaining new capabilities to utilise in Australia
For most of the participants, the experience of volunteering in a developing country has gifted them with the insight that the skills acquired in Nepal can be transferred back to their own environment. For participant three, the experience afforded them the opportunity to reflect on the benefits of education and health promotion “I feel like in Australia if you were to teach the education side of it better you wouldn’t have so many people coming in to the hospitals with preventable causes blocking up the system.” In terms of improving patient outcomes through the integration of health promotion and education into nursing practice, participant three additionally stated “It takes two to tango and if clients are willing to listen and I am as their nurse willing to provide the education then I think it could go a long way. It may not impact everyone but if we change one person then it all counts.” Furthermore, participant three gained insight into health promotion and education as being critically important in Australia, as a result of the effects of first world diseases disabling our society.
The perception of the role of nurses as educators in health has not been altered by the experience in Nepal for participant two, it has become “much more of a reality” and has clarified “what nursing is, in an environment like that.” They further maintain that as nurses, integrating health promotion and education into everyday interactions with patients is “very much something that we can do, there’s no reason why we can’t.”
For participant four the experience has increased awareness of the importance to take the opportunity to educate when it presents itself. “You see other nurses on the ward and if they’ve got a spare moment they’ll sit at the desk and take a breather. But you might think ‘I’ve got a spare moment, I’ll go see this patient and see what their idea of their condition is and what they know about it and if I can help with any questions they might have about it.” For participant one the experience of delivering health education to the Nepalese people initiated the view that public health is “more important over there (in Nepal) than what it is here (in Australia) to be honest.” This view was reinforced by participant four, who also stated “It’s so easy in Australia. If you want to know something you just grab your phone.” Seemingly from these statements, there is a perception that the ability to access information via internet and media indicates a less urgent requirement for health promotion and education in our country by nurses, and furthermore that nurses have been made almost redundant by the media in their role as educators as well as their capacity to deliver health education to the community.
In contrast to these comments, participant one felt that they didn’t really learn anything new from their experience in Nepal, and that in terms of integrating health promotion and education into generic nursing “everything we do over there (in Nepal) is pretty well put into practice in the Australian health care system. I don’t think we learnt how to approach nursing in a different way. I think that again just reinforcing that non- judgmental approach and just to be open and empathetic but we already do that, or should be doing that.” This statement, begs the question of how much emphasis is being placed on PHC within the nursing curriculums, seeing as it is an integral aspect of nursing and should be valued as first line care of the population.
2. Discussion
This study had the stated objective of seeking to determine if student nurse professional identity was affected by their experiences of overseas volunteering. The thematic results are suggestive that the participants all had experiences that directly impacted on their personal and professional understandings of nursing.
Participants experienced being in a more responsible role whilst delivering health care, rather than the more familiar position of being supported by an educator, as is common in nursing practicum experiences in Australia. Consequently, the participants drew on knowledge and skills they had gained from university but had not had the opportunity to put into practice. This finding echoes that of
Ng'ang'a, 2006
who found volunteering challenged both her personal and professional boundaries. also identified that international health care experiences can increase self- confidence and enhance a long list of new clinical skills.Through working in an unfamiliar professional capacity and making semi- independent decisions based on their theoretical knowledge and skills based practice, the participants had the significant early career experience of enacting their university based learning in a ‘hands on’ clinical context. As a consequence the participants became more aware of the need to increase and expand their knowledge and skills, in order to improve outcomes for patients in the future. This heightened sense of awareness of the link between knowledge and capability to patient outcomes appears to be a significant finding in the context of student nurse learning and identity formation. Witnessing the context in which health care is delivered in the low socio- economic communities of Nepal with a heavy focus on health promotion and primary health care enabled participants to incorporate a new aspect of their identity as a nurse than that gained in previous hospital based practicums. These findings are reflective of those from the qualitative exploratory study conducted by
Reid-Searl et al., 2011
who suggested that international clinical placements might impact on the personal and professional development of participants.While the majority of participants experienced a growth of professional capability through the volunteering experience, for a minority, an unexpected finding was that of the experience of delivering education and health promotion in Nepal as a volunteer having highlighted that nursing is a passive occupation. Further, these minority views were reflective of health care not necessarily being delivered in a multidisciplinary approach, and that nurses are only bystanders awaiting instruction.
The research discovered the majority of participants reflected the findings of
Barbeau, 2003
, who found that many health professionals and students see the inherent opportunity in volunteer experiences abroad to not only expand their career options, but also for them to be an agent of change. However, the minority experience of nursing passivity is also evident within the literature from other studies and, as such, suggests the profession of nursing may be perceived by some student nurses to be a passive occupation, and that nurses lack confidence in demonstrating autonomy. This should alert academics, educators and curriculum planners of the need to incorporate learning into the curriculum that demonstrates that qualified nurses can be independent and autonomous, particularly given the future workforce expectations of the profession, to improve productivity and patient outcomes by ‘improving inter-professional collaborations and enabling health professionals to work to their full or expanded scope of practice’ (HWA, 2012
).Another significant finding was that participants expressed a rediscovered empathy and compassion within their nursing identities following their volunteer experience, as well as an increase in caring for patients and their personal situations. Such capabilities underpin patient positive experiences of nursing care (
Maben and Griffiths, 2008
). Witnessing the lack of education of the local people, the conditions in which they live and the insecurity of their futures created an improved understanding of equality, an appreciation and respect for the Nepalese peoples’ endurance and perseverance as well as a greater desire to create positive change. Findings from similar studies found that experience aided participants in developing new cultural, spiritual and physical nursing capabilities (Blockey and Moore, 2006
) whereas Ng'ang'a, 2006
was challenged both professionally and personally, whilst still feeling as though she had performed a service to the wider community and made a difference. While being beyond the scope of this small research, this finding does question how the current training and preparation of student nurses influences the traditional identity characteristics of nursing compassion and empathy. Findings from this study resonate with a construction of nursing identity and attributes as coming from more than academic based experiences alone; a stance shared with that of Willetts and Clark, 2014
who highlight that a complete nurse identity is one that must not be limited to the academic preparation of nurses and the transition of those graduates into the workplace. The building of empathy, compassion and caring through this volunteer experience has awakened in participants an awareness of the connection between our social environment and our wellness, and more importantly, recognition that delivery of effective health care involves consideration of these factors.3. Conclusion
Engaging in overseas volunteering assisted the student nurses to reconnect with their empathy and compassion, the humanistic and interpersonal nature of nursing rather than the technical skill based components of nursing identity. Additionally, the challenging contexts of health care delivery in a developing country forced them to enact their nursing skills to the very boundaries of their capabilities and to be more innovative. These skills and capabilities are imperative when dealing with not only indigenous or non-English speaking Australians, but with an ageing population and the broader community as well.
The lived experiences reported in this research also reinforces that nursing identity can play an important role within primary health care, arguably a role that has been neglected within current undergraduate nursing preparation, that has historically predominantly focused on preparing nurses for hospital based roles.
The strengths of this small qualitative exploratory study lie in seeking a better understanding of the lived experiences of student volunteers in Nepal. As such the findings whilst informative are not necessarily replicable, as is the nature of qualitative studies. The views and impressions of five people cannot be expanded to reflect those of the general population, nor would this study be replicable, being subject to the experience of lived space, time, body and lived human relation (
van Manen, 1990
). The strengths of this study are that strong links have been formed with existing literature, and gaps have been identified within the literature. The conclusions having been drawn directly from the findings and supported by the peer reviewed literature, confirm trustworthiness.Based on the conclusions from this study it is hoped that future nursing curriculums will offer opportunities for students to not only maintain but build their compassion and empathy and to also offer some primary health care experiences for undergraduate nurse students. This would be congruent with the overarching government policies of
HWA, 2011
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Article info
Publication history
Published online: August 07, 2016
Accepted:
July 18,
2016
Received in revised form:
May 27,
2016
Received:
September 18,
2015
Identification
Copyright
© 2016 Published by Elsevier Ltd on behalf of Australian College of Nursing Ltd.
