The Unexplained “Magic” of A Global Immersion program

The Immersion

For the past six years, nursing students from pre and post licensure programs at the Nell Hodgson Woodruff School of Nursing at Emory University (Emory SON) have had clinical immersions in Cusco, a 7^th most populous city in Peru, in collaboration with a community-based clinic in Cusco. The immersion activities include health screenings in community-based settings under the supervision of Peruvian nurses and obstetra (the equivalence of midwife/women’s health clinicians), observation in public and private hospitals and clinics under the supervision of physicians, nurses, patient technicians, and lab observation under the supervision of pathologists. As part of their course requirements, students and faculty debriefed and reflected on their experiences. Consistently, one big theme that comes out from the group debrief and individual written reflection is the students’ perception on the strong collaborative work among nurses, doctors, patient care techs, lab personnel, and obstetra.

Peru’s Interprofessional Educational Model

To gain an insight into the American nursing students and faculty’s observation above, it’s important to understand the context of the health professional education in Cusco, Peru. Peruvian medical students are enrolled in a seven-year program straight out of high school, while a bachelor in nursing programs are 5 years, similar to obstetra education, which has an emphasis on sexual and reproductive health of women, family and community. Medical, nursing, and obstetra students must complete a year of “medical internship”, besides their clinical rotation, in the final year of their formal education. This year-long internship consists of one or more immersive clinical-training experience, under a preceptor, in some of the clinical services of public or private hospital institutions (for medical students) and in hospital and primary care services of the Public Health System (for nursing students) (López-Morales et al., 2020). This internship, organized under the Servicio Rural Urbano y Marginal de Salud (SERUMS) or Health Ministry’s Rural and Marginal Urban Health Service, not only provides essential healthcare workforce for the underserved and rural communities, but also provides future healthcare workforce an immersion in clinical and collaborative learning. The SERUMS internship, however, does not provide didactic training in collaborative learning.

The Impact of the Care Delivery Model

Review of the English literatures provides little information on formal curricular integration of interprofessional collaborative practice training in Cusco in particular, or in Peru in general. There is a perception that the SERUMS internship, while having a negative effect on the perceived wellbeing of the health professional trainees due to the stress, also cements their inter-professional collaboration. A study by López-Morales et al. (2020) examined elements that affect health professional perception of well-being, using the Jefferson Scale of Attitudes toward Physician-Nurse Collaboration (JSAPNC) as a tool to measure professionalism among medical and nursing professionals in the SERUMS program. “The JSAPNC is a tool designed for the measurement of specific skills oriented to collaborative inter-professional work in medicine and nursing. The tool evaluates the assessments made on shared education and the ability to recognize differences and complementarity between the two professional areas.” (López-Morales et al., 2020, p. 5). The study found that inter-professional collaboration is one of the factors that has a positive influence on the perception of well-being in physicians and nurses in the SERUMS program – meaning health professionals near the end of their training program. Review of the literature and informal discussion with healthcare professionals in Cusco, Peru reveals very little insight into factors that positively influence the cordial inter-professional collaborative culture that American nursing students observed during their immersion experience.

Reflections: Align with the IPEC Competencies

Despite Peru’s lack of formal training in IPEC, the clinical work environment and collaborative practice model shapes their perceptions and certainly, the observations of our immersion students.

During our group debriefings, multiple nursing students reflected about their observation of positive teamwork spirit among Peruvian physicians, nurses, obstetra, and other healthcare professionals, and comparing it with the less-than-ideal observation at home. Nursing students’ observation during group debriefings, and their reflective journals, published with their permission, could be grouped into four themes, matching the four IPEC competencies of Values and Ethics, Roles and Responsibilities, Communication, and Teams and Teamwork (Interprofessional Education Collaborative, 2023).

In examining the first competency, Values and Ethics, students’ reflection highlighted Peruvian healthcare professionals meeting sub-competencies VE7: “Practice trust, empathy, respect, and compassion with persons, caregivers, health professionals, and populations”, and VE11: “Support a workplace where differences are respected, career satisfaction is supported, and well-being is prioritized” stood out. One student commented:

“From the doctors and nurses to all the patients we served, every individual was so respectful, kind, and appreciative. During rotations in the States, students tend to be disrespected during rotations by doctors, nurses and even patients sometimes. Even though we are trying to learn so we can become better professionals, we are looked down upon and not treated with respect simply because we are students. The most beautiful thing is that they not only treated us this way, but they also treat each other with so much kindness and respect. The support within the community and its people was one of the most impactful things I experienced during our time in Peru.” (Personal communication 1, 2024)

Multiple students commented on how they noticed the positive collaboration among Peruvian healthcare professionals, including physicians, nurses, obstetra, pharmacists…working together to address patient health issues, putting the patient in the center of their work, rather than paying attention to their titles or rankings. This theme addresses the Roles and Responsibilities, particularly RR1: “Include the full scope of knowledge, skills, and attitudes of team members to provide care that is person-centered, safe, cost-effective, timely, efficient, effective, and equitable”. One student’s journal reflection illustrates this theme:

“Healthcare professionals in the U.S. are in constant worry of losing their license due to betrayal from other colleagues or for being blamed for other people’s mistakes. This makes it so easy to lose focus on their main priority which is the patient. In Peru, doctors, nurses, and techs come together as one to provide the best experience for their patient and truly care for their patient. It’s been beautiful to see that despite the lack of resources, their patients still receive the best experience and care because each healthcare professional in the room comes together as one and treat each other as equal despite their roles.” (Personal communication 2, 2024)

Another student noted how the Peruvian healthcare professionals, despite lack of resources and other challenges, collaborated to account for their patients’ care: “Despite these challenges (resources, finances…), the dedication and resilience of the healthcare professionals were admirable, highlighting their commitment to patient care amidst adversity.” (Personal communication 5, 2024)

Students also discussed how they observed the positive, respectful communication among the Peruvian healthcare professional team members, and between the care team and the patients and their families. This theme aligns with IPEC’s Communication competency, particularly sub-competency C5: “Practice active listening that encourages ideas and opinions of other team members.” One student wrote:

“It was refreshing to see the entire care team, and often the loved ones of the patients, being actively involved in every aspect of the care being provided. The nurses, obstetric specialists, students and physicians were part of the patients’ assessment, interpretation, planning and implementation of the care plan, while the patient and their loved ones were actively notified of next steps in the process. I have seen this in the U.S., but not to the same extent and active effort to include all members of the care team as I witnessed in Cusco.” (Personal communication 3, 2024)

Last but not least, the IPEC Teams and Teamwork competency is permeated in the nursing students’ observation. They spoke highly of how the Peruvian healthcare professionals seem to “get it” when it comes to adapting their roles to a variety of team settings, after witnessing the patient care in various settings, including low-resourced clinics and nursing homes. Their reflection points to the sub-competency TT2 “Appreciate team members’ diverse experiences, expertise, cultures, positions, power, and roles towards improving team function”, with one student writing:

“I loved seeing how kind everyone was and how they did not let their titles separate them. In many places we went to, everyone worked together as a team. They even invited me and other students with open arms to be part of their team, even for a short period.” (Personal communication 4, 2024)

What is the take home message?

Student’s reflections uniformly highlighted the positive interprofessional collaboration among the Peruvian healthcare professionals in various healthcare settings. While it is unclear from literature and conversations with the Peruvian healthcare professionals what factors contribute to this positive teamwork culture. Despite not having a formal curriculum or explicit dialogue around a framework such as the IPEC competencies, the culture of teamwork was pervasive and observable. The power of leveraging the clinical learning environment to teach, learn and experience interprofessional collaboration cannot be ignored. While hard to attribute anyone thing to the student’s interpretations of their experiences/observations, it does seem the year-long SERUMS internship with high stress and low resources may in some way, bind them together with a singular shared purpose. In that shared purpose, they appreciate each other’s value, role, responsibilities. It might be an observation that is specific to Cusco and should not be generalized to other parts of Peru, however there is some “magic” that is happening that should not be ignored. Luckily, we were able to learn from our counterparts in Cusco and our students, learned some great insight from those role models.

Disclaimer: Despite having collaborated with the community health partner in Cusco, Peru for the past eight years, the author is not an expert on health professional education system in Peru. This is written based on informal conversations with various Peruvian health professionals and debriefing/reflection from various US student groups, many of whom have been through formal interprofessional team training in their program.

photo courtesy of IStock

References

About the Author: Quyen Phan, DNP, APRN, FNP-BC, is an Associate Clinical Professor at Emory University’s Nursing school. With nursing background in both Canada and the United States., Dr. Phan’s areas of expertise include public health, primary care, academic-practice partnership, and nursing education.

Dr. Phan is the primary investigator/project director of two HRSA-funded grants totaling $8 million dollars, focusing on expanding healthcare to underserved and rural populations and preparing nursing students through nurse-led mobile health programs, and improving the nursing workforce in eight states in the Southeastern region of the United States through the training of clinical faculty and preceptors in underserved and rural areas of the region. She is the co-investigator on two other HRSA grants, totaling $4 million dollars to train nursing students in assessing and addressing social determinants of health, and to train Community Health Workers to better serve their community’s health needs.

Dr. Phan is the immersion trip leader for both pre and post-licensure nursing students in Cusco, Peru. Collaborating with community-based clinics and health professionals in Peru for the past eight years, she trains nursing students in health education, prevention, and screenings, including cervical cancer and breast cancer, with a focus on underserved and rural areas around Cusco.

The views and opinions expressed in this post are those of the author and do not necessarily reflect the official policy or position of The University of Ottawa. For more details on our site disclaimers, please see our ‘About’ page

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