A Mixed Methods Case Study of Partnerships in International Service-Learning: Exploring Reciprocity and Bi-Directional Benefits

Background: Based on demographic shifts toward more diversity and increasing health care disparities in the United States, nursing educators need to find innovative pedagogies to teach cultural competence and social justice concepts. International service-learning (ISL) programs are proliferating, as there is evidence that these experiences can promote desired competencies. However, concerns have been raised about host communities serving as learning laboratories for US students, while little attention is given to how reciprocity of teaching and learning, and mutual outcomes are achieved as well as the potential burdens the already resource-constrained host community assumes, and what, if any, benefits accrue to the host community partners. Furthermore, questions are being expressed about potential harmful effects that arise from international programs that have not (a) established ongoing, reciprocal partnerships, (b) addressed a need identified by the host community, (c) considered how issues of power and privilege influence relationships, (d) communicated respect for indigenous knowledge and skill, and (e) focused on feasibility and sustainability of program interventions (Crabtree, 2008; Foster, 2009; Leffers & Mitchell, 2012; Levi, 2009, Miller, 2009). As the number of international service -learning programs continues to rise in nursing education it is imperative that the partnerships within these programs be examined. Therefore, studies need to be designed that can explore in depth the partnerships formed in international service learning programs to gain more insight into if and how reciprocity and equitable sharing of burdens and benefits are established. 

Project Description: The purpose of this mixed methods case study was to examine the characteristics and outcomes of partnerships formed within an innovative international service learning (ISL) program in nursing education and to explore how power/privilege, reciprocity, and the achievement of bi-directional benefits were addressed. Post-colonial theory provided a critical lens, while Leffers and Mitchell’s conceptual framework guided the analysis of partnership formation, reciprocity, and outcomes. Four schools of nursing (1 in the US, 3 in Kenya) partnered to carry out a service-learning, research and advocacy partnership focused on the emerging epidemic of non-communicable diseases in Kenya. US/Kenyan students/faculty/clinicians were paired 1:1 to carry out community based cardiovascular-metabolic screenings and treatment in 5 Ministry of Health (MOH) community health centers. Students and Kenyan faculty colleagues were engaged in community outreach, patient education and treatment as well as data collection, analysis and dissemination. MOH nurses in the community health centers were central to the academic-clinical linkages established in the project and this partnership facilitated sustained access to NCD care at the community level. All partners were actively engaged in advocacy with Kenyan and US nursing leaders and policy makers through presentations, testimony and conferences.

 Methods: Data were collected through interviews, observation and document analysis. The central question guiding this qualitative inquiry is:  How do partnerships in an international service-learning program support or hinder the development of reciprocity and bi-directional benefits?

 A mixed methods design was used, with the qualitative approach serving as primary, as the characteristics of qualitative research were a good fit for the intentions of this study. The study proceeded according to the principles of a hybrid intrinsic-instrumental, single embedded case study. The following principles were strictly adhered to; the investigators used a bounded system (2013-2014), the phenomenon of interest and the context were addressed, and multiple forms of data were collected. Partnerships were operationally defined as 1) institutional partnerships, 2) founding partnerships, 3) faculty partnerships, 4) student partnerships and 5) community clinic partnerships. Sampling occurred at two different levels within case study design. The first involved the selection of the case to be studied. The service learning program that provided the context of this study was the Kenya Service-Learning Project (KSLP). The second level of sampling involved selection of the people to be interviewed within the case.  This study employed a purposeful sampling strategy as the criteria for sampling in case studies are usually purposeful, with an emphasis on information-rich participants. This strategy was used within the student, faculty, and clinician sample, in order to achieve adequate representation from the four schools and six clinics affiliated with the program. A sample size of 70 (considered large for case study methodology) was determined to provide adequate inclusion of all the key stakeholders, and allow for maximum variation and thematic saturation.

Participants completed a brief demographic questionnaire, with the following sample description. The age range was 20-65 years (mean age 30. The sample included 59% (41) females. The racial composition was 77% (53) Black, 22% (16) White, and 1% (1) Latina. The range of years of participation in KSLP for the sample was 1-7 years, and consisted of the following percentages: 1 year=26% (18), 2 years= 33% (23), 3 years=11% (8), and 4/more years=30% (21). Kenyan students, faculty, and all founding partners accounted for the more frequent participation in the program. The majority of US students only participated for one year.  Interviews and participant observation occurred between February and October 2014. Seventy semi-structured interviews were conducted, recorded, transcribed and analyzed for themes. A single investigator not associated with the Parent Project carried out the analysis so as to avoid any conflict of interest. Following the initial analysis of the data, all of the investigators and other participants involved in the project reviewed the themes and supporting evidence to assure the trustworthiness of the findings. This was done when the Kenyan team was in the US in April 2015. In addition one investigator carried out participant observation of all aspects of the project and documents were analyzed for supporting evidence.

Data analysis is a process of making sense of and finding meaning in the data. Interviews yielded over 1000 pages (single typed) of transcripts, which were carefully read over several times, first in entirety to gain an overall impression, and then by grouping (US students, Kenyan students by school, Kenyan faculty by school, founding partners, community leaders) to explore similarities and differences within and across groups, allowing the researcher to be fully immersed in the data. Data analysis spiral, which depicts a circular process, allowing back and forth movement among data collection, management, memoing, describing, coding, interpreting, and representing was followed. Data were analyzed in a fluid manner, using the constant comparative method and  two-step coding process, which began with initial coding of, individual words, lines, and segments (initial coding). Initial codes were documented in a Code Handbook, and focused and pattern coding allowed for clustering of initial codes, developing new insights, categorizing and relating codes to completely and incisively identify and interpret the major themes.  In addition to the theoretical lens and conceptual model described above, the RE-AIM  (reach, effectiveness, adoption, impact, maintenance/sustainability) framework was utilized to guide the quantitative component of the study, thus providing a fuller understanding of the programs outcomes/benefits.

Results: The sample (n=70) included US and Kenyan students, faculty, and clinicians and Kenyan community leaders who have participated in the service-learning program. Data were analyzed using a constant comparative method, and two-step coding process, providing a thick description of the case and identifying the central themes. The three central themes emerged as: a) Establishing and Strengthening Partnerships, b) Achieving Reciprocity: Acknowledging the Challenges, and c) Reaching Sustainability: A Generative Process and d) advocacy.  Findings point to the importance of dispelling assumptions, making connections, addressing privilege, sharing power, balancing contributions and benefits, and building sustainability. Trustworthiness was ensured through triangulation of data and member checks. Quantitative results were sorted into the following categories; service learning, policy and advocacy, research, and reciprocity. Service learning outputs included; over 6,000 community members screened and treated, implementation of patient follow-up for positive screens, 8 community health centers now participate, 115 US and 435 Kenyan students/faculty/clinicians have participated, implementation of a peer-led, nurse directed cardiovascular-metabolic self-management group (50 patients now enrolled). Policy and advocacy included 7 debriefing sessions with Kenyan policy leaders and the ISL team, annual, joint presentations to the chief nursing office at the ministry of health, presentation to the Kenyan Prime Minister on NCD burden and opportunities for nursing, and meetings with the Kenya Nursing Council. Research outputs include; 18 grants funded, 28 data based abstracts presented locally, national, internationally with 79% having Kenyan co-authors and 100% having US students, 4 peer-reviewed publications in high impact journals, 4 dissertations and 5 masters capstone projects. Reciprocity included 2 Kenyan faculty who are now enrolled in the BS to PhD program in the US partner university.

Conclusions/Recommendations: This study contributed to our understanding of how ISL partnerships can be structured to establish reciprocity and achieve equitable outcomes related to clinical, teaching, research, and advocacy competencies. Taken together, the qualitative and quantitative outcomes observed in this study indicate that it is feasible to implement locally tailored, culturally appropriate international service-learning programs that accrue bi-directional benefits and reciprocity. Intentional 1:1 paring of US and host country students, faculty and clinicians appears to be a critical element of the project. In addition, building partnerships that are based on respect, altruism and collaboration are critical to the foundation of trust essential to the success of the program.