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 Table of Contents  
Year : 2019  |  Volume : 32  |  Issue : 3  |  Page : 136-140

Bridging the Atlantic: Optimizing the health of vulnerable community aggregates through international student exchange

1 Community Department, University of Massachusetts, College of Nursing and Health Sciences, N. Dartmouth, MA, USA
2 Department of Nursing, University of the Azores School of Health, Ponta Delgada, Portugal, Portuga

Date of Web Publication18-Apr-2020

Correspondence Address:
Maryellen D Brisbois
University of Massachusetts, College of Nursing and Health Sciences, 285 Old Westport Road, N. Dartmouth, MA 02747
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/efh.EfH_268_19

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Background: A growing diversity of cultures globally has intensified the need to educate health professionals to deliver safe, effective, and culturally appropriate care. Collaboration among global partners and development of cultural competence in nursing students in distant communities is one pedagogy to address competencies. Context: Universities in the United States (US) and Portugal established a bi-directional student exchange to foster professional relationships, enhance cultural awareness, identify health and health care roles from a global perspective, and explore collaborative research opportunities to address the health needs of vulnerable aggregates in both countries. Activities: Students from each country are paired to work collaboratively with faculty on research or health promotion projects, visit health care facilities, participate in university classes, language instruction, visit cultural and points of interest, and disseminate new knowledge. Outcomes: Students expressed an understanding of cultural differences and health care systems, reconsidered the role of community nurse, integrated theory into practice, and experienced peer mutual learning. A framework to organize philosophies related to a student exchange was developed. Future Directions: Forthcoming student exchanges are being planned. Work in previous exchanges allows for sustainability and a growing body of research and health promotion activities focused on impacting vulnerability in like communities in different countries. Conclusions: A shared vision of exchange, student involvement, multi inter-institutional research, perceived relevance of work with vulnerable groups, and improved ties between local and international community agencies allows for project sustainability. Student exchanges with vulnerable groups in communities provide a catalyst to promote heightened awareness of these aggregates.

Keywords: Collaborative research, community health, global competencies, health promotion, personal and professional growth, student exchange, vulnerable aggregates

How to cite this article:
Brisbois MD, Pereira HR. Bridging the Atlantic: Optimizing the health of vulnerable community aggregates through international student exchange. Educ Health 2019;32:136-40

How to cite this URL:
Brisbois MD, Pereira HR. Bridging the Atlantic: Optimizing the health of vulnerable community aggregates through international student exchange. Educ Health [serial online] 2019 [cited 2022 Nov 27];32:136-40. Available from:

  Background Top

A growing diversity of cultures within global societies has intensified the need to educate health professionals to deliver safe, effective, and culturally appropriate care.[1],[2],[3] Institutions of higher education have examined how civic engagement can change the nature of faculty work, enhance student learning, fulfill the mission of a university to embrace social accountability, and improve the quality of life in communities.[4]

Nurse educators in community health practice are accountable for addressing student competence, with the goal of interdisciplinary collaboration that benefits the health of the community[5],[6] and shared the responsibility for disease prevention and health promotion.

The south east coast of Massachusetts, the US and Azores, and Portugal have maintained strong networking, cultural, familial, social, and commercial ties for over 200 years,[7] as Azoreans have migrated to the US, with an estimated 300,000 residents of Portuguese descent currently living in Massachusetts.[8] There is also a political affiliation between the US and Azores, as the US Air Force had military rights at Lajes Field, Terceira Island, for over 70 years.[9]

Both the University of Massachusetts, Dartmouth and University of the Azores, Portugal, have been committed to establishing a collaborative relationship between nursing students and faculty. In November 2013, a delegation from Massachusetts traveled to Sao Miguel and Terceira Islands as a part of Portuguese/American Legislative Caucus and International Caucus on Global Competitiveness Trade Mission to the Azores. At the university level, a prearranged meeting between administration and faculty to identify potential opportunities for collaborative work was organized to include the input from community nursing faculty.

This long sought-after collaboration was realized as the nursing faculty from each university had a shared vision regarding the creation and sustainability of an exchange effort, which had the potential to create dynamic partnerships to empower communities, significantly impact health among aggregate vulnerable groups in each country though research and health promotion activities, develop cultural competence among nursing students, and champion international collaboration with nursing faculty to identify and address social determinants of health, disparities, and ethical concerns. The exchange was known as “Bridging the Atlantic.”

  Mission Top

The mission of “Bridging the Atlantic” was to create a sustainable international alliance in community health among American and Azorean nursing faculty and students by fostering professional relationships, enhancing cultural awareness, identifying health and health-care roles from a global perspective, and exploring collaborative research opportunities.

The goals of the project were to:

  1. Establish sustainable collaborative professional relationships among the nursing students, faculty, universities, and respective communities
  2. Prepare culturally competent nursing students with an open-mindedness toward the impact of global nursing and international cooperation to achieve positive health outcomes and
  3. Develop a research plan of the study based on mutual healthcare priorities to improve the health outcomes in both countries.

  Context Top

The inaugural bidirectional student exchange was successfully initiated in 2015. Since then, an educational experience of international collaboration has been designed annually to allow students' exposure to different cultures, nursing educational systems, and health-care delivery systems through participation in an intervention project with a vulnerable aggregate selected for this purpose.[10] To this end, each annual project is organized to (1) promote relevant activities that allow diverse exposure to culturally distinct contexts and populations that allow a reflexive and critical approach to the practice of nursing care; (2) facilitate peer work of students from different institutions and training programs in a pedagogically supervised manner; and, (3) guarantee opportunities for students to engage in different media at a professional and academic level.[10]

While an actual “exchange” of students is approximately 8 days in each country, the work transpires across the full spring semester as part of the nursing students' community health clinical rotation. This bidirectional clinical exchange aligns with community health experiential courses and parallel outcomes in both curriculums.[11]

The first two exchanges were in Dartmouth and Sao Miguel Island, with an expansion to Terceira Island in 2017, as there are university campuses on both Sao Miguel and Terceira. With the completion of the planned 2019 exchanges, 110 students and 15 faculty will have actively participated with the support of both universities. During each exchange, a vulnerable group in the community is identified through discussions with key informants and community agencies in both countries, and a related research or health promotion project is implemented and evaluated.

  Activities Top

“Bridging the Atlantic” has been important as nursing students have learned about two distinct but related countries. Students are paired (one from each country) at the semester beginning and “meet” through videoconference. This has allowed a seamless transition when meeting face to face, as working relationships are pre-established.

Although the focus on research or health promotion shifts with each exchange, there has been consistency in visits to health facilities, participation in university classes, language instruction, cultural and point of interest visits, and dissemination of new knowledge at regional, national, and international conferences in peer-reviewed journals and through interviews with radio, television, and newspaper outlets in both countries.

Students and faculties have conducted research, and an intervention with men and women deported from the US to Portugal to understand their physical and mental health and quality of life;[12] data from a study with men and women with forced early retirement from Lajes Air Force base to understand the impact of the downsizing and related social determinants of health are being analyzed, and a cross-sectional study to explore the psychosocial work environment, health, and well-being of fishermen/women in the port of New Bedford, Massachusetts, is underway. Health promotion fairs with Portuguese elders with an increase cancer diagnoses and with the fishing community in New Bedford were undertaken with positive feedback [Table 1].
Table 1: Overview of annual projects

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  Outcomes Top

The impact of “Bridging the Atlantic” has been multidimensional, in which it involves international student teamwork and learning, faculty collaboration in research and pedagogy, mutual university support, cooperation among community agencies, and impact health among aggregate vulnerable groups. In addition to the strong ties noted previously (networking, cultural, familial, social, and commercial), this project also realized the goal of improved health in communities, as disparities and social determinants of health are understood and addressed through health promotion and intervention efforts.

  Evaluation Top

A mixed-method study evaluation of the first-year exchange[11] delineated that students were able to (a) understand cultural differences; (b) recognize a different health-care system; (c) reconsider the role of the nurse; (d) build working teams; (e) integrate theory into practice; and (f) experience peer mutual learning [Figure 1].
Figure 1: Learning beyond expectations: Results from a bidirectional nursing student exchange (Pereira et al., 2018. p. 80)

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Personal reflection exhibited that students acquired personal and professional competencies learned were “beyond their expectations” of the exchange.[10],[11] Students responded positively to nontraditional learning experiences and dynamic activities that evolved and describe themselves as being better global citizens.[11] While students described an overarching self-awareness, positive impact of the exchange in their lives, an increased self-responsibility in learning, and obligation to their communities [Figure 1].

  Framework Development Top

A guide for faculty and community agencies, the International Student Exchange Partnership (IN-STEP) Frameworkwas developed to make distinctions and recommendations between the steps needed to organize ideas related to the nursing student exchange. The framework consists of five steps: explore, design, engage, evaluate, and disseminate. The aim of the IN-STEP frameworkis to provide an organized approach to generate a sequence of desired outcomes. It is seen as an iterative process that is ongoing, can be built upon, and sustained.

The IN-STEP Framework has been implemented in the expansion of this project to Terceira and with a group of post-graduate nursing students with positive feedback. The framework was originally intended for undergraduate nursing students enrolled in a short-term bidirectional project in community health but may be applied to diverse disciplines: education, sociology, medical, public health, physical therapy, pharmacy, mental health, dental, occupational health, and anthropology; with associated organizational and community partners. In addition, faculties from both universities, not engaged in this project, have developed teams to engage in international research related to their own interests and expertise.

  Future Directions Top

Currently, the seventh and eighth “Bridging the Atlantic” nursing student exchanges are in the planning stages. The work of the previous eight exchanges is part of a growing body of research and health promotion activities with a focus on the impact of vulnerability in like communities in different countries.

After 4 years of exchanges and evaluation to measure project impact, benefit, feasibility, and sustainability, the next step is to publish the IN-STEP framework. This will provide other organizations, students, and community groups to have an applicable tool to implement an exchange experience. Finally, submission of a proposal for grant funding to sustain and further expand this project is planned.

  Conclusions Top

With any project, there are successes and challenges. The “Bridging the Atlantic” project has received tremendous support, multi-level funding (private, foundation and government) with student, faculty, and community engagement, allowing for a sustainable project. Challenges faced are related to different time zones, class schedules, meeting course outcomes with short exchange periods, and the necessity for documents and project materials to be translated in Portuguese and English.

Access to vulnerable groups can be challenging at times. Building trust and relationships within the communities has allowed entrée for the identification of health needs and subsequent interventions. Vulnerable people are seemingly less likely to seek healthcare or participate in research activities during uncertain political periods of time.

Organizations interested in similar projects can learn from this experience by focusing on creating and building:

Shared vision of faculty involved with strong support of their universities

The project has a coordinator from each university with a robust, shared vision to provide innovative experiences to community nursing students. The universities' commitment to provide varied support throughout the exchange (i.e., university housing and meals) allows the students to experience a dissimilar academic lifestyle.

Student involvement

Engaging students in creative activities allow for skill development (academic, professional, linguistic, cultural, and personal). The impetus to become change agents began with students understanding of vulnerability in their own community, and related country and measures to address them, improve their health status, and raise awareness of these groups to empower their communities to act. This unconventional academic experience with social relevance, coupled with being in a different country, provides high satisfaction levels among students, who are best ambassadors to recruit participants in subsequent years.

Multi inter-institutional researchbeyond the student exchange project allows faculty to provide examples for students to realize that projects established over time result from long-term partnerships and ongoing communication.

Perceived health/social/professional relevance through the development of cultural competence in health with international peers/faculty and vulnerable groups (deported people, elderly immigrants, fishermen, and unemployed individuals) has attracted recognition of local and international institutions willing to collaborate.

Finally, ties between local and international community agencies improved, as they now work more closely together to lessen vulnerability on both sides of the Atlantic Ocean. By strengthening personal, agency and institutional relationships and refining project coordination, an empowerment to expand and sustain this project, its research program and improve the health of communities in both countries has occurred. Student engagement with vulnerable groups in the community provides a catalyst to promote heightened awareness to the plight of these aggregates.

Financial support and sponsorship

“Bridging the Atlantic” is supported by The DeMello Charitable Foundation and The Regional Government of the Azores.

Conflicts of interest

There are no conflicts of interest.

  References Top

Bentley R, Ellison KJ. Increasing cultural competence in nursing through international service-learning experiences. Nurse Educ 2007;32:207-211.  Back to cited text no. 1
Koskinen L, Jokinen P. Multicultural healthcare: A transatlantic project. Nurse Educ 2007;32:89-93.  Back to cited text no. 2
Visovsky C, McGhee S, Jordan E, Dominic S, Morrison-Beedy D. Planning and executing a global health experience for undergraduate nursing students: A comprehensive guide to creating global citizens. Nurse Educ Today 2016;40:29-32.  Back to cited text no. 3
Bringle RG, Hatcher JA, Jones SJ. International service learning: Conceptual frameworks and research. 1st ed. Sterling, Virginia: Stylus Publishing, LLC; 2011.  Back to cited text no. 4
Brown CL. Linking public health nursing competencies and service-learning in a global setting. Public Health Nurs 2017;34:485-92.  Back to cited text no. 5
Wilson L, Harper DC, Tami-Maury I, Zarate R, Salas S, Farley J, et al. Global health competencies for nurses in the Americas. J Prof Nurs 2012;28:213-22.  Back to cited text no. 6
Williams JR. In pursuit of their dreams: A history of Azorean immigration to the United States. North Dartmouth, Massachusetts: University of Massachusetts, Tagus Press; 2007.  Back to cited text no. 7
United States Census Americans Community Survey Estimates. 2012-2016. Available from: [Last retrieved on 2018 Oct 12].  Back to cited text no. 8
History Office 65th Airbase Wing. Short History of Lages Field. Available from: [Last retrieved on 2018 Oct 13].  Back to cited text no. 9
Duarte A, Pereira H, Brisbois MD, Waite S. Development of skills of nursing students in an international collaborative experience. In: González PF, editor. Intervention and New Social Realities: International Meeting of Educational Innovation Organizers. Ponta Delgada, Azores: University of the Azores; 2018. p. 15-22.  Back to cited text no. 10
Pereira HR, Brisbois MD, Silva HO, Stover CM. Learning beyond expectations: Evaluation of an international nursing student exchange. J Nurs Educ Pract 2018;8:72-82.  Back to cited text no. 11
Brisbois MD, Silva HO, Pereira HR, Sethares KA. Self-perceived health and quality of life among Azorean deportees: A cross sectional descriptive study. Springerplus 2016;5:1576.  Back to cited text no. 12


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  [Table 1]


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