Around the Corner, Across the Globe: Developing Global Citizens through Civic Engagement

Nursing educators wrestle with preparing the future nursing workforce to meet the needs of underserved, vulnerable populations in marginalized communities who suffer significant health disparities and social injustices. This article illustrates the integration of engaged civic learning (ECL) within a social justice framework that prepares baccalaureate nurses as global citizens to provide culturally congruent health care around the corner in local communities and learning abroad programs across the globe. Multiple partnerships with local organizations were strengthened, with ECL integrated across the nursing curriculum and aligned with local needs of community housing, schools, churches, shelters, and fitness centers. The nursing faculty at Rutgers School of Nursing-Camden collaborated with language professors to develop a Spanish for Health Professions program to increase communication between students and the high percentage of Spanish-speaking populations served locally and globally. A mixed-methods design evaluated program outcomes using descriptive data, student reflections, and the Global Perspective Inventory (GPI) to assess students’ experiences and global learning related to learning abroad during their college experience. Results from presurveys to post-survey results showed significant improvement (p < .05) in global learning in 16 of 35 question items. As students journey from entrance into nursing school until graduation, ECL develops them into engaged global citizens.

Four million nurses in the United States, as well as 20 million nurses across the globe, provide high-quality, transformative health care to increasingly diverse populations. Nurses are the lifeline to care delivery and their contributions are critical to elevating a future workforce that is civically minded and socially responsive, including advancing health across the globe with a societal commitment to care for all people everywhere. As nursing and other health educators prepare the future workforce to fill the health equity gap among diverse, often vulnerable communities, a specific skill set beyond technical nursing competencies must include interpersonal communication, critical thinking, and cultural humility (Nokes et al., 2005;Sabo et al., 2015).
This article illustrates how integration of engaged civic learning (ECL) within a social justice framework develops nurses as global citizens to provide culturally congruent health care services within diverse settings, including around the corner in local communities and learning abroad programs across the globe.

Cultural Humility
Cultural congruence is a highly valued aspect of nursing and health care delivery; it is central to the concept of caring and person-centered care. A related concept, cultural humility, is seen as an important pathway toward cultural congruence. Foronda et al. described it in the following way: In a multicultural world where power imbalances exist, cultural humility is a process of openness, self-awareness, being egoless, and incorporating selfreflection and critique after willingly interacting with diverse individuals. The results of achieving cultural humility are mutual empowerment, respect, partnerships, optimal care, and lifelong learning. (Foronda et al., 2017, pg. 215) Cultural humility is "other-oriented," and involves the balance of listening and observing with curiosity and respectful inquiry. Another important aspect of cultural humility is a lifelong commitment to self-evaluation, and nursing students can be introduced to this practice through reflection and critical thinking (Sedgwick & Atthill, 2019;Schuessler et al., 2012). The concept of power imbalances applies to the nursing profession as we rethink our perceptions of provider and patient relationships. Individuals are experts on their symptoms, their strengths, and their lived experience. Reframing the provider-patient relationship without power imbalances empowers individuals to embrace their own health decisions. Nurses often describe themselves as patient advocates, but in terms of cultural humility, nurses should advocate for "systemic humility," which is often lacking in health care delivery, especially among those most vulnerable whose human rights are often overlooked and ignored (Foronda et al., 2017).

Social Justice as a Foundation for Nursing Practice
Social justice is defined in several ways (Boutain, 2005), but based on concepts of human rights and equality can be defined as "how human rights are manifested in the everyday lives of people at every level of society" (Edmund Rice Centre, 2000, pg.1). Social justice is inextricably linked to nursing and health through interrelated concepts of equity, access, participation and human rights (Westwood, 2019). According to Faden and Bowers (2011), the most important population health goals for social justice are the improvement of health and wellbeing and the mitigation of social determinants that negatively impact health and wellbeing. The United State's Healthy People 2020 (HP2020) overall goal to increase health equity and eliminate health disparities is based upon principles of social justice (Braveman et al., 2020).
Concepts of social justice are heavily nuanced and systemically interconnected with social determinants of health and health disparities. Vulnerable populations are groups who have more health disparities, including a higher burden of disease, injury, disability, or mortality, when compared to other population groups. Populations with these disparities cannot be explored outside the context of their lived environment, and often require supportive social networks as they are more likely to live in communities lacking supportive social environments: welldesigned built environments with safe and walkable access to stores and transportation, playgrounds, and schools (National Academies of Sciences, Engineering & Medicine, 2017). Instead, their communities often have crumbling infrastructures that reduce access to safe outdoor environments, efficient transportation, and quality educational systems. Likewise, these communities have limited access to high quality health care, which not only challenges wellbeing, but impacts longevity (Arias et al., 2018). Herein is the essence of a health equity gap.
Health equity allows individuals and communities to have the opportunities needed for optimal health and longevity. Although systemic oppression lies at the root of these inequities (Westwood, 2019), community leaders and residents who embrace the values of fairness and inclusion can use an equity framework to advance opportunities for neighbors living in marginalized communities (Faden & Powers, 2011). To eliminate barriers to health access and equity, there must be policies and programs to address the fundamental conditions necessary for achieving good health, especially among populations that have experienced cumulative disadvantage or stigma (National Academies of Sciences, Engineering, & Medicine, 2017).

Civic Learning Matters: Next Generation of Socially Responsible Learners
A major challenge for nursing and other educational programs is how to increase student awareness of vulnerable populations and how the health equity gap profoundly impacts the health and wellbeing of entire populations. Often there is a disconnect between curricula and practice: nursing students are often more focused on acute care practice in hospitals, and while essential, they overlook these health-harming social determinants, especially once hospitalized individuals are discharged and return to living in their community (Baker & Baker, 2017;Sabo et al., 2015). Many of these overlooked factors contribute to expensive readmissions, medical errors, and other complications, that if better understood, could be foreseen and mitigated early on (Makary & Daniel, 2016).
One approach to bridging this health equity gap and the social-determinant divide is the integration of civic and socially responsible learning. In the case of nursing education, highimpact pedagogical practices target social, economic, and political dimensions of health that are nested in communities with vulnerable populations (Sabo et al., 2015). This approach creates a dynamic partnership between educational institutions and communities that creates a mutually beneficial relationship. Moreover, universities, as anchor institutions, support efforts to meet the challenges facing their local community, city, county, and region with service-learning that fosters civic engagement through integrated efforts and partnerships. In turn, civic engagement builds and releases social capital, which is necessary to strengthen community among nurses and builds networks of reciprocal social relationships (Persut, 2002). Thus, an anchor institution within an urban city becoming civically engaged and socially responsible is a means to overcome systemic oppression among specific groups and populations (Sabo et al., 2015).
ECL is a teaching strategy that enhances courses across a wide range of disciplines. Innovative partnerships with community organizations help deepen students' understanding of course content through active engagement with communities beyond the campus. Students engage in service, advocacy, and other forms of participation that connect course material to the efforts of real people to make a positive change (Yorio & Fe, 2012). Civically engaged learning activities are experiential and address human and community needs via structured opportunities for learning; they involve thoughtful reflection and are respectful of the concept of reciprocity between the civic engagement experience and the individuals served (Markus et al., 1993;Nokes et al., 2005).
Although ECL is integrated throughout curricula in many nursing programs, educators struggle to train the nursing workforce to leverage communities for long-term impact (Small, 2019). In this program, it was essential to partner with the university's Office of Civic Engagement, which already had multiple established connections to the local urban community and beyond. Due to the coexisting relationships developed over the past 40 years, program implementation worked through them to connect with interested community partners (Hill & Powell, 2012). Through their guided Civic Engagement Faculty Fellows Program nursing and other faculty members developed or enhanced their courses using best practices for implementing ECL into curricula.
As a result, students at their entrance into the nursing school through graduation embark upon a journey toward becoming engaged global citizens who can address needs of increasingly diverse populations within their practice. Examples of their civic engagement include local preschools and schools, organizations to help those with housing and food insecurity, community health centers located in low income housing programs, school-based health centers, veteran centers, and a state-of-the-art recreational facility for economically disadvantaged community members.
ECL courses contribute to Camden and the region while preparing Rutgers University-Camden students for lives of active citizenship and informed leadership. Research reveals that ECL is superior to traditional classroom learning, especially lecture format (Ciacco & Walker, 1998;Markus et al., 1993). ECL has been linked with increased GPA (Newell & Saxena, 2018) and "joy in learning" while students gain a larger sense of who they are and the value of their contributions (Finley, 2016). The outcomes of ECL are impactful in several dimensions for both the university as an anchor institution, directly, and as a provider of much-needed services to the community while student-learners gain personal insights and new knowledge about advocacy, activism, and civic duty.

Spanish for Health Professions Program
The Center on Aging Society (2002) reports more that 37 million adults in the U.S. speak a language other than English and some 18 million people, 48%, report that they speak English less than "very well." One challenge encountered with ECL courses is the difficulty communicating effectively with a large percentage of community members in a city where nearly 50% of residents are Spanish heritage speakers, many with limited English proficiency (DataUSA, 2017). Communication barriers are factors that impact the amount and quality of health care individuals received. For example, Spanish-speaking Latinx persons are less likely than White persons to visit a physician or mental health provider or receive preventive care, such as a mammography exam or influenza vaccination (Fiscella et al. 2002).
Overall, health-related errors are the third leading cause of death in the United States and account for more than 250,000 deaths per year (Makary & Daniel, 2016). Communication errors related to language and cultural differences are a major cause of these mistakes (Schyve, 2007). Conversely, Spanish language proficiency among health care providers is associated with improved cultural competencies (Rubenfeld et al., 2006), and increased patient satisfaction (Sherrill et al., 2016). Nurses must overcome language barriers to reduce medical errors.
The challenge of language and cultural differences prompted our strategic partnership with the department of World Languages and Cultures that had developed a course entitled Spanish for Health Professions. In 2016, we applied for and received a grant from the Department of Education to expand international studies and Spanish for Health Professions courses, and we collaborated with Ana Laguna who started the Spanish for Health Professions courses, and with her colleague, Dana Pilla, further expanded the courses into a fully expanded Spanish for Health Professions program. In 2018, a new certificate program was offered, which embeds ECL with the courses. The expanded program, offered in-person or online, enables both novice and heritage Spanish-speakers to increase proficiency through four course levels and offers ECL internships and learning abroad courses to Spanish-speaking countries, expanding the footprint of students who wish to make a positive impact, possibly lifelong, on vulnerable populations. Often, students whose heritage language is not English feel disadvantaged compared to other students, but becoming a Spanish medical interpreter turns a perceived liability to an advantage. At the same time, communicating in the preferred language of those served improves health equity and quality for the community, and demonstrates cultural humility as a core value of human caring and compassion.

Learning Abroad as a Path Toward Becoming Global Citizens
Learning abroad programs were developed to further enhance nursing students' growth, cultural competence, and capacity as global citizens (Kelleher, 2013;Lin, 2001). The concept of global citizenship is often attributed to learning abroad programs without a clear delineation of its concepts or educational outcomes. Hans Schattle described six concepts listed here and described below as foundational to global citizenry: awareness, responsibility, participation, cross-cultural empathy, international mobility, and personal achievement (Lewin, 2009). A key component of developing global citizens is what Lewin (2009, Pg 14) describes as the willingness to build relationships and, "nurture a sense of belonging in an unfamiliar setting." A common challenge with learning abroad programs is a mismatch between student learner and organizational partner needs. For practical reasons, schedules are set with rigid timetables and limited free time, only to be met with student and faculty frustration as the realistic schedule and activities unfold. Too often student learner objectives and departure planning lack cultural congruency with international partners. Ouma and Dimaris' work (2013) emphasizes principles of cultural humility such as increased flexibility built into the plan and the removal of power differentials with the international organization so a mutual partnership evolves. Faculty should provide students with anticipatory guidance about expectations and the importance of flexibility as a part of global learning.
Learning abroad courses within Rutgers School of Nursing-Camden are designed to help develop global citizens and to foster students' own belongingness while abroad. Key building blocks of these programs are ECL activities and language immersion within the Spanish-speaking countries of Guatemala, Cuba, and the Commonwealth of Puerto Rico. Pre-departure activities described as best practices for learning abroad included lessons on the country's social and political history, the health care system and their health disparities, basic Spanish language instruction, and cultural differences (Visovsky et al., 2016). Thoughtful debriefing sessions, along with guided reflection during the experience, were the most important teaching strategies to help students think critically and evaluate concepts related to their sense of belongingness and global citizenry (Lewin, 2009;Schuessler et al., 2012).
While abroad, specific experiences were selected to strengthen connections within the group and acclimate them to the country. Students visited local markets, learned Latin dances, and participated in cultural festivals and religious ceremonies. Depending on the country visited, students' ECL projects included stove building among indigenous highlanders, and health screening and education programming in schools, elder centers and women's circles, with Spanish language immersion throughout. After guided reflection journaling and group debriefings which helped students think critically, these experiences were then deconstructed and reframed within a social justice framework emphasizing health equity and cultural humility. A few individual quotations from students were included below based on interviews and reflections from their Photo Reflection Journals. Box 1 and 2 contrain descriptions of the existing courses.

Box 1
An example of International Engaged Civic Learning in Guatemala: The course entitled Health and Healing in Guatemala: A Service Learning Journey involves three pre-departure meetings in preparation for the in-country experience. The preparation focuses on preparing the student to engage with the highland community in a culturally congruent manner. Group work focuses on preparing health and educational outreach activities. Students are partnered with a non-governmental organization (NGO) whose goal is to produce "hope and not dependency." Their mission is to "innovate transformational models of development that break cycles of dependency" through engagement with indigenous communities that fosters their interdependence to live well within their own culture and community (Highland Support Project, n.d. This learning-abroad course introduces students with an overview of population health through the lens of community development within the Republic of Cuba. The emphasis of this course is to introduce key concepts of the Cuban health care system and sustainable community development: 1. Why they are important and how connections among social, cultural, educational and environmental systems are core to successful community development and health. 2. The second goal of this course is to provide a set of tools for students to utilize while interacting with the Cuban people in the community, health and educational settings.
This course also emphasizes Spanish language immersion activities within the community, thus combining engaged civic learning while increasing Spanish language proficiency. Upon return, students will analyze how lessons from the Cuban experience can be applied to U.S. communities with vulnerable populations experiencing poverty, health disparities, and poor health outcomes.
"The forced disconnection from social media and texting allowed me to enjoy those around me and to be more perspective,...This experience has changed me." (Student Reflection)

Program Outcomes and Impact
The Spanish for the Health Professions Program evaluation used a mixed-methods approach to identify outcomes. First, enrollment data was compiled to demonstrate the increase in enrollment and successful completion of the Spanish for Health Professions courses. Grant funding was the catalyst for partnerships between the School of Nursing, the Offices of Learning Abroad and Civic Engagement, and the department of World Languages and Cultures. Within three years, there was a five-fold increase in enrollment, and course offerings increased from two to eight. Although rapid course growth alone does not guarantee successful learning, it reflects students' interest in increasing their Spanish proficiency as future health professionals. At the conclusion of the first interpreting course in Spring 2019, 22 students passed the national exam and were certified for providing medical interpretation within hospitals and other health organizations. This certification also provides a path for nurses and other health professionals who are Spanish heritage speakers to quickly increase the Spanish interpreter workforce, which will decrease health care costs, reduce communication errors, and help bridge the equity gap.
The newer ECL and independent study courses in the certificate program include several outreach activities within the local underserved community. Students at a large non-profit health and fitness centers provided nutritional information to guide clients' food selections at the organization's food pantry. Recently, this partner organization awarded the 2019 class Volunteer of the Year, which attests to the positive outcomes of the course. One certificate student describes below how this program is essential to increasing health equity among the underserved Latino/Hispanic populations: The number of Spanish speakers in America will continue to grow, and I'm pleased to be a part of the university's award-winning effort to ensure they can receive health care from someone who can communicate with them in their native language," she says,…, "It felt good to be doing work in my hometown, helping Spanish speakers get the most out of the healthcare system. (Rutgers-Camden NewsNow, 2019, pg.1)

Learning Abroad Programs
In general, learning abroad courses are regarded as valuable, but they often lack prospectivedesign program evaluation and improvement strategies. Some faculty may question the value of more costly international programs versus less expensive local service-learning programs. In order to measure learning abroad student outcomes, we evaluated students both before and after the learning abroad experience (prospective/retrospective). Students were surveyed (N = 40) in the learning abroad courses to Cuba and Guatemala during the spring 2018 semester. More than 50% of the students enrolled in these programs were nursing majors in baccalaureate, accelerated BS, and RN to BS programs; other majors included business, Spanish, and health science majors. Over 50% of the students enrolled identified as Hispanic/Latinx, Black/African American, Asian, or mixed race. The pre-evaluations were performed at the beginning of the semester in mid-January. The post-trip evaluations were performed approximately one month after the studyabroad trip was completed.
The instrument selected to evaluate students was the Global Perspective Inventory (GPI) (Research Institute for Studies in Education, 2017). GPI is a validated tool to assess students' experiences and global learning related to learning abroad during their college experience (Braskamp et al., 2014). Test-retest reliabilities ranged between .57 and .73, and internal consistency had coefficient alpha reliabilities between .657 and .773. Intercorrelations between three subscales were sufficiently independent (145, .324, .241). The 35-item questions can be further classified into three dimensions: cognitive, intrapersonal, and interpersonal (Iowa State University, n.d.). For this report, only preliminary data is reported for the 2018 cohort using individual items rather than the three dimensions. Permission was obtained from Iowa State University to administer the GPI for two years (2018 to 2020). Paper and pencil surveys were administered the first week of class, followed by a post-test one month after students returned from their learning abroad experiences. As a post-versus-pre instrument, data were analyzed using IBM SPSS Statistics 24 using within-subjects (post -pre) t-tests for each of the 35 individual item scores, as visible in Table 2. Within-subjects t-tests subtract post minus pre responses and estimate whether the result is significantly greater than zero. Some items are worded so favorable items are the highest value, while other items are worded so favorable items are the lowest value. Of the 35 questions, 16 of them showed significant improvement (p < .05) in the post-versus-pre assessment. Given the small sample of 40, it is likely that a larger sample would have more items showing significance. Some of the responses to note were concepts of "giving back," "making a difference," interacting with people from different cultures, having "purpose" in life, and considering different cultural perspectives. These responses demonstrate movement toward cultural humility, advocacy, and an interest in interacting with other cultures and racial/ethnic populations.
Future evaluation will focus upon reinforcing the areas of significant improvement and addressing those areas in need of greater cultural sensitivity. Furthermore, these data will be combined with 2019 data, which will enable further review according to the three cognitive, intrapersonal, and interpersonal dimensions.

Conclusion
Robert Caret's (2019, Pg. 10) vision for higher education parallels our own goal, "to graduate educated, enlightened citizens who are ready to go to work in all facets of life to make their lives, their communities, and our nation [world] better." Undergraduate nursing students are ignited by personal insight, skill development, and opportunities gained through local and global ECL, that propels them toward becoming engaged citizens who advocate for social justice, become change agents, and demonstrate cultural humility (Nickitas et al., 2016). Each student, in their way, becomes a socially responsive learner as they journey toward global citizenship. From the time students enter the university until graduation, faculty have numerous opportunities to create pathways for ECL that are influential and impactful, including grounding civic learning within a social justice framework, and equipping the nursing workforce to care for culturally diverse populations. Thus, being civically engaged creates a possible place where a student's "deep gladness and the world's deep hunger coincide" (Buechner, 1973, pg. 95).

Implications for Practice and Future Research
Further research is needed to identify specific pedagogical interventions to optimize student development, especially during the current COVID-19 era of less physical human connection within communities. Existing challenges are now layered with limitations of a pandemic, where vulnerable communities need more connection, not less, from academic institutions and health professionals. Students, in turn, need safe options to create a place for their "deep gladness" that is unexpected, but no less effective. Now more than ever, a social justice framework for developing global citizens is paramount in order to accomplish HP2020 goals for health equity and the elimination of health disparities (Braveman et al., 2020). Preparation of future nurses within this paradigm is essential, but nonetheless insufficient without increasing language proficiency nurses and other providers that is congruent with the community. Pedagogical goals in nursing and other health programs should consider including both cultural and language competencies with a commitment to rigorous measurement of health outcomes in order to bridge the equity gap and accomplish the HP2020 goals.