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International Clinical Experience

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Lake Superior State University (LSSU), situated on the U.S./Canadian border in Sault Sainte Marie, MI, is taking an international approach concerning clinical experience. Just across the river from Sault Sainte Marie, Ontario, LSSU nursing students gain clinical experience in both countries.

As with most nursing programs, finding suitable clinical sites for student learning is a constant challenge. In our case, the challenge was made more difficult by the small size of the local hospital (about 30 inpatient beds) and location of other clinical sites on the U.S. side (50-90 miles from the school). If we were limited to the local sites in Michigan, the number of students we could educate would be much less. However, we have developed a creative approach that might have application for other programs in similar areas.

Clinical Placement

When the RN program was first planned in the early 1970s, the assessment was that without Canadian clinical sites, there would not be sufficient depth and variety of clinical experiences to meet the needs of nursing students at the RN level. We don't know who first contacted the Canadian hospitals, but we do know they were very positive about allowing our nursing students to have clinical experiences with them. Our history as an international community and the fact that many Canadian students enroll in our university is likely to have played a part in this relationship.

The next step in the process was to obtain permission from both the Michigan and Ontario boards of nursing. From the Michigan side, the primary concern was that the clinical sites met the educational needs of the students. The Canadian hospitals and other clinical sites were evaluated the same as if they were in the U.S. From the Canadian side, the primary concern was that the clinical placement of our students did not interfere with the clinical educational needs of Canadian students (a nursing program was being developed in Sault Ontario at the same time). The two programs collaborated on their schedules (as they have done since) and were able to satisfy these concerns, and international clinical placement began.

Unfortunately, our Canadian colleagues were shut out of U.S. clinicals after 9/11 due to increasing Homeland Security concerns, and we are working with them.

Benefits Beyond Borders

In many ways we think of Sault Sainte Marie as one city that happens to have an international border. The Michigan side of the city has a population of about 15,000 while the Ontario side has a population of about 74,000.

We believe this situation offers many advantages beyond the ability to place students in appropriate clinical sites. First, as the U.S. and Canadian healthcare systems are organized from very different perspectives, students have direct experience in both models. This allows for a more in-depth analysis of healthcare policies and issues than would be possible otherwise; student learning goes far beyond what they might read in a textbook. In addition, there are several Canadian members of the nursing faculty and about 10 percent of the nursing students, offering a wealth of direct experience for classroom discussions.

Second, we are able to evaluate nursing regulation in both jurisdictions. As with health system matters, many issues reflect similar concerns, but the approach and solutions are different. We also use Ontario nursing standards in many of our courses. Again, the similarities and differences enhance our ability to analyze the effectiveness of each system. For example, both Michigan and Ontario have standards for reporting suspected child abuse, but the laws (at what age, mandatory reporters, report process, etc.), local resources and community support systems are different.

Students have benefited greatly from these opportunities in planning for the future of healthcare. They are better able to advocate for healthcare policy improvements, analyzing the strengths and weaknesses about reimbursement issues, entry into practice, etc. Yet, the primary goals of patient care remain the same - providing the best quality patient care. We are able to draw comparisons and ask students to analyze the approach they think will provide the best care - or how they believe outcomes will differ depending on different choices.

Working with cross-border clinical agencies and with our counterparts in nursing education has enhanced the experiences for nursing faculty as well. We regularly pool resources for educational presentations and have explored the possibility of setting up an international local chapter of Sigma Theta Tau.

As with most nursing programs that share a clinical area with others, collaboration has served the needs of the students wherever they are enrolled. In addition, our relationship with the Canadian college has allowed us to have access to a very well-developed patient simulation lab that we do not have at our university. This is a tremendous value to our students.

We have also taken the opportunity to set up a unique BSN completion program. In Canada, there is a level of nursing designated as a registered practical nurse (RPN). This nurse is educated at what we would call an associate-degree level and has a scope of practice somewhere between a U.S. LPN and RN. We have worked with our Canadian counterpart to develop an articulation so the graduates of the RPN program can complete their BSN with us. This option is not available anywhere in the region on the Canadian side and serves to add professionally prepared nurses to our local community. Additionally, graduates of our program are able to take the Canadian boards as well as the NCLEX-RN.

Problems to Overcome

There are some challenges with setting up an international clinical program. The previously mentioned nursing board approvals are a necessary step. Clinical faculty members need licensure where they are teaching, so most faculty members maintain licenses in both Michigan and Ontario. Since the license is in a different country, most faculty members need to take the Canadian nursing board exams to obtain their Ontario license. Our students and faculty members need to cross an international border on a daily basis, and complexity with border-crossing has increased in recent years. Students and faculty also need to meet the legal and health requirements for both jurisdictions.

We believe other nursing programs should consider this option. To our knowledge, we are the only nursing program to take this approach. While not every nursing program is situated on a border, there are many that are. We have found that the benefits far outweigh the challenges.

Maureen O'Shea is assistant professor of nursing, and Steven Merrill is dean of nursing and health sciences, both at the School of Nursing, Lake Superior State University, Sault Sainte Marie, MI.

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