Academic service-learning nursing partnerships in the Americas: a scoping review

All articles described a formal partnership with presence of an MOU, grant, contract or agreement. One third of those partnerships had an explicit service-learning mission, whereas two thirds demonstrated implicit service-learning components. Multiple disciplines/stakeholders, including nursing students and faculty, comprised the study populations, with most of the studies taking place in community-based organizations, public schools, free standing clinics, universities, VA medical centers, community hospital outpatient departments, and public health departments. The vast majority of articles provided descriptive/qualitative/mixed methods evidence or experiential and non-research evidence. Academic nursing partnerships with community, federal, and non-profit organizations in North America have attempted to bridge gaps in PHC and population health services by building on the service-learning component. Among the sampled literature, only one article reported an ASLNP in affiliation with a WHOCC in Community Safety Promotion to prevent opioid abuse through a public health practicum [40]. Counter-intuitively, six other articles from US institutions with designated WHOCCs for Nursing and Midwifery did not appear to stem from a WHOCC-related activity. Those ASLNP initiatives focused on: teaching team-based care through a nurse-led clinic [56], preparing students for IP collaboration with local partners [60], establishing a long-term care community program for high-risk elderly [69], advancing patient safety competence along with student leadership [58], and improving quality of care for veterans [50, 51]. Such partnerships have been shown to be further enhanced by the use of an IP collaborative practice model for chronic disease management coordination [79]. Hence, all evidence points to the link between successful leveraging of resources among partners and advancing health with underserved populations.

Synthesis of conceptual frameworks and models, used by the sampled articles, showed the following focus areas: communities/populations and nursing, followed by pedagogy, targeted outreach, IP collaboration, and health determinants. The small number of articles focusing on IP collaboration and health determinants is not surprising given the academic disciplinary approach that has been prominent in the past. This trend seems to be changing over the last 2–3 years, with a more accelerated pace expected in the U.S. literature brought about by the COVID-19 pandemic and the widespread movement to address social justice and healthcare inequalities. Given the convergence of these urgent demands on healthcare systems and nursing’s frontline role across the Americas, new focus areas may potentially evolve in ASLNPs.

The scope of ASLNPs, illustrated in Fig. 3, was captured through five emerging themes: (1) sustaining educational standards and processes - improving academic outcomes (i.e. clinical placement, preceptorship, quality improvement); (2) strengthening capacity for collaborative practice and IPE in the community; (3) preparing nurses of the future (recruitment, mentorship, job transition, mobility, civic responsibility, either faculty or student); (4) enhancing community services and outcomes (extended hours, access to PHC services, wide scope of services, universal coverage); and (5) conceptualizing or implementing innovative academic nursing partnerships (agenda, policy, funding, frameworks/models). Not surprisingly, the timeline distribution of those themes in relation to seminal document publication year (Fig. 4) showed that theme #3 has been more prevalent since 2018, whereas themes #4 and #5 peaked in 2014, following publication of seminal policy documents. Hence, the earlier observation by DeGeest et al. [9] of a proliferation in U.S. articles, triggered by nursing policy paper publication, is confirmed.

Four enablers for strong ASLNPs were identified: (1) guiding principles, (2) quality processes, (3) meaningful outcomes, and (4) transformative experiences. All were consistent with those reported among seasoned community and academic partners engaged in authentic partnerships [20]. However, for ASLNPs with a specific focus on collaborative practice and IPE (theme #2), an array of inherent barriers to IPE were reported in relation to: curriculum, leadership, resources, stereotypes and attitudes, variety of students, teaching, and enthusiasm. In agreement with a 2014 systematic review across developing and developed countries [80], the presence of flexible, enthusiastic institutional champions and resources were key determinants of success in embedding meaningful IPE learning opportunities as part of a health professions core curriculum and overcoming administrative barriers. Faculty and workforce development were also an essential component for successful ASLNPs that promote IPE and IP practice [30, 32, 45, 46, 50, 51, 54‐56, 60, 73]. In addition to investment in educational technology, partnerships enabling faculty practice to build expertise and spark the cultural change were essential for overcoming the pervasive stereotypes, skepticism, and long-held attitudes about other professions. Most of these ASLNPs were developed individually, rather than systematically, through established public health or governmental programs. Similarly, many were started from grants and/or philanthropic and in-kind donations based on individual relationships which contributes to sustainability challenges. The need for further research to identify best-practice models for integrating IPE as core curriculum, communicating consistent expectations for ASLNP outcomes, and seeking perspectives of patients and community partners regarding their experiences in partnership with learners has been underscored [15]. Being aware of these challenges and barriers in advance, academic nursing institutions in LAC countries will be more prepared and can enhance the partnerships’ potential success.

Despite recognized challenges and barriers in establishing and sustaining ASLNPs, evidence points to numerous benefits including fostering collaborative practice and IPE, improving professional satisfaction, and ultimately improving patient care and outcomes. However, the majority of evidence comes from North America, with only five articles from LAC countries. Additional analysis of the literature sample showed consistencies across service-learning structures, processes and outcomes. ASLNPs provide enhanced clinical experiences for nursing students, targeted population health for vulnerable or marginalized groups, student/faculty engagement in community awareness and well-being, and cultural/global health competency development. Twenty-one articles from the USA demonstrated integration of public health perspectives/needs with nursing program accreditation standards, and student leadership enhancement. Fourteen articles focused on health promotion and disease prevention, especially in the school setting. Eleven articles examined development of faculty practice, clinical skills, and preceptorship through innovative partnerships for clinical placement. Among those innovative partnerships, VANAP allowed for transformation of veterans’ health care through educational, research, and clinical practice outcomes achieved by students, practitioners, and faculty [50, 51]. Designed to address the nursing workforce shortage, the VA framework contextualizes the local needs and demands of all partners [7]. Recipients of VA services have access to an array of essential services comparable to universal health coverage. In comparison, articles from Brazil [29, 30], Haiti [31], Guatemala [33], Canada and Colombia [32] focused on the engagement of nursing faculty and students with culturally diverse, underserved populations and the acquisition of cultural competence skills gained while performing community diagnostics, home visits, and health education.

Beyond the value to partnering practice organizations, the benefits of ASLNPs for students included greater confidence in problem solving, and development of professional competence. Learners were able to build relationships with patients and community agencies, some of them longer term, and gain insight into unique needs as well as strengths of the community and its members. There was also evidence that students grew personally in their understanding of other cultures, some gaining cultural competencies in an international context, through collaboration with other professions and engagement in multi-disciplinary teamwork. These benefits are consistent with those previously reported [13]. Likewise, the benefits of ASLNPs for faculty included opportunities to engage in social justice and real-world scholarly activities that build grass-roots community-based capacity. Yet, there was no evidence of the effect of structural or systemic inequalities on ASLNPs, despite the emerged importance of cultural competence and safety in Preparing Nurses of the Future. These experiences expand academic nursing’s contributions beyond traditional acute care settings, broadening nursing’s social impact.

This scoping review was based primarily on North American literature and academic-service policy statements. Given the lack of geographically broad evidence, adoption of ASLNPs in LAC countries based on assumptions and tools derived mostly from the US experience may need modification. According to the two Brazilian studies [29, 30], the authors describe a “cooperative inter-organizational” relationship that integrates education and service in PHC. Clearly this model differs from the ones adopted by investigators of North American studies. Hence, successes and challenges encountered across USA academic nursing partnerships focusing on service-learning, might be culturally biased and therefore, one should proceed cautiously with a broad plan of action for LAC countries.

Developing a joint policy paper with representation from key stakeholders in the Americas, while adapting the AACN toolkit, could facilitate ASLNP proliferation throughout the region. According to the New Era Report [6], partner representatives from each side of academia and service should have “a seat at the table” to plan the advancement of ASLNPs that address joint needs and objectives. Considering the ability of each partner to leverage joint resources for advancing a shared agenda is critical. However, the cultural differences in nursing education across the Americas predicate that a sequence scoping review of multi-lingual studies be conducted, before these frameworks are generalized. It is indeed plausible that academic-service community-based partnerships in LAC countries are already integrated in nursing education programs; therefore, they are not viewed as novel or unique. According to Santos [81], the theoretical frameworks of the global South differ greatly from those of Western societies (the global North). Acknowledging the different ways of knowing, by which people across the global South live their lives and provide meaning to their existence, is an important step as we explore ASLNPs in the future. Building upon diverse sources of knowledge and experience in nursing is an important step towards achieving global social justice in health.

Following the release of the “State of the World’s Nursing − 2020” report [82], and the rapidly deployed changes as a result of the COVID-19 pandemic, optimizing and re-evaluating ASLNPs is highly recommended. The National Academy of Medicine’s [83] vision and path for the nursing profession to create a culture of health, reduce health disparities, and improve the health and well-being of the USA population in the 21st century could offer a starting point. Countries where nursing has a seat at the national health policy table should partner with institutions from less-privileged countries to build the evidence from different geographical, cultural and political contexts. The previously identified need for a stepwise model to accommodate countries of varying academic nursing capacity and resources within the same region should be considered [84]. Future reviews should include the grey literature on the topic (i.e. government reports, policy papers, academic documents, etc.), while research studies should address literature gaps through empirical inquiries. A more comprehensive understanding of expected outcomes for service-learners and recipients of services, as well as ASLNP challenges in countries with different educational and healthcare systems will facilitate next steps.

This review was based on an extensive search of five electronic databases spanning ten years. Special emphasis was given to resources from Latin America and the Caribbean by searching through the LILACS database, a comprehensive index of scientific and technical literature from this region. All articles were independently reviewed, and level of evidence was appraised with an adapted hierarchy scale [26, 27], classifying the vast majority as level VI or VII which indicates a low level of evidence. However, it is important to note the ongoing debate over the applicability of the hierarchy of evidence when evaluating qualitative nursing research [85].

Furthermore, we only searched for English-language peer-reviewed publications, which would have excluded any relevant grey literature from the targeted region published in Spanish or Portuguese languages. the grey literature on the topic (i.e. government reports, policy papers, academic documents, etc.) should be scanned as well in order to get a comprehensive picture. As the search yielded only five articles from the LAC region, we first reviewed the 46 articles from the North American region. Then, after identifying common challenges and barriers, we compared them to the five articles from LAC countries to develop recommendations for the PAHO region. The outcomes of interest, barriers and challenges, were mostly measured qualitatively which was consistent with the qualitative nature of our aim. Other potential limitations included selection bias and variation in criteria application, upon appraisal. Last, cross-country differences in the education and health system, such as regulation and accreditation of nursing programs, existence of a national health system, as well as cultural and linguistic variations are acknowledged.