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Practical Advice Paper

Bridging the Atlantic: Optimizing the Health

of Vulnerable Community Aggregates through
International Student Exchange
Maryellen D. Brisbois1, Helder Rocha Pereira2
Community Department, University of Massachusetts, College of Nursing and Health Sciences, N. Dartmouth, MA, USA, 2Department of Nursing,
1

University of the Azores School of Health, Ponta Delgada, Portugal

ABSTRACT
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

Background engagement can change the nature of faculty work, enhance

A growing diversity of cultures within global societies has
intensified the need to educate health professionals to
deliver safe, effective, and culturally appropriate care.[1‑3]
Institutions of higher education have examined how civic
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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.

DOI: This is an open access journal, and articles are distributed under the terms of
10.4103/efh.EfH_268_19 the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License,
which allows others to remix, tweak, and build upon the work non‑commercially,
as long as appropriate credit is given and the new creations are licensed under
the identical terms.

Address for correspondence:

For reprints contact: reprints@medknow.com
Dr. Maryellen D. Brisbois, University of Massachusetts, College of
Nursing and Health Sciences, 285 Old Westport Road, N. Dartmouth,
How to cite this article: Brisbois MD, Pereira HR. Bridging the Atlantic:
MA 02747, USA. Optimizing the health of vulnerable community aggregates through
E‑mail: mbrisbois@umassd.edu international student exchange. Educ Health 2019;32:136-40.

136 © 2020 Education for Health | Published by Wolters Kluwer - Medknow

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Brisbois and Pereira: Bridging the Atlantic international exchange
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
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.
Education for Health • Volume 32 • Issue 3 (September-December 2019) 137
Context
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
“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.
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Brisbois and Pereira: Bridging the Atlantic international exchange

Students and faculties have conducted research, and an the fishing community in New Bedford were undertaken with
intervention with men and women deported from the US to positive feedback [Table 1].
Portugal to understand their physical and mental health and
quality of life;[12] data from a study with men and women with Outcomes
forced early retirement from Lajes Air Force base to understand
the impact of the downsizing and related social determinants The impact of “Bridging the Atlantic” has been
of health are being analyzed, and a cross‑sectional study to multidimensional, in which it involves international student
explore the psychosocial work environment, health, and teamwork and learning, faculty collaboration in research
well‑being of fishermen/women in the port of New Bedford, and pedagogy, mutual university support, cooperation
Massachusetts, is underway. Health promotion fairs with among community agencies, and impact health among
Portuguese elders with an increase cancer diagnoses and with aggregate vulnerable groups. In addition to the strong ties

Table 1: Overview of annual projects

Project Main activities
2015 “Assessing the quality of life and well‑being among people Meetings with key informants in The Azores (Portugal) and the US to provide a deep insight about
deported from the US to the Azores” (Sao Miguel Island) the context of deportation among the two countries
Data collection (WHO Promis Tool) to measure physical and mental health, and quality of life
(Azores) with the support of local agencies
Informal interviews with families of deportees “left behind” at the Immigrants Assistance Center
(New Bedford/US)
Findings presentation to local agencies that provide support to deportees in the Azores
dissemination:
(i) Global Health and Innovation Conference 2016 (Yale University, US) - Posters presentation
(ii) Beyond Flexner Alliance Conference 2016 (Miami, Florida, US) Global social mission in action:
Creating dynamic student programs with domestic and global partnerships (workshop)
2016 “Bridging the Nature” intervention with men/women deported from Meetings with key informants in the Azores (Portugal) and the US to provide a deep insight about the
the US to the Azores (Sao Miguel Island) context of deportation among the two countries
Prioritization of health needs from women/men related to data collected in 2015
Health Promotion project aiming to reduce feelings of loneliness among deported people
(in collaboration with local agencies)
Dissemination:
(i) International Council of Nursing Congress 2017 (Barcelona) ‑ Poster presentations.
(ii) Podium presentation at the “Encontro internacional de inovação educacional ‑ Intervenção e
novas realidades sociais” (International Meeting of Educational Innovation - Intervention and New
Social Contexts), Ponta Delgada, Portugal, 2017
2017 “Bridging Luso‑American Health” with Portuguese Elders in the Meetings with key informants in The Azores (Portugal) and the US to provide a deep insight about
US the context of elderly immigrants living in the US
Preparation of educational posters, games, and activities to deliver health education
Health Promotion Fair organization regarding increased cancer rates among this group
Health Educational Group Session among Elderly Portuguese Immigrants living in the US
Dissemination:
(i) 2018 Network: TUFH Conference “Community Empowerment for Health: A multi‑sector
approach” ‑ Poster presentations
2017 “Lajes Air Force Base: The impact of the closure on a population” Meetings with key informants and interviews with retirees using focus group methodologies
with employees facing forced retirement (Terceira Island) Analysis of meeting and focus group data to establish research priorities
Planned research study to understand the phenomenon of the retirees.
Dissemination:
(i) University of the Azores and University of Massachusetts Dartmouth Symposium
2018 “A Bridge to Wellness: Port of New Bedford, MA” with fishermen Data collection regarding health, social determinants of health, and working conditions using the
and women in the US COPSOQ tool
Health Fair in fishing community to address identified gaps in knowledge related to hypertension,
diabetes, nutrition, and skin cancer as part of a multi‑year project
Informal interviews with elderly immigrants regarding their experience of immigration
Dissemination:
(i) University of the Azores and University of Massachusetts Dartmouth Symposiums
2018 “Perception, transition, adaptation, and quality of life from the Data collection regarding the phenomenon of forced early retirement due to downsizing of Lajes
Lajes base downsizing: A situation diagnosis” (Terceira Island) base
Data analysis and early findings presented at symposium
Meetings with key informants and visit to City Hall of Praia da Vitória for press conference
Dissemination:
(i) University of the Azores and University of Massachusetts Dartmouth Symposium
In addition to the vulnerable aggregate projects; each exchange includes the following activities in both countries: (i) Visits to hospital and health‑care centers, (ii) Participation in nursing
classes, (iii) Cultural experiences, (iv) Organization of a symposium to share the work and experience of the exchange with local stakeholders. TUFH=The Network: Toward Unity for Health,
COPSOQ=Copenhagen Psychosocial Questionnaire

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Brisbois and Pereira: Bridging the Atlantic international exchange

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
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].
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
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
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.

A guide for faculty and community agencies, the International
Student Exchange Partnership (IN‑STEP) Framework was
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 framework is to provide an organized
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.

Figure 1: Learning beyond expectations: Results from a bidirectional nursing student exchange (Pereira et al., 2018. p. 80)

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Brisbois and Pereira: Bridging the Atlantic international exchange
Conclusions
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 research beyond 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.
140 Education for Health • Volume 32 • Issue 3 (September-December 2019)
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.
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