Western Norway University of Applied Sciences (HVL) and the University of North Carolina at Chapel Hill (USA)

Overview

In Fall 2023, Western Norway University of Applied Sciences (HVL) and the University of North Carolina at Chapel Hill (UNC-CH) initiated their first COIL collaboration between two nursing programs. HVL's course on Public Health in a National and Global Perspective, led by Professors Elisabeth Hemnes and Grethe Lofthus, partnered with UNC-CH's Reproductive Health and Nursing Care of the Childbearing Family, taught by Professors Catherine Crawford and Rhonda Lanning. This initial partnership saw over 300 undergraduate nursing students participate across both institutions, with a continued expansion into the Spring 2024 semester to include additional students and campuses.

Curricular Framework

The COIL collaboration between HVL and UNC-CH was designed to integrate nursing education with global and intercultural perspectives through a combination of asynchronous and synchronous learning activities. The curriculum emphasized both theoretical and practical applications, allowing students to explore healthcare systems in Norway and the U.S.

Key aspects of the curricular framework include:

• Interdisciplinary Approach: The courses were specifically tailored to address both public health and reproductive health issues, drawing from the expertise of faculty from HVL and UNC-CH to create a holistic learning experience.
• Digital Tools: The collaboration used digital learning platforms such as Canvas and Padlet to facilitate asynchronous discussions, allowing students to engage in reflective dialogue across time zones.
• Synchronous Sessions: Live Zoom sessions were held regularly, where students worked in breakout rooms to collaboratively address healthcare challenges. These real-time discussions helped bridge cultural and academic differences, fostering deeper engagement between students from different institutions.
• Collaborative Projects: Students were tasked with creating joint models of maternity and newborn healthcare, drawing on best practices from both healthcare systems. These group projects allowed students to apply course concepts while enhancing their intercultural communication skills.
• Continuous Improvement: Based on student feedback and faculty experiences from Fall 2023, the course framework was expanded in Spring 2024 to include additional students from HVL’s Haugesund campus, providing a more balanced and enriched collaborative experience.

This curricular framework promoted critical thinking, cross-cultural engagement, and the development of globally-minded nursing professionals.

Goals & Outcomes

The COIL initiative between HVL and UNC-CH was designed to broaden nursing students’ global perspectives and intercultural competencies, focusing on both academic content and professional skills. The key goals and expected outcomes of the collaboration include:

Learning Objectives

• Intercultural Communication: Students were expected to develop stronger intercultural communication skills by collaborating with peers from a different healthcare system and cultural background. This included not only verbal communication but also understanding and interpreting non-verbal cues within the context of patient care.
• Global Awareness in Healthcare: A primary objective was to explore and critically analyze the differences in healthcare systems, practices, and policies between Norway and the U.S. Topics included maternity and newborn healthcare, midwifery, nursing roles, and the impact of sociocultural factors on healthcare delivery.
• Cultural Responsiveness: Students were tasked with understanding and applying culturally responsive nursing care techniques in real-world scenarios, particularly in the areas of maternal and child health. 
• Collaborative Problem-Solving: Through group assignments, students were expected to work collaboratively to identify and solve healthcare-related challenges, integrating best practices from both healthcare systems.
• Critical Reflection: By the end of the course, students were to engage in reflective practices, including written reflections and class discussions, focusing on how their experiences in the COIL module contributed to their intercultural awareness and professional growth.

Outcomes

1. Intercultural Competency: Pre- and post-COIL ASKS2+ surveys revealed that students made significant gains in their intercultural competency, particularly in areas of empathy, verbal communication, and cultural awareness. Students rated their abilities higher on scales related to cultural self-awareness, openness, and curiosity.
   ○    ASKS2+ Data: Most students reported moderate to high growth in empathy, particularly in understanding the cultural nuances of patient care. 75% of students rated their post-COIL understanding of cultural perspectives as “high” or “very high.”
2. Collaborative Healthcare Model Development: Students successfully designed collaborative healthcare models that combined best practices from the Norwegian and U.S. systems. These models were presented during the final synchronous session, demonstrating a deepened understanding of healthcare differences and the role of cultural and environmental factors in shaping healthcare practices.
3. Application of Learning to Practice: Students reported that the collaborative nature of the project allowed them to apply theoretical concepts to real-world healthcare scenarios. A reflection assignment post-COIL revealed that students felt more confident navigating cross-cultural healthcare settings and were eager to incorporate these skills into their future nursing practice.
4. Professional Growth: The COIL initiative also had a positive impact on students' professional development. By working across borders, students were able to expand their global networks, understand diverse healthcare systems, and learn to navigate the complexities of cross-cultural collaboration. HVL and UNC students have indicated a strong interest in pursuing international exchanges or global healthcare work in their future careers.
5. Improved Awareness of Sustainability in Healthcare: A key outcome related to the environmental differences in healthcare practices was highlighted during the faculty visit to Bergen, Norway. Students and faculty from UNC-CH were able to observe firsthand how Norwegian hospitals prioritize environmental sustainability by using materials like stainless steel and cardboard instead of plastic, a practice that sparked meaningful discussions on integrating sustainability into healthcare.

Activities

The COIL collaboration between HVL and UNC-CH was structured to provide both synchronous and asynchronous learning opportunities, facilitating a meaningful exchange of ideas and practices in nursing education.

Asynchronous Activities

• Discussion Boards: Students from both HVL and UNC-CH engaged in asynchronous discussions via Canvas, reflecting on key topics such as maternity care, midwifery, and public health. These discussions provided a platform for students to explore how healthcare practices differ between Norway and the U.S., particularly in relation to cultural and geographical factors.
• Collaborative Reflection Papers: Students were tasked with writing reflection papers after engaging in virtual discussions and course content. These papers allowed them to express their understanding of cultural differences in healthcare and how these might affect patient outcomes.
• Padlet for Cross-Cultural Exchange: A Padlet board was used to share images, resources, and short video responses, fostering an ongoing dialogue between students from different cultural backgrounds. This tool facilitated student engagement beyond classroom hours, encouraging deeper reflection on global healthcare practices.

Synchronous Activities

• Weekly Zoom Sessions: Each week, students participated in synchronous sessions via Zoom. During these live sessions, students engaged in breakout rooms, where small groups of HVL and UNC-CH students collaborated on case studies and discussed topics such as culturally responsive nursing care, sustainable practices in healthcare, and midwifery.
• Guest Lectures and Faculty Presentations: Both institutions invited guest speakers to share insights on healthcare practices in Norway and the U.S. These sessions included comparative presentations on topics such as neonatal care, environmental sustainability in hospitals, and maternal health services.
• Intercultural Healthcare Projects: Students were placed into mixed teams and given a healthcare challenge related to maternity and newborn care. Each group was tasked with developing a model for care that integrated the best practices from both healthcare systems. These projects were presented during the final Zoom session, allowing students to showcase their collaborative work and cultural insights.
• Collaborative Case Study on Maternal Care: A major component of the course was the development of a shared case study on maternal healthcare. Teams of students from HVL and UNC-CH worked together to analyze the differences in healthcare delivery between the two countries, focusing on key issues such as patient care, healthcare sustainability, and the role of midwifery in childbirth.

Interactive Elements

• Icebreaker Sessions: Early in the course, students participated in icebreaker activities to foster connections across cultures. This helped build trust and camaraderie, which was essential for their later collaborative work. 
• Shared Canvas and Padlet Spaces: The course utilized shared online platforms such as Canvas and Padlet to facilitate group work and ongoing dialogue, enabling students to upload and share resources, reflections, and presentations with one another.

 These activities were designed to cultivate not only academic learning but also intercultural competence, ensuring that students gained a deeper understanding of how cultural contexts shape healthcare practices in different parts of the world.

Results & Impact

The COIL initiative between HVL and UNC-CH yielded significant results in terms of student engagement, learning outcomes, and intercultural understanding. Through a combination of synchronous and asynchronous activities, students were able to broaden their knowledge of global healthcare practices while enhancing their communication and collaboration skills in a cross-cultural setting.

Key Learning Outcomes 

• Intercultural Competence: Students demonstrated significant growth in their ability to understand and appreciate different cultural approaches to healthcare. The use of the ASKS2+ survey provided valuable insights into how students improved in areas of intercultural communication, empathy, and cultural self-awareness. Preliminary analysis showed a marked increase in students' ability to recognize and respect cultural differences in healthcare practices, particularly in the context of midwifery and maternity care.
• Collaborative Problem Solving: One of the major goals of this initiative was to foster collaboration among students from different cultural and educational backgrounds. The collaborative case study on maternal healthcare allowed students to apply their theoretical knowledge to real-world healthcare challenges, combining best practices from both the U.S. and Norway. Despite initial challenges related to time zones and group dynamics, students reported a high level of satisfaction with the collaborative work and expressed a desire for more time to explore these topics in greater depth.
• Practical Application of Learning: Many students noted that the COIL experience helped them connect their academic studies to practical healthcare settings. For example, students from UNC-CH reported being particularly struck by the sustainability practices in Norwegian hospitals, while HVL students gained insight into the technological advancements and patient care approaches in the U.S. Through reflection assignments, students expressed a deeper understanding of how global perspectives can inform and improve their future professional practices.

Student Reflections on COIL Experience

• Positive Feedback: The majority of students expressed enthusiasm about the cross-cultural experience, with many highlighting the value of interacting with peers from a different healthcare system. They appreciated the opportunity to explore how healthcare is delivered in different cultural contexts, especially in terms of sustainability and culturally responsive care. Students also appreciated the structured group projects, which allowed them to engage in meaningful discussions and build connections with their peers.
• Challenges Encountered: While the overall feedback was positive, students encountered some challenges. The imbalance between the number of students from the U.S. and Norway occasionally made group dynamics difficult, with some U.S. students reporting that they often had little interaction with their Norwegian peers during synchronous sessions. The timing of these sessions also posed a challenge, particularly for U.S. students who had to join early morning meetings.
• Preliminary Data from ASKS2+ Survey: The ASKS2+ survey, which measured changes in attitudes, knowledge, and skills related to intercultural communication, revealed promising results. While response rates were low in the first semester (with 19 responses from UNC-CH and 8 from HVL), those who completed the survey showed improvements in their ability to communicate across cultural boundaries. Students reported increased openness to diverse perspectives, greater empathy in cross-cultural settings, and heightened awareness of their own cultural biases. Many expressed a desire to continue working with international peers in future courses and professional settings.

Testimonials & Experiences

The COIL initiative between HVL and UNC-CH left a significant impact on both students and faculty, who found the collaboration enriching both professionally and personally.

Student Testimonials

I learned so much about how healthcare systems in Norway prioritize environmental sustainability in ways that we don’t often see in the U.S. It opened my eyes to how much we can learn from each other’s practices in nursing and healthcare.

— UNC-CH Nursing Student

This was my first experience working with students from another country. It really changed how I view cultural differences, especially in how nurses care for patients from different backgrounds. I can definitely see myself working in a global healthcare setting after this.

— HVL Student

The discussions about the differences in midwifery practices between Norway and the U.S. were so eye-opening. We have different approaches, but it was amazing to see how our shared goal of providing the best care for mothers and babies brought us together.

— UNC-CH Nursing Student

I didn’t expect to feel so connected to students from the other side of the world. It’s really inspired me to continue learning about global healthcare and how we can improve patient care by sharing knowledge across borders.

— HVL Student

Faculty Reflections

Watching our students engage with their peers from another country was incredibly rewarding. They not only learned about different healthcare practices but also how to communicate across cultural divides. This COIL experience has truly prepared them for working in a global healthcare environment.

— Professor Catherine Crawford, UNC-CH

The level of collaboration exceeded my expectations. Our students showed tremendous growth, not just in their knowledge of healthcare systems but in their understanding of the cultural factors that shape how we care for patients. I look forward to continuing and expanding this partnership.

— Professor Elisabeth Hemnes, HVL
 

Experiential Insights

Throughout the COIL experience, students were able to overcome challenges such as time zone differences and varying group sizes to work effectively in their collaborative projects. Some of the most profound learning moments occurred during synchronous breakout sessions, where students explored real-world healthcare scenarios and worked together to design sustainable, culturally responsive solutions.

One of the most interesting parts of this experience was seeing how Norwegian hospitals are more focused on sustainability than what I’m used to in the U.S. It really made me think about how we can bring those ideas into our own healthcare system.

— UNC-CH Student Reflection

Future Directions

The success of the COIL initiative between HVL and UNC-CH has laid the groundwork for further collaboration and deeper integration of global learning experiences into the nursing curriculum. Both institutions are committed to building on the lessons learned from this partnership, expanding opportunities for student exchange, and enhancing cross-cultural healthcare education.

Planned Expansions

• Trilateral Partnerships: Based on the positive outcomes of the HVL and UNC-CH collaboration, there are ongoing discussions about including additional international partners in future iterations of the course. This would involve expanding the COIL initiative to nursing programs in other countries, further enriching the global perspectives offered to students.
• Physical Student Exchanges: Both HVL and UNC-CH are actively exploring opportunities for physical student exchanges, allowing students to gain hands-on experience in healthcare systems abroad. These exchanges will build on the virtual connections established through COIL, giving students the chance to engage in clinical placements in Norway or the U.S.
• Joint Research Initiatives: Faculty from both institutions are in the process of developing joint research projects that explore the impact of COIL on nursing education and intercultural competence. These research initiatives will aim to publish findings on the effectiveness of virtual exchanges in enhancing global healthcare knowledge and skills.

Curricular Integration

• Sustainable Healthcare Practices: Given the strong interest from both students and faculty in exploring the environmental sustainability of healthcare systems, future collaborations will place greater emphasis on sustainable practices in healthcare. This includes developing modules focused on how healthcare institutions can reduce their environmental impact and sharing best practices between countries.
• Expanded Course Offerings: HVL and UNC-CH are considering expanding the COIL framework to include other areas of nursing and public health, such as mental health, community nursing, and infectious disease control. This would allow for a broader range of global healthcare topics to be explored through virtual exchange.

Ongoing Assessment and Improvement

• Enhanced Assessment Tools: Building on the preliminary results of the ASKS2+ survey, future iterations of the COIL initiative will integrate more robust assessment tools to measure intercultural competence and global awareness. This will include a combination of quantitative and qualitative data collection to better understand the long-term impact of the COIL experience on student learning.
•  Improved Student Participation: Based on the challenges faced in balancing student participation between HVL and UNC-CH, future COIL courses will aim for more even student representation and increased opportunities for synchronous collaboration. Faculty are also exploring new ways to engage students in asynchronous activities, such as the use of video reflections and interactive case studies.

Through these efforts, HVL and UNC-CH are committed to sustaining and expanding their COIL partnership, ensuring that nursing students continue to benefit from a global, culturally responsive education that prepares them for the challenges of a diverse and interconnected healthcare environment.