Investing in Health Education to Reduce Rural Health Disparities

Abstract

The global rural population accounts for almost half of the total global population. Access to health care for these rural populations is reduced, leading to increased health disparities. Nurses play a critical role in reducing health disparities but with limited models to guide their practice. The Community Health Assessment Sustainable Education model is a practical teaching and learning solution, which has been developed to engage student nurse learners in a health promotion philosophy for rural areas. Nurse learners assess and gather data to progress community development and navigate the holistic landscape of health. In this chapter, we describe how this approach integrates the sociopolitical, cultural, sustainable, economic, and environmental aspects of rural communities’ health. Our focus is on preparing nurse learners to improve the health of rural populations globally and reduce health disparities. The CHASE model enables nurse learners to influence and change policy and legal responsibilities at local, national, and global levels, while community development aims to address nurses’ role in advocacy that requires them to act on behalf of communities from a social justice perspective as they prepare for registered nurse practice.

1. Introduction

Improving the quality of life in rural areas requires investment in rural health. While such investment often involves spending on physical infrastructure, we focus on the education of nurse learners in preparation for registered nurse practice in rural contexts. Nursing in rural areas is not the same as urban centers. Rural nurses must combine their clinical skills with that of community developers. In this chapter, we describe how the Community Health Assessment Sustainable Education (CHASE) model is used for introducing nurse learners to this complex nature of rural health [1, 2].

Rural nurses must be prepared for situations that are outside their usual lived experience and outside the textbook of clinical practice. Even for rural nurses who work in their home districts, we need them to be able to step back and look at the rural communities as if through the eyes of geographers or perhaps as strategic designers. These capabilities as community change agents will not come about through the usual clinically focused placements alone. We need to invest in the difference, that is, rurality. The CHASE model, therefore, enables nurse learners to influence and change policy and legal responsibilities at local, national, and global levels, while community development aims to address nurses’ role in advocacy that requires them to act on behalf of communities from a social justice perspective as they prepare for registered nurse practice.

After canvassing the challenges of rural health education, we outline the development and nature of the CHASE model. We then describe an international collaboration of investment in rural health education using the CHASE model. We commissioned the production of a film of the rural village of Bishop’s Castle (Shropshire, UK) to enhance the learners’ engagement and critical thinking and questioning of this community to enhance their community profiling and assessment.

The purpose of this chapter is to add to the growing debate of improving the provision of rural health care and equally rural workforce planning. Our focus is on preparing nurse learners to enhance the health of rural populations globally. To achieve this, we demonstrate the value of engaging with a research framework guiding our collaborations as we collaborate with rural communities. This project is explored using ethnographic reflections of the participating academics (authors), as we engage with an authentic teaching practice to consider the success of the CHASE model in preparing nurse learners for rural practice.

2. Background

Nurses make up the largest segment of the global health care profession [3] and play a critical role in assessing the health care of rural populations while working collaboratively with rural community residents to reduce rural health disparities [4]. In consideration of nurses’ positionality as community development practitioners, it is therefore imperative that an understanding of this joint role—of assessing and collaboration—is passed onto nurse learners. The demand of educating nurse learners for rural areas goes beyond the clinical, to provide them also with the opportunity to practice as community development practitioners a term derived by the International Association of Community Development (IACD) who note the inclusivity of all people whether in unpaid or paid work who offer their services to improve community welfare are considered community development practitioners [5].

The challenges of practicing within the contexts of rural geographical locations are numerous, which add to the complexity of practicing nursing in rural locations. Rural locations are widely dispersed and often isolated. Nurses practice health care in these contexts at times as solo practitioners, as a member of an intradisciplinary, interdisciplinary, or multidisciplinary teams in small hospitals, community venues, residents’ homes, schools, recreation facilities [4] the outback, a village, the bush, or an open space [6]. Equally, these practitioners care for rural residents and visitors from birth to death and experience all manner of health care eventualities. In addition to the clinical practice of all nurses, the scope of practice of rural nurses includes the complexities of living rural, the economic factors, isolation; limited transportation and communication and the variety of occupations including engaging with nature; and agriculture and farm life, including animals; farmed space; domesticated; and wild [7].

The rural resident population accounts for 44 percent of the total global population [8]. People in rural areas experience similar rural health issues yet often suffer more than urban communities because of a lack of access to health care including affordability [9]. The provision of health care services in rural locations are under threat with centralization (hence urbanization) of services [10]. The provision of rural health care services is of global concern and has been recognized as such for the past two decades [11, 12, 13]. Despite the huge differences between developing and developed countries, access to health care is the major issue in rural health around the world [14]. The provision of health care within rural communities remains a global challenge [15].

The state of rural health is one of the disparities and inequities [16]. This recognition acknowledges that the health of rural people experiences numerous health disparities and suffers more than their suburban and urban counterparts. A lack of access to health care is in turn related to the lack of health providers including the availability of specialists [9]. Further, the reduced numbers of rural health care practitioners have led to the lack of availability and recruitment of experienced health practitioners and a corresponding lack of rural planning and dedicated funding. Rural health care practitioners include doctors, nurses, midwives, and pharmacists, who make up most of current practicing rural professionals to improve access for the provision of health care and to highlight these issues to health planners, regulators, and governments, globally [17]. Rural nurses are one of the main contributors of this action [18].

Rural nurses need to have the capability of working with rural communities to gather and analyze population-level data, promote wellness and disease prevention, assist in adopting and disseminating best practices for population health, and identify patients who are at greater risk of disparities, necessitating greater outreach efforts [18]. Therefore, nurses need broad-based knowledge to succeed with this endeavor and more importantly to ensure that they are prepared and competent to practice successfully in rural contexts. There is no better time to engage with nurse learners about community development and the practice of “nursing a community” to improve health care. Student nurse learners can be immersed in community development, to enable them to develop the professional competence to contribute to solution-focused and sustainable health care. It is therefore imperative that nurse educators expose, facilitate, and provide their experience of practicing community development, for the future endeavors of rural health care as nurse learners prepare for registered nurse practice.

3. CHASE model

The purpose of this chapter is to add to the growing debate of improving the provision of rural health care and equally rural workforce planning. Our focus is on preparing nurse learners to enhance the health of rural populations globally, in keeping with the vision of the Global Rural Nursing Exchange Network (GRNEN) [19] which is discussed in relation to the student nurse learners project grant, later in this chapter. To achieve this, we demonstrate the value of engaging with a research framework guiding our collaborations as we collaborate with rural communities.

The Community Health Assessment Sustainable Education (CHASE) model is used for introducing nurse learners to rural health [1, 2]. CHASE provides a consolidated structure that immerses nurse learners in community development practice and involves them to be active in their own learning in partnership with their team peer members, community organizations, community key stakeholders, and educational supervisors. CHASE guides learners through ethical, cultural, professional, and critical thinking, verbal and written communication, and visual presentations. CHASE enables nurse learners to influence and change policy and legal responsibilities at local, national, and global levels.

It is therefore imperative that student nurse learners experience community development work, as part of their primary health care clinical placements. Students are guided by the CHASE model to create opportunities for improved community health among rural population groups. Learners use both primary and secondary data collection to describe the community, map resources, uncover inequities, and listen to stories of community resilience. Health needs are identified between learners and community members, and sustainable responses evolved in the form of solution-focused strategies and resources and disseminated within the community to improve well-being.

3.1 CHASE engagement

CHASE stands for Community Health Assessment Sustainable Education model. CHASE was developed in 2017 to assist nurse learners (as a component of their Bachelor of Nursing (BN) degree program from the School of Nursing, Otago Polytechnic, Dunedin, in New Zealand) to undertake community development projects. These projects related to clinical practice experience and received ethical approval in 2021–2024 to proceed by the School of Nursing, Ethics Committee, Otago Polytechnic, Dunedin, New Zealand, for learners to profile and assess the rural community, take action, and design and develop health promotion messages and resources to improve the health of the identified population associated with that rural community. CHASE consists of two preparatory stages: a pre-engagement stage and pre-orientation, an orientation stage and six phases [1].

The pre-engagement stage is extremely important, where the facilitator or the lecturer engages with the community.

The orientation stage offers learners the opportunity to become acquainted with team members (nurse learners) whom they participate with throughout this 4-week project, the supervising lecturers, and the rural geographical location to which they have been assigned to conduct the community development project.

Phase one commences with the planning stage to undertake the community assessment associated with the identified rural geographical location. The community assessment is guided by an adapted version of Anderson and McFarlane’s community-as-partner wheel [20], which enhances the collection of both secondary and primary data including the demographics and social, political, and economic services aligned with the community. One of the outcomes is to “get to know the community better”; therefore, developing a film of the community was recognized as beneficial and could assist the students to experience visually, the community.

Phase two requires learners to prepare a draft written report for verbal and visual presentation in consultation with the supervising lecturers and community stakeholders and identify health disparities and health needs.

Phase three learners work in smaller teams and progress their individual component of the wider project. Additional consultation may occur with community members specific to the learners focus on the agreed (with the community) identified health need and population group. A detailed evidence-based literature review is completed related to this health need.

Phase four learners continue to work collaboratively and progress with their written report and engage with the Ottawa Charter [21] and design and develop evidence-based resources that match the health need for the identified population group.

Phase five learners present back to the identified community partners the final completed published written report, the health promotion resources, and presentation.

Phase six learners initially assessed the health promotion resources designed to improve the health of the identified population 3–6 months following completion of phase five.

4. Investment in action

In the collaborative nature of rural practice, CHASE is not just a teaching device. The model is one of co-design, research, evaluations, education and ongoing and future collaborations, and community development. We illustrate this working research framework [22] with an example of a community development project connected to the rural community of Bishop’s Castle, Shropshire, England, United Kingdom. This community development project commenced in February 2020, revisited in 2021 and 2022. We are showcasing the 2022 project in this chapter, while the community development projects 2020 and 2021 provide an informative background to the 2022 project. Our overall focus in this chapter is to share the collaboration between the Bishop’s Castle community stakeholders, the educators from La Trobe Rural Health School, Victoria, Australia, (LRHS) the School of Nursing, Otago Polytechnic, Dunedin, New Zealand, and the funders of the GRNEN project grant. This GRNEN international learning grant partnered this collaborative venture between these education institutions, the rural community Bishop’s Castle, Shropshire, United Kingdom.

This international project offered a platform for meaningful conversations and encouraged global diversity for rural student nurse learners to improve decision-making and progress on issues that matter most to rural nurses and rural communities around the globe. The goal for this endeavor was to advance nurse learners’ community development practice and to provide an opportunity for learners to engage with each other to:

• participate and engage with rural communities;

• undertake community assessment to identify issues;

• plan community development;

• assist with change as necessary;

• build leadership and teamwork;

• challenge policy if relevant.

Beyond the community development goals and learning experiences for learners, the project had research goals to:

• foster interactive virtual global relationships and collaboration between nine New Zealand and nine Australian Year 3 BN nursing students, as they engaged with this interactive project and shared their knowledge from their own countries associated with rural community development and public health focused on the mental health of rural youth and COVID-19 lockdowns;

• improve the understanding, of the local-global connections, unique cultural relationships, similarities, and differences associated with rural locations, rural locale, and rural sense of belonging among the Year 3 BN nursing students;

• engage with the CHASE model to enhance the New Zealand and Australia BN Year 3 nursing students’ engagement and understanding of the rural village of Bishop’s Castle, Shropshire, United Kingdom community profile and health needs assessment through film;

• incorporate the CHASE model (supported with the film of Bishop’s Castle the identified rural community) as the Australian and New Zealand BN Year 3 nursing students progressed their involvement and contributions to improve the health care of this community from an illness-focused perspective to one that incorporates sustainability and holism and have increased their awareness of health inequities for vulnerable population groups.

Thus, the project had the following objectives that integrated the educational, community development, and research goals:

• to share the students’ learning journey and communication/collaboration along the way with GRNEN, the following mediums were engaged with Higher Logic including film, videos, photography, art, or poems. These mediums were aimed to support virtual connections via Zoom including videoconferencing, collaboration tools for co-creating and updating documents that would support collaboration and communication among the students, and the residents of the rural village, and the nurse educators that support social networking and create online communities;

• to promote awareness of mental health, mental ill health, and mental well-being, build positive behavior constructs, and destigmatize mental health among the community residents of Bishop’s Castle while progressing the nurse learner’s engagement and understanding, especially when confronted with different cultural groups;

• to stimulate self-esteem, empowerment, and self-actualization for the community residents and identified population groups residing in Bishop’s Castle;

• to combat loneliness and social isolation for the community residents of Bishop’s Castle;

• to kindle team building and networking among the nursing students associated with La Trobe Rural Health School and School of Nursing, Otago Polytechnic, Dunedin, New Zealand, and together work on the project virtually together;

• to enhance individual learning development and showcase community knowledge and share ideas;

• to create cohesion between the partnering universities and foster ongoing virtual relationships among students and educators.

This project, therefore, provides an example of investing in nurse learners’ education as a mechanism for addressing rural health disparities. The collaboration that occurs across stakeholders and education providers offers learnings and resources that would not otherwise be available to nursing students. Investing in nursing education with a focus on rural health and rural communities provides students with the opportunity to genuinely understand the health disparities that occur between metropolitan, regional, and rural areas. Engaging with rural communities is a key characteristic of building a sustainable health workforce [17]; therefore, incorporating this into undergraduate nursing curricula at a university rural health school is vital.

4.1 Investment in community story

We engaged with a local professional filmmaker from Bishop’s Castle to film the community. To achieve this, we set a task for the filmmaker to engage with a foot-survey template in looking at the different aspects of how the students were going to profile and assess this community. The foot-survey encourages students to review, for example, housing, roading, safety, transportation, education, recreation, economics, and health care services based on the original Anderson and McFarlane’s community-as-partner wheel [20]. This assisted the filmmaker in creating the story line and then producing the film (Figure 1).

Figure 1.

Rural community Bishop’s Castle. Source: John Keeley (published with permission).

4.2 Investment in virtual platform

A virtual platform is developed using a platform within a Learning Management System (LMS—“Moodle”). This Moodle shell allowed us to retain resources and information, offer direction and discussion, and support for teams of nurse learners locally, regionally, nationally, and internationally. The Moodle shell is a working space and resource for students and staff and in the future will accommodate community users. All relevant content organized into a cohesive Moodle course, including downloading documents/materials including videos to include virtual conference rooms and whiteboard animations with narration (Figure 2). Interactive lessons outlining the platform and how to use Moodle and forums as required for student groups and community were provided. Technical support and ongoing revisions were also provided. The content and direction provided in the Moodle shell has showcased through numerous community case studies engaged by the learners, in which all CHASE model phases are exemplified. The CHASE model enhances collaborative relationships in the global landscape and further contributes to inform nursing curricula and teaching and learning pedagogy internationally. CHASE supports the community development project, and the LMS is the means to achieve this.

Figure 2.

Moodle shell CHASE whiteboard animations. Source: Authors.

4.3 Engaging with rural health

There was a total of 4 weeks of collaboration between the universities in New Zealand and Australia during 2021. The New Zealand students shared their community profile assessment and analysis presentation comprising phases one and two of CHASE of Bishops Castle in the United Kingdom to the Australian students. Following this, the New Zealand and Australian students discussed together using GRNEN virtual platform for student correspondence (a requirement of the GRNEN grant) and the mental health of youth and other members of the community from their own countries’ perspective while critiquing and reviewing the literature related to the information that would be relevant to assist the United Kingdom of Bishop’s Castle, youth community. The academic team invested time and communicated regularly with students to assess their progress, ensuring there was a strong alignment in their thinking and their progress of their piece of work with community needs, making sure that it was continually coming back to the information that they received about Bishop’s Castle and the challenges and then lifting that up to think about the global context as well and what was going on in this community. There was an emphasis on mental health and appreciating where we were at in terms of the globe and coming out of the COVID-19 pandemic, and it is not surprising that mental health was high on everyone’s agenda and an area that was worth paying some attention to.

Nursing students from both Australia and New Zealand interacted with the virtual networking and collaboration tools that were created, and by using these platforms and engagement opportunities they were able to right from the commencement of the community development project, connect with each other, and share in different ways and at different points of time, through the project and also draw the project to completion.

4.3.1 Reflection on learning

(First author reflection): Community Assessment – Getting to know the community.

The film we created to assist the students to assess and get to know the community certainly had that desired effect. What we found was that the students who watched the film both from Australia and in New Zealand, could start to really understand the complexity of this medieval village. What we as lecturers and registered nurses are facilitating through this learning are the complexities of the landscapes of the village. The changing British seasons that the film identified included a snow scene; a spring scene and a summer scene, those changes in weather patterns, the trained eye of a registered nurse would consider, how these seasonal changes impact on the village residents which further stimulates the registered nurse to consider the services local to the village, for example is there an ambulance service? is there a hospital service?, how do people get from one place to the other, especially during seasonal changes which could impact the residents on accessing services. Being introduced to these complexities through the medium of image (film) we found that the students could ask more significantly in-depth questions to the community stakeholders (via Zoom meetings and emails) to gather and be able to develop a much better comprehensive assessment of the community, which enhanced their understanding as they progressed with the CHASE phases.

(Third author reflection): Community Engagement – Increasing Awareness.

Our nursing students did impressive work, and the feedback from them revealed they felt the CHASE model and engaging in this program was beneficial to their practice, in that it could be used to inform a health promotion message, or an event endorsed by health promotion to a real rural community, rather than exploring these concepts theoretically. They were pleased with identifying the strengths of the rural community and offer to build a health promotion message based on that strength [23]. Nursing students reported an enhanced understanding of the local-global connections, unique cultural relationships, similarities, and differences associated with rural locations and rural sense of belonging of rural communities, their people, and their health. At the completion of the project, they developed a mental health promotion recommendation for the community. This project increased their awareness and knowledge of mental health needs in rural communities and how important it is to engage communities in health promotion for sustainable outcomes.

(Third author reflection): Collaboration – CHASE in Action.

The information about the rural community via film was really important. The communication channel that was established between students and facilitators with time differences, had some challenges there but it was not something that we couldn’t negate or overcome and that was part of the students’ learning as well in terms of when you’re collaborating with colleagues overseas. The skills developed in terms of teamwork stemmed from creating that sense of team in an online interface, and that’s where the structure that’s provided in the CHASE model gave the students a great sense of shared understanding of the point of collaboration and their role in what they were going to contribute.

5. Implications of the investment in rural health education

We invested in the community development project by embedding it into curriculum. When learning opportunities are part of an undergraduate curriculum, the engagement of students is high [24].

Engaging with this global research project supported with the film of the rural village of Bishop’s Castle enhanced the nursing students across international universities’ engagement and understanding of the rural community. Nurse learners profiled and assessed this community’s health and identified the health needs with a strong focus on mental health of the rural community (Figure 3).

Figure 3.

Screen shot introduction to film. Source: Authors.

(First and third authors reflections): community Assessment – Film as Asset.

We are keen to explore the possibilities of linking similar films of rural communities together in the future and even aspire to growing a regional, national and global network of rural communities and making sure that extends to student nurses and their learnings and how they’ve engaged with the CHASE model. This will enhance this way of working and could promote international collaboration, and unique learning opportunities, and also enable students to have global connections and foster relationships with other students but also then connect with the community case study. This is a focus on the work of GRNEN and we hope to collaborate further with them in this endeavor. This would also lend itself to being able to research the way that students are connecting and groups of nursing students and nurse educators relative to the healthcare discussions from their respective countries because it’s been quite interesting in terms of what’s been revealed.

(Third author reflection): creative Learning – Being Courageous.

When learning opportunities are part of an undergraduate curriculum the engagement of students is high, so it was really important for us to be able to create an alternate assessment for nursing students and gain approval from La Trobe’s Academic Board. This approval was a significant milestone because we weren’t adding to students’ work, this was part of their learning embedded in a third-year mental health subject. In terms of the implementation that the information about the rural community via video was really important and the communication channel that was established between students and facilitators with time differences, there were challenges there but it was certainly not something that we couldn’t negate or overcome and that was part of the students’ learning as well in terms of when you’re collaborating with colleagues overseas, how do you actually create that sense of team and that’s where the structure that’s provided in this piece of work really gave the students a great sense of shared understanding of the point of collaboration and their role in what they were going to contribute.

In terms of monitoring, we were in touch and communicating regularly with students’ progress and also making sure that there was a strong alignment in their thinking and their progress of their piece of work with community needs, so making sure that it was continually coming back to the information that they received about Bishop’s Castle and the challenges, and then lifting that up to think about the global context as well and what was going on in this community.

(Third author reflection): collaboration – Responding Virtually.

An interesting finding engaging in the project for students at that point in time coming out of the COVID-19 pandemic, was to think about collaboration using these online platforms, because the expectations of the students with working online via different online mediums was actually quite low because they have become so used to it over COVID, they’re used to using technologies, they’re used to working with other colleagues even within their cohort via Zoom and via different platforms, so in terms of where they were sitting with expectations they were really quite open to this way of learning. Feedback from the students was that they really enjoyed the experience, time zones, that was a bit challenging and we needed to think about our timeframe, appreciating that they’re all enrolled in other subjects as well, so really making sure that we were providing resources in a timely manner and the expectations of participation were realistic; and the other thing too is it was really interesting for students at this point in time to think about collaboration using these platforms, because the expectations of the students with working online via different online mediums was actually quite low because they’ve got so used to it over COVID-19 lockdowns, they’re used to using technologies, they’re used to working with other colleagues even within their cohort via Zoom and via different platforms, so in terms of where they were sitting with expectations they were really quite open to this way of learning.

5.1 Implications of the project to improve health disparities

Our approach to this project was cyclic, aligning with a quality assurance approach. The implications of undertaking community development as a component of the wider collaborative research project were evaluated between the two educational institutions and the community stakeholders of Bishop’s Castle, Shropshire, United Kingdom, who assessed that the project was meeting its goals and objectives (introduced above) on three monthly intervals and at the completion of the project.

(First author reflection): community Development – Improving Health Disparities.

A positive impact of the project and engaging with CHASE was demonstrated by the students’ commitment to improve health disparities. The students stayed in regular connect with the community stakeholders supported with regular facilitation and guidance by the lecturers. This was achieved through live virtual meetings such as Zoom and email correspondence they were able to update the community and liaise with them around the identified health issues and latterly as the project developed the health promotion messages and then in partnership with this community, they were able to focus on designing and producing the health promotion resource benefitting the health of the population of Bishop’s Castle youth.

(Third author reflection): community Development – Working Together.

La Trobe nurse learners offered a significant and a wonderful focus of mental health and youth within their own community to actually share with the students of New Zealand, and they focused on the Rainbow community.

The students from New Zealand presented their findings on Bishop’s Castle by using nursing frameworks, they incorporated the framework of Te Whare Tapa Whā [25] which is the New Zealand indigenous population framework, into their presentation by using a holistic approach to discuss all four aspects of the health needs – physical, mental, social and spiritual [25]. They also used the framework of the community -as-partner wheel by Anderson and McFarlane [20] this allowed them to develop a comprehensive display of all relevant health issues disparities within the community, together with these frameworks enabled them to give the Australian students an extensive insight into the health needs of Bishop’s Castle which they picked up on and it became evident that they successfully communicated this information after La Trobe students produced a presentation to the students of New Zealand in return which contained and expanded all that they had developed.

(First author reflection): community Development – Sustainable Practice.

Developing and maintaining ongoing relationships, and model development partnership collaboration and communication are very important to maintain sustainability between the three groups and with GRNEN. Sustainability included meeting with the stakeholders where we could discuss with the local health professionals including general practitioners, and district nurses, and from our conversations we were able to reflect upon the position Bishop’s Castle was in with the closure through COVID-19 pandemic of their community hospital and how it had affected health outcomes for those with more serious conditions and medical events that required very prompt medical response. Through this we discovered that there were five district nurses that covered 10 rural communities in the Shropshire region, and therefore there was an empathy towards those district nurses and how they were expected to work with the closure of that hospital and with the increase in social isolation of older people and the mental ill-health of youth.

6. Conclusion

In this chapter, we have described how the CHASE model works to engage learners and provide benefits for rural community despite geographic separation. These students were positioned to act as community development practitioners with the aim to reduce health disparities in partnership with community stakeholders.

A challenge of educating nurses for rural health is directly related to the nature of rural health. The isolation, complexity, and diversity of health needs mean it is challenging to provide authentic learning experiences that cover the breadth of rural health. Added to this is the need for learners to experience and learn the integrated nature of clinical practice and what might be called community development needed for rural practice.

Herrington et al. [24] laid out a set of situated learning principles for authentic learning. Key elements include a real-world problem that is ill defined at the beginning; the learners need to incorporate multiple perspectives to first understand the problem, and then propose and select from a diversity of solutions that are seamless integrated into the real world. The development requires complex activities over time to deliver polished products that are whole and valued; and all takes the leaners outside their comfort zones, with work across subject boundaries and into diverse roles; and much of the learning is through reflection. The application of the CHASE model as a framework for rural-nurse learning meets all of these objectives. The learners engaged with a community without preconceived or predetermined ideas of what the problem is. They used the tools of CHASE to engage with the community to understand the health of the community as a system and to identify a pressing health need that could be addressed in the relatively short time available. The learners engaged with each other through virtual platforms and pitched their potential solutions to the community and delivered actual useful resources.

Thus, CHASE can be seen to be operating in a sweet spot. The model enables learners to navigate the complexity of learning rural practice. The project mirrors rural nursing practice; in that, it is unavoidably purposeful, collaborative, and relationship-based.

This has resulted substantial positive impact on improving the understanding, local-global connections, unique cultural relationships, similarities and differences associated with rural locations and rural communities, their people, and their health, among nine BN Year 3 students from New Zealand and nine from Australia. The use of the film to provide the context of the community and their health is new, as is the learners being part of an international collaboration with learners from two countries in partnership with a community in a third.

We intend to do further research on these aspects of collaboration between international nurse learners. Anecdotally, these discussions helped with the reflective process and helped learners with the challenges of identity formation as to what it means to be a rural nurse.

All three locations involved in the CHASE project described here are from the Global North (despite the southern positioning!). Previous applications of CHASE have involved rural communities in the Global South – primarily Small Island States in the Pacific (or “Large Ocean States”) [26, 27], but with New Zealand as the source of nurse learners. It would be interesting to flip this and have LOS nurse learners.

Remote collaboration is enabled by virtual networking and collaboration tools. Further research will be to explore the value of a film as part of the CHASE model and to enhance the collaboration tools within the networking environment. These international collaborations will foster global connections and deeper research as the groups of nursing students and nurse educator(s) will launch rural/remote health care discussions from their respective countries. We share a community of academics situated in Australia, New Zealand, and the United Kingdom who are involved in this project and are positioned to examine the process, outcomes, and evaluation of this initiative so that the results can be shared locally and globally through GRNEN.

Given the cost of producing films for every community, it would be interesting to explore whether we could link or group similar interactive films of rural communities together in the future, perhaps to grow a regional, national, and global network. Or would this defeat the purpose of an introduction to each specific rural community?

Acknowledgments

The authors wish to acknowledge the Global Rural Nursing Exchange Network (GRNEN) learning grant which stimulated and supported this international learning protect. The authors also thank the community stakeholders and residents from Bishop’s Castle, Shropshire, United Kingdom, for their time and engagement with the nursing learners. The authors also thank the Latrobe University, Victoria, Australia COIL Programme Funding, La Trobe Rural Health School, Victoria, Australia final-year Bachelor of Nursing students 2022 for their engagement, commitment, and feedback with this project work. The authors also thank the Otago Polytechnic, Dunedin, New Zealand Contestable Research Funding, and the School of Nursing, Otago Polytechnic, Dunedin, New Zealand Year 3 Bachelor of Nursing students’ 2022 engagement with community development and virtual platform communication and learning. The authors also thank Associate Professor Mel Bish for her commitment to this learning project from its inception to completion.