adventist education · by patricia s. jones and edelweiss ramal 4 a distinctive framework for...

ADVENTIST EDUCATIONWebsi te : h t tp : / / jae .advent is t .o rg October-December 2017T H E J O U R N A L O F

ADVENTISTNURSING

EDUCATION

S P E C I A L I S S U E

C O N T E N T S

3 Guest Editorial: The Past and Future of Adventist Nursing

By Patricia S. Jones and Edelweiss Ramal

4 A Distinctive Framework for Adventist Nursing

By Patricia S. Jones, Barbara R. James, Joyce Owino, Marie Abemyil, Angela Paredes de Beltrán, and Edelweiss Ramal

14 Core Components of the Nursing Curriculum

By Dolores J. Wright and Jacqueline Wosinski

20 Teaching Spiritually Sensitive Nursing Care: Recommendations

for an Ethical Adventist Approach

By Elizabeth Johnston Taylor

26 Inviting a Spiritual Dialogue: A Loma Linda University Perspective

By Iris Mamier, Edelweiss Ramal, Anne Berit Petersen, and Harvey Elder

33 Clinical Teaching in Adventist Nursing

By Susy A. Jael and Lucille Krull

38 Interprofessional Education at Two Adventist Universities

By Kathi Wild and Lili Fernandez Molocho

43 Adventist Graduate Nursing Education: An Interview

By Susan L. Lloyd, Holly Gadd, Shirley Tohm Bristol, and Patricia S. Jones

49 Developing Presence and Faith in Online Teaching

By Pegi Flynt, Flor Contreras Castro, and Tammy Overstreet

55 Seventh-day Adventist Nursing Programs

Photo and art credits: Cover and issue design, Harry Knox; cover photos, courtesy Center for Adventist Research, Think-stock; pp. 6, 21, and 39, courtesy Loma Linda University School of Nursing; p. 27, Thinkstock.

The Journal of Adventist Education®, Adventist®, and Seventh-day Adventist® are the registered trademarks of the GeneralConference Corporation of Seventh-day Adventists®.

O C T O B E R- D E C E M B E R • VO LU M E 7 9 , N O. 5

THE JOURNAL OF ADVENTIST EDUCATION publishes articles con-cerned with a variety of topics pertinent to Adventist education.Opinions expressed by our writers do not necessarily representthe views of the staff or the official position of the Department ofEducation of the General Conference of Seventh-day Adventists.

THE JOURNAL OF ADVENTIST EDUCATION (ISSN 0021-8480[print], ISSN 2572-7753 [online]) is published quarterly by theDepartment of Education, General Conference of Seventh-day Ad-ventists, 12501 Old Columbia Pike, Silver Spring, MD 20904-6600, U.S.A. TELEPHONE: (301) 680-5071; FAX: (301) 622-9627;E-mail: [email protected]. Address all editorial and ad-vertising correspondence to the Editor. Copyright 2018 GeneralConference of SDA.

ADVENTIST EDUCATIONEDITOR

Faith-Ann McGarrell

EDITOR EMERITUSBeverly J. Robinson-Rumble

ASSOCIATE EDITOR(INTERNATIONAL EDITION)

Julián M. Melgosa

SENIOR CONSULTANTSJohn Wesley Taylor V

Lisa M. Beardsley-HardyGeoffrey G. Mwbana, Ella Smith Simmons

CONSULTANTSGENERAL CONFERENCE

Hudson E. Kibuuka, Mike Mile Lekic,Julián M. Melgosa

EAST-CENTRAL AFRICAAndrew Mutero

EURO-AFRICAMarius Munteanu

EURO-ASIAVladimir Tkachuk

INTER-AMERICAGamaliel Florez

MIDDLE EAST-NORTH AFRICALeif Hongisto

NORTH AMERICALarry Blackmer

NORTHERN ASIA-PACIFICRichard A. Saubin

SOUTH AMERICAEdgard Luz

SOUTH PACIFICCarol Tasker

SOUTHERN AFRICA-INDIAN OCEANEllMozecie Kadyakapitando

SOUTHERN ASIAPrabhu Das R N

SOUTHERN ASIA-PACIFICLawrence L. Domingo

TRANS-EUROPEANDaniel Duda

WEST-CENTRAL AFRICAJuvenal Balisasa

COPY EDITORRandy Hall

ART DIRECTION/GRAPHIC DESIGNHarry Knox

ADVISORY BOARDJohn Wesley Taylor V (Chair), Sharon Aka, Ophelia Barizo, LisaM. Beardsley-Hardy, Larry Blackmer, Jeanette Bryson, ErlineBurgess, George Egwakhe, Keith Hallam, Hudson E. Kibuuka,Brian Kittleson, Linda Mei Lin Koh, Gary Krause, Davenia J.Lea, Mike Mile Lekic, Julián M. Melgosa, James Mbyirukira,

Carole Smith, Charles H. Tidwell, Jr., David Trim

The Journal of

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2 The Journal of Adventist Education • October-December 2017 http:// jae.adventist.org

3http:// jae.adventist.org The Journal of Adventist Education • October-December 2017

G U E S T E D I T O R I A L

3

Our Legacy

At the beginning of the 20th century, Adventist nursingwas not only an important player in the development ofmodern nursing, it was also a pioneer and global leader.For example, when Dr. Kate Lindsay started the BattleCreek Sanitarium School of Nursing in 1883, she followedthe model of nursing care and education she observedwhile doing a medical specialty at Bellevue Hospital inNew York City a few years earlier.1 Bellevue HospitalSchool of Nursing was one of the firstnursing schools in the United States basedon the Night in gale model. Florence Night -ingale and Ellen G. White were contem-poraries, and both were pas sionate abouthealth, healing, and care of the sick. Al-though there is no evidence that eitherwas aware of the other, the combined in-fluence of their principles gave Adventistnursing an outstanding start.

As the health ministry of the Seventh-day Adventist Church reached out aroundthe globe, so did Adventist nursing andnursing education. It often started withthe development of clinics by doctors andnurses, followed by a small hospital anda school of nursing to train nurses to staffthe facility. This is evident in the recordof where and when Adventist schools ofnursing were established outside of theU.S., for example in Australia (1898),South Africa (1900), Argentina (1908),China (1921), and India (1925). From thebeginning, graduates excelled in providing whole-personcare and were in wide demand. According to Chapman,nursing graduates of Battle Creek College were recog-nized as exceptional and “eagerly sought after in all partsof the civilized world.”2 The same was true of the grad-uates of the Shanghai Sanitarium and Hospital School ofNursing and many other Adventist nursing programs allover the world.

As early as 1921, a young nurse educator, Kathryn Jen -sen Nelson, was appointed to the Medical Department ofthe General Conference to oversee Adventist nursing glob-ally. Jensen promptly developed a system of college cred-its for nursing curricula, which at that time were still hos-pital-based. By the time of the Goldmark Report (1923),3

and later the Brown/Bridge man Report (1953),4 both ofwhich recommended that nursing education be con-

ducted in institutions of higher education, Adventistnursing was already moving in that direction. Washing-ton Missionary College in Takoma Park, Mary land,started a Bachelor of Science degree in nursing in 1924and first graduated students with baccalaureate degreesin 1928. Jensen’s visionary leadership provided a foun-dation for the merging of nursing education into the ex-isting network of Adventist colleges, and a relativelysmooth transition into higher education.

Throughout the 20th century, Advent-ist nursing continued to pioneer the de-velopment of innovative and progressivenursing education. For example, in the1970s, the University of Eastern Africa,Baraton, in Kenya, developed the firstgeneric university-based curriculum fora baccalaureate degree in nursing in sub-Saharan Africa (not including South Af - ri ca). It earned a strong academic repu-tation and is still widely recognized as asuperior program in the preparation ofprofessional nurses. Graduates from Ad-ventist programs in Asia and Africa, andall over the world, frequently earn thehighest scores on the national examina-tions in their respective countries.

Our Future

In 2010, health care and the educationof health professionals entered a newera. In the U.S., it began with the Insti-tute of Medicine report (2011)5 and the

Carn egie Commission (2010).6 Globally, it started withthe Global Commission on Education of Health Profes-sionals for the 21st Century.7 All three reports called forchanges in the education of health professionals that willchallenge Adventist educators in the years to come. Theglobal report called for a “fresh vision” to transform ed-ucation in the health professions (including nursing) inall countries, rich and poor. The situation was describedas a ”slow burning crisis” requiring that the educationof health professionals in the 21st century be transfor-mative, team-based, and interdependent.

Given our record as pioneers in the 20th century,how will Adventist nursing respond to this new chal-lenge? Will we continue to be leaders in this new era?Will we continue to be passionate, innovative, and fu-turistic in our approach to educating nursing profes-

Patricia S. Jones

Continued on page 54

Edelweiss Ramal

The Past and Future of Adventist

Nursing It’s a remarkable story—

one of courage, dedication, innovation, passion, and mission.

Kate Lindsay

http:// jae.adventist.org The Journal of Adventist Education • October-December 2017

ues and legacy of Adventist education. This article describes a research

project that sought to identify the dis-tinctive values of Adventist nursingfrom the perspective of Adventistnurses and nurse educators aroundthe world. Its goal was to create aframework that will help new and ex-isting programs to reflect the out-standing legacy of Adventist nursingeducation. Based on data from 33countries and 213 respondents, theresearchers concluded that Adventistnursing shares three overlapping con-structs—caring, connecting, and em-powering—that can support and facil-itate its global mission.

Conceptual Frameworks

In 1973, the National League forNursing (NLN) initiated workshops toaddress how conceptual frameworksinfluence curriculum development innursing. A review of 50 accreditedbaccalaureate nursing programs in1972 and 1973 revealed that most ofthe schools were using the conceptsof man, society, health, and nursingas the primary focus of their curric-ula. Since that time, these conceptshave been referred to as the core, ormetaparadigm, concepts, and areused to depict the phenomena of pri-

mary concern for nursing science inboth education and practice. Tobroaden the concept of man, the termwas later changed to person orhuman being, and the concept of so-ciety was broadened to environmentto include both social and naturalcontexts. Reflection on these now-classic documents2 provided a back-ground for developing a project tocreate a conceptual framework forAdventist nursing in the 21st century.

The Research Project

The principal investigators designeda qualitative study to determine whatAdventist nurses and nurse educatorsperceived as distinctive about Advent-ist nursing in their context and culture.Investigators collected data in 10 of the13 divisions of the world church, rep-resenting 33 countries. Nurses fromeight countries were Spanish-speaking,from three countries French-speaking,and the rest were English-speaking.Focus groups of 10 to 15 people en-couraged open discussions, whichwere documented by designated re -corders. Analysis and categorization ofthe data were done according to theprinciples of qualitative analysis,3 andusing the electronic software NVivo 10.

B Y PAT R I C I A S. J O N E S, B A R B A R A R . J A M E S, J O Y C E O W I N O, M A R I E A B E M Y I L ,A N G E L A PA R E D E S D E B E LT R Á N, a n d E D E LW E I S S R A M A L


A DISTINCTIVEFRAMEWORK

FOR ADVENTIST NURSINGn the late 19th and early 20th cen-turies, Seventh-day Adventist sani-tariums and hospitals establishedschools of nursing that rapidlyearned high regard in their com-

munities as a result of the excellentinstruction and training their studentsreceived. Patients in those facilitiesreceived high-quality care from thestudents and graduates, and the cyclereinforced itself.

In the 21st century, nursing is apopular career choice for youngadults, both male and female, in manyparts of the world. With a globalshortage of nurses and the denomina-tion’s long history of highly ratedschools of nursing, Adventist collegesand universities around the worldhave been eager to establish academicprograms in nursing to meet the edu-cational interests of the church’syoung people, as well as the health-care needs of citizens in their country.Accordingly, the possibility of a gapbetween the mission of Adventistnursing education and market-drivenmotives to attract students and boostenrollment is real.1 It is possible for acollege or university to offer a nursingprogram that attracts a large numberof students, yet fails to reflect the val-

I

The principal investigators then ana-lyzed the data and categorized themaccording to their relevance to the fouressential metaparadigm concepts de-scribed above. Continued analysis ledto the identification of key conceptsand constructs that describe distinctiveelements of Adventist nursing, accord-ing to the perceptions of the inform-ants. The findings from this analysisprovided the foundation for creating amodel and conceptual framework thatare presented in this article as “An In-tegrative Global Framework for Ad-ventist Nursing.” The consistency ofthese concepts across diverse nationalbackgrounds indicates that they arethe product of a shared professionalculture unique to Seventh-day Advent-ist nursing education.

Methodology

During 2013 and 2014, 27 focusgroups composed of professionalnurses and nurse educators were con-ducted at three international confer-ences—in Indonesia, Argentina, andRwanda. Countries represented in theconference in Argentina included Ar-gentina, Bolivia, Brazil, Chile, Colom-bia, Mexico, Paraguay, Peru, PuertoRico, and the United States. Partici-pants in the 11 focus groups con-ducted in Bali, Indonesia, came fromAustralia, Botswana, China, India,Indonesia, Japan, Korea, Malaysia,Nepal, Pakistan, Peru, the Philip-pines, Thailand, and the U.S.A. Atthe conference in Rwanda, six focusgroups were conducted with partici-pants representing Botswana,Cameroon, Congo, Democratic Re-public of the Congo, Kenya, Liberia,Nigeria, and Rwanda.

Prior to the discussions, group facil-itators received instructions on how toconduct a focus group and document,summarize, and report their findingsto the conference participants. Thequestions that guided the group dis-cussions are shown in Table 1. Re -corders documented in writing whatthe groups had generated verbally intheir discussions and then summarizedthe salient points discussed in re-

sponse to the questions. Additionaldata were gathered via questionnairesat the Adventist International NursingEducation Consortium (AINEC) meet-ing at Union College in Lincoln, Ne-braska, in May 2014, and from Advent-ist nurse educators in Australia andPapua New Guinea in August of thatsame year. The same questions wereused to facilitate focus group discus-sions at all the conferences.

Data collected in Spanish andFrench were translated into English bybilingual investigators and/or researchassistants and entered into the NVivosoftware program, as were the datacollected via written questionnaires.Once all the data were entered, thetwo principal investigators started toindependently analyze and code theinformation. Data analysis4 began with“open coding,” which involved read-ing the data line by line and identify-ing the ideas or nodes therein. Coau-thors independently followed the sameprocedure.

“Axial coding” followed the “opencoding.” Axial coding is a process bywhich the ideas or nodes alreadyidentified are organized and groupedinto categories. First, the nodes wereorganized into the categories identi-fied by the NLN as the metaparadigmconcepts of nursing.5 After this step,other nodes and concepts consis-tently reported in the data as descrip-tive of Adventist nursing educationand practice were identified. Afterworking independently on the openand axial coding, the two principalinvestigators worked together to do“selective coding,” which identifiedthe categories with the greatestamount of qualitative data support.These categories were organized ac-cording to their relevance to the coremetaparadigm concepts of person/ human, health, environment, andnursing (practice and education),and were used in developing theglobal integrative framework for Ad-ventist nursing. Table 2 (page 7)


1. What is the essence of nursing?

2. What is unique about Adventist nursing?

3. What values and beliefs led you to answer question No. 2 as you did?

4. How does our Adventist heritage affect nursing care?

5. What are the similarities in nursing care across cultural settings?

6. What are the differences in nursing care across cultural settings?

7. Which of the beliefs that you have identified as distinctly Adventist do you see

evidenced in the practice of nursing in Seventh-day Adventist institutions?

8. What strategies, approaches, and tools would facilitate integration and imple-

mentation of these values and beliefs into the curriculum?

9. What strategies would promote application of these values and beliefs into

the practice of nursing?

10. What strategies would facilitate commitment to shared responsibility for

translating the values and beliefs from the classroom to the clinical setting?

Table 1. Focus Group Discussion Questions

shows selected quotes related to eachof the core concepts.

The Distinctiveness of Adventist Nursing

The various levels of analysis re-vealed distinctive concepts describingthe metaparadigm concepts of nursingfrom an Adventist perspective. Theseare reflected in the stated mission, thedescriptions/definitions of the essen-tial concepts, and in the nature ofnursing education and practice.

The Mission, Values, and Beliefs ofAdventist Nursing

The mission of Adventist nursingwas identified in the data as a re-sponse to questions about the unique-ness of Adventist nursing (see Table1) with comments like “reflectingChrist’s healing ministry to the wholeperson” and “restoration of the imageof God in human beings.” Thesestatements are in keeping with EllenG. White’s description of Christ’s mis-sion as bringing complete restoration,health, and peace to human beings.6

Reflection on these comments led re-searchers to a statement of the missionof Adventist nursing as follows: To pro-mote healing, well-being, and restora-tion of the connection between humans

and their Creator. In this statement, thedistinctive aspect is restoring the connec-tion between humans and their Creator.The data were rich in statements aboutthe values inherent in Adventist nurs-ing. Some were not surprising, such asthe altruistic values of love, empathy,compassion, excellence, kindness, hope,integrity, dedication, service, and re-spect. However, it was gratifying to alsosee the concepts of equality, justice,human rights, and charity, which reflectan awareness of current social ills thatnurses need to recognize and to whichthey can respond. Although an empha-sis on human rights is in keeping withcontemporary concerns, it is interestingto note that Ellen White wrote abouthuman rights in the early part of the20th century, saying: “the Lord Jesusdemands our acknowledgement of therights of every person. People’s socialrights, and their rights as Christians, areto be taken into consideration. All are tobe treated with refinement and delicacy,as the sons and daughters of God.”7

Along with these values, researchersidentified beliefs and assumptions thatprovided a platform for the conceptsand framework presented here. For ex-ample, belief in the sanctity of life, thatGod is the giver of life, that humanbodies are the temples of the Holy

Spirit, and that each person is a childof God. Closely associated with thesebeliefs and values were ethical princi-ples such as the following: Everyhuman being is worthy of dignity andrespect; nurses should promote andpreserve human dignity; and everyhuman being has a right to live. Thesedeep values and ethical principles wereprominent in the data and viewed asfoundational to Adventist nursing.

The Metaparadigm ConceptsThe metaparadigm concepts hu-

mans, health, environment, and nursingwere present in statements by inform-ants. This provided substantive mean-ing to define them from an Adventistperspective. Excerpts from the data andour definitions are provided below:

• Humans were described as cre-ated by God and designed to have apersonal relationship with Him.Christ admonished His disciples to“‘Abide in me as I abide in you. Justas the branch cannot bear fruit by it-self unless it abides in the vine, nei-ther can you unless you abide in me.I am the vine, you are the branches.Those who abide in me and I in thembear much fruit, because apart from


me you can do nothing’” (John 15:4,5 NRSV).8 Based on the data, and onScripture, the researchers define hu-mans as complex integrated beings—bio-psycho-social-cultural and spiri-tual—created as interactive beings forthe purpose of connecting with God,humans, and all of God’s creation.

• Comments about health de-scribed it as wholistic, includingphysical, mental, social, spiritual, andcultural well-being, and that com-munion with God affects health. EllenG. White advised that it is our re-sponsibility to cooperate with God inrestoring health to the body as wellas the soul.9 In this article, we definehealth as integrated well-being nur-tured by interconnectedness with Godand the whole of creation.

• Environment, according to therespondents, reflects God’s laws ofbeauty and harmony (aesthetics), andimpacts healing. In the data, nurseswere viewed as having a responsibil-ity to conserve the environment, andas being capable of creating a healingenvironment. Ellen White had muchto say about the environment. For ex-ample, “The pure air, the bright sun-shine, the flowers and trees, the or-chards and vineyards, and outdoorexercise amid these surroundings, arehealth-giving, life-giving.10 Also, “Na-ture testifies that one infinite inpower, great in goodness, mercy andlove, created the earth and filled itwith life and gladness.”11 Accordingly,in this article, environment is de-scribed as reflecting God’s laws ofbeauty and harmony; creating a heal-ing environment that inspires hope;and promoting respect, care for andconservation of the environment.

• In the responses, nursing is de-scribed as a sacred calling and a self-less service manifested in providingwholistic care (see Table 2). EllenWhite wrote that in ministering to thesick, “success depends on the spirit ofconsecration and self-sacrifice withwhich the work is done.”12 In this ar-ticle, the researchers define nursing asa sacred calling for service to human-ity, and a human science that facili-

tates healing and restoration to well-being through connecting and caring.

Nursing Education and PracticeIn the data, nursing education and

practice were described as a callingand a ministry. Nurses and nurse edu-cators were described as interdiscipli-nary, functioning as advocates andagencies of change, empowering theclient/student for change, and as rolemodels. The belief that nursing is acall to ministry implies that a nurseeducator not only accepts the call butalso has an added responsibility tonurture that call in students. Nurtur-

ing implies empowering students togrow and develop into caring profes-sionals. Empowerment happens whenstudents feel respected, when learningis facilitated rather than hindered, andwhen teachers reflect God’s uncondi-tional love. Familiarity with the legacyof Adventist nursing education willinfluence the educator’s commitmentto maintaining and promoting the un-derlying values and ethic of extraordi-nary caring for which Adventist nurs-ing education is known. Therefore,Adventist nursing education is builton a foundation of beliefs that hu-mans are sacred because they are cre-


Table 2. Quotes Related to the Core Concepts of Nursing

Identified During Selective Coding

Humans

Environment

Concepts

Health

Nursing

Quotes

“Created in the image of God”

“Human body is the temple of God”

“Deserving of dignity and respect”

“Respect each person’s priorities”

“Strong focus on prevention and change of total lifestyle”

“Healing comes from God”

“Health promotion and wellness”

“Promoting an aesthetic environment that will show God’s lawsof beauty and harmony”

“Creating a friendly spiritual environment will enable translationof values”

“Promoting the conservation of the environment”

“To imitate Jesus’ model, who healed the physical and spiritualcomponent of the individual”

“Hope is a vision: where science fails, Adventist nursing has theopportunity to offer care, strengthened by hope and faith”

“The management of integrated health care for the individual,family, and community”

“Wholistic care—taking into consideration the physical, mental,cultural, socio-economic, and spiritual aspects of the person forpromoting a high quality of care”

“Love and compassion, integrity, manifested through a vocationalsense to others and dedication to Christ”

“To re-establish God’s image in human beings”

ated in God’s image, that health iswholistic, and that nursing is a call toministry. Accordingly, Adventist nurseeducators must respect the diversityand uniqueness of each student; re-flect God’s unconditional love; facili-tate healing and well-being in stu-dents; and role-model as well aspromote wholistic health. Based onthese elements in the data, this docu-ment suggests that nursing educationintegrates values, knowledge, andskills; promotes development of clini-cal judgment and professional com-petence; and prepares the student forinterdisciplinary practice.

In addition to the comments aboutnursing practice mentioned above,other descriptors in the data portrayednursing as providing humane, wholis-tic care; promoting connectednessamong humans and their environ-ment; and empowering the client forchange through education and role-modeling. Along with comments thatrelated to the metaparadigm concepts,informants’ responses contributedkeen insights about the distinctivenessof Adventist nursing. These ideas andconcepts were clustered according totheir meaning and significance. Over-arching key constructs and sub-con-cepts emerged, which appear in Tables4 and 5. In summary, the distinctive-ness of Adventist nursing as seen inthe mission, education, and practice ofnursing is a focus on the sacredness ofGod’s creation, and on nursing as acall to ministry to promote well-beingin all aspects of that creation throughcaring, connecting, and empowering.

Key Constructs

CaringCaring has long been the primary

focus of nursing practice and has beendescribed as the essence of nursing.Although not limited to one professionor culture, caring is recognized as thefundamental value associated with thediscipline of nursing. The fact that Ad-ventist nurses repeatedly referred to“caring” as a primary concept under-lying their nursing practice and educa-

tion affirms the validity of caring inthe profession and its centrality in Ad-ventist nursing. The concepts of em-pathy, compassion, sensitivity to theneeds of others, caring beyond the or-dinary, and selfless service wereamong the most frequently mentionedaspects of Adventist nursing by peopleparticipating in the study.

A number of theorists have se-lected caring as the core concept from

which to develop a theoretical frame-work for the discipline of nursing.13

In spite of varying theoretical per-spectives, most agree that care is apowerful and distinctive attribute ofthe discipline, and that one goal ofnursing education is to develop thecapacity to care.

In today’s health-care systems, al-though the ethic of caring is chal-lenged, it is what keeps them human.


Empathy

Compassion

Going beyond the ordinary

Sensitivity toward others

Going the extra mile

Compassionate care with the fruits of the Spirit

Valuing each individual

Selfless service

Communion

Prayer

Personal relationship with God

Social interaction

Compassion

Presence

Therapeutic communication

Active listening

Connectedness

Mentoring and facilitating learning

Coordinating and managing care

Lead by example in teaching and student interactions

Professors role-model their beliefs and values to students

Role-model compassionate patient care

Demonstrate caring in personal life

Practice a healthy lifestyle. Promote healthy living in patients

Advocate for the patient through inter-professional collaboration

Nurture students’ critical-thinking skills

Table 3. Key Constructs Supported by the Data

Caring

Connecting

Key Constructs Terms and phrases from the data

Empowering

According to Sara Fry,14 “The very na-ture of nursing requires and reinforcesthe ethic of caring”; in order for caringto survive, the values that underlienursing have to be realized—for exam-ple, advocacy and respect for otherhuman beings. Roach15 emphasizes thedual nature of caring—attitudes andvalues on the one hand, and action onthe other. She describes the six C’s ofCaring as Compassion, Competence,Confidence, Conscience, Commitment,and Comportment. Roach argues thatcaring is the human mode of being,and that nursing is the professionaliza-tion of human caring.16 Compassionbrings sensitivity to the experiences ofanother person, Competence brings theknowledge and skills necessary to re-spond appropriately, Confidence fosterstrust, Conscience implies moral aware-ness, and Commitment leads to invest-ment of time for the person beinghelped. Comportment reflects a sincereattitude and demeanor of concern forthe patient’s total well-being—includ-ing the spiritual component.

Wikberg and Eriksson17 maintain

that caring is not only the essence ofnursing care, but also the subject ofnursing science. They believe that thereason for caring is suffering and themotive of caring is to alleviate suffer-ing. To these authors, caring is notbehavior, but a way of living demon-strated in the spirit of the relationshipbetween the caregiver and the carereceiver. They describe that spirit ascaritative.

Eriksson18 explains that caring isnot limited to one discipline such asnursing, and that each brings its ownunderstandings and methods to howcaring is practiced. The assumptionsunderlying her theory are compatiblewith Adventist beliefs. For example,she describes the human being as areligious entity composed of body,soul, and spirit; and says that caringis an act of compassion and love inresponse to human suffering. Themission of the human being, accord-ing to Eriksson, is to serve, to exist forthe sake of others.19 Caring is mani-fested in a relationship to anotherhuman being; and such relationshipsinvolve ethics, respect, and regard for

the dignity and rights of the other. In nursing education, students

learn best about caring by experienc-ing caring interactions with their men-tors. Students defined instructor-car-ing as an “awareness of a mutual andreciprocal connection between the selfand the instructor that enables themto search for meaning and wholenessand grow as caring professionalnurses.”20 Caring is communicatedsubtly by faculty through their teach-ing and interactions with students.21

Beck described caring interactions asmutual simultaneous dimensions ofintimacy, connectedness, sharing, andrespect.22 Tools have been developedto measure perceptions of instructorcaring.23 Faculty caring behaviors canalso be rated by nursing students ac-cording to the six C’s of Caring byRoach24 described earlier. When nurs-ing students perceive a strong caringconnection among nursing faculty andbetween faculty and students, they areempowered to strengthen the caringconnection with their patients and toprovide spiritual care.25

ConnectingThe idea of connecting as an over-

arching construct for Adventist nurs-ing practice and education emergedfrom statements and conceptual ele-ments in the data—for example, refer-ences to social interaction, therapeu-tic communication, presence, activelistening, and a personal relationshipwith God (see Table 3). From thesestatements, and in agreement withEriksson, the researchers believe that“To connect is, arguably, one of themost fundamental human needs . . .and a significant dimension of what itmeans to be human.”26 Whether it isconnecting in a family or a commu-nity, connection with others is basicto human well-being. Furthermore,healthy relationships on all levels re-quire authentic connecting with theself. And, above all, connecting withGod is essential, for through that con-nection we are empowered to connect


Table 4. Quotes Related to Sub-concepts Identified

During Selective Coding

Mission

Beliefs

Sub-Concepts

Values

Ethics

Quotes

Restoration of the image of God in human beings

Reflect Christ’s healing ministry to the whole person—includingthe spiritual

• Love, Empathy, Excellence, Kindness, Integrity, Respect, Loyalty,Hope, Service, Trustworthiness, Commitment, Equality, Justice,Human rights, Charity

We believe in the sanctity of life.

• God is the giver of life.

• We are temples of the Holy Spirit.

• Each person is a child of God.

• Every human being is worthy of dignity and respect.

• Every human being has a right to live.

• Nurses should promote and preserve human dignity.

• Nurses advocate and act for the welfare of others.

with others. Even individuals on theautistic spectrum, for whom connect-ing is difficult, acknowledge the needfor connectedness with God.27

Ellen G. White wrote that “Christcame to the earth and stood beforethe children of men . . . that throughour connection with Him we are toreceive, to reveal, and to impart.”28

“Our growth in grace, our joy, ourusefulness—all depend on our unionwith Christ. It is by communion withHim . . . that we are to grow ingrace.”29 One nursing author has de-scribed life as a journey of connec-tions and disconnections—physical,psychological, and spiritual.30 An-other pointed out that evidence isstrong that connection to others islinked to positive outcomes, particu-larly in times of stress and trauma.31

The concept of presence wasspecifically mentioned in the data. Al-though hard to describe, most nursesknow that being fully present for apatient can have a healing effect onthe spirit and body of the personneeding care. Similarly, therapeuticcommunication and active listeningmay be healing interventions. Thenurse’s personal relationship withGod influences and contributes tothis presence, and can be communi-cated through prayer or even silence.

Connecting is a powerful factor inthe teacher-student relationship aswell. In the data, it was clear thatmentoring, facilitating, and coordinat-ing learning experiences are neces-sary. In order for teachers to facilitatelearning and to mentor effectively,interactive exchanges are vital forthe teacher and student to connectdeeply, and for the student to feelheard and understood.

Feely and Long32 developed a the-ory of connectivity to guide nursingpractice with patients experiencingdepression. They describe connectivecare as a process of using the self toconnect human beings to one an-other; similarly, they describe the selfas the soul or spirit of the person—the being, seeing, thinking, and feel-

ing aspects of the person. Connectingwith family members is an importantintervention for nurses who are caringfor individuals, and connecting familymembers with one another is an ef-fective intervention in family nursingpractice. Connecting clients with thehuman and technical resourcesneeded to facilitate wellness empow-ers clients and increases their energyfor growth, recovery, and wholeness.33

EmpoweringEmpowering nurses to provide

quality care and improve patient out-comes has been propagated since thebeginning of modern nursing by Flo-rence Nightingale.34 Empowerment—possessing the power to have influ-ence over someone or something—is adynamic concept that permeates allaspects of nursing practice and educa-tion. Nurses need to not only be em-powered themselves35; it is also theirresponsibility to empower clients forself-care and wholistic health improve-ment.36 Nurse educators similarly needto empower students for lifelonglearning and ongoing professional de-velopment.37 A continuous cycle ofempowerment is thus created.

Types of power described in the lit-erature include legal, coercive, remu-nerative, normative, and expert.Nursing is particularly interested inexpert power.38 Although knowledgeis one of the first steps toward devel-oping expert power, much more is re-quired for empowering than an accu-mulation of knowledge. In the modelpresented in this article, empoweringinvolves inspiring and motivating pa-tients and students to reach theirgoals of being healthy, to challengeexisting paradigms, to embracechange, to face adversity, and to per-sist, overcome, and conquer difficul-ties in the path to wholistic well-being. Much of the inspiration andmotivation needed for empowermentis done through role-modeling andmentoring.

Students and clients need to feelvalued. Advocating, inspiring, andmotivating (concepts important in the

process of empowering) require con-necting with the Source of life andwith the individuals one desires toempower. According to Ellen White,Christ revealed the secret of a life ofpower, which was communion withHis heavenly Father. He frequentlywent away to the sanctuary of themountains to be alone with God, andwhen He returned, the disciplesnoted a look of freshness, life, andpower that seemed to pervade Hiswhole being.39 Ellen White also ad-monished Adventist nurses that “ifyou have a living connection withGod, you can in confidence presentthe sick before Him. He will comfortand bless the suffering ones, moldingand fashioning the mind, inspiring itwith faith and hope and courage.”40

However, in certain situations,change is still dependent on the avail-ability of resources. For example, stu-dents need mentors, scholarships, androle models. Clients need facilitatorsto connect them with resources spe-cific to their health needs. In eachcase, as wholistic beings, an increasein one resource can inspire, providehope, and empower energy in anotherarea of health or growth. Thus, con-necting with resources can increaseenergy and empower growth toward ahigher level of health potential.41

The Model

The three constructs just de-scribed, caring, connecting, and em-powering, are actually three processesin which nurses and nurse educatorsengage when caring for the sick, pro-moting well-being, and when educat-ing nursing students to become pro-fessional nurses. The informants inthis research project representednursing practice and nursing educa-tion. Thus, the relevance of theseconstructs for both nursing care andnursing education is part of the sig-nificance of the model as a frame-work for Adventist nursing.

When these three constructs areplaced together in overlapping circles,


the central component area that theyshare can be interpreted to representAdventist nursing (see Figure 1).However, these constructs don’t standalone. Nursing practice, and educa-tion, occur in an environment that in-corporates the individual humanbeing, the families with whom the in-dividual interacts, and the communi-ties in which individuals and familieslive. All exist and function in an envi-ronment that encompasses natural,socio-cultural, political, and materialaspects. Beyond the individual andenvironmental contexts is the over -arching power of God, the Creator ofhuman beings, the environment, andindeed the universe. Thus, Adventistnursing is viewed from a philosophi-cal perspective that is grounded in aChristian view of the inherent spiri-tual nature of human beings who in-teract with their environment andwith God in achieving well-being and

wholeness. Accordingly, the con-structs depicted in this model providea framework that can guide the prac-tice of nursing as well as the processof educating students to engage inthe ministry of wholistic nursing care(see Figure 1).

Caring, for example, reflects theheart and soul of nursing practice. Inthe data, caring was described as overand above the usual level of care thatis expected from a health professional,and as “caring beyond the ordinary.”Such caring emanates from a profoundrespect for the individual as a child ofGod, and a deep desire to show God’slove to the person in need. The sameis true for the teacher who views stu-dents as sons and daughters of God,and respects their potential to growand become all that God intended.This level of caring implies faith ineach student’s ability to learn and a

commitment to invest time and energyto help him or her achieve success.

Connecting is perhaps the most con-crete of the three concepts. Becausehumans were created as social beings,connecting is crucial to their survival.Being connected with another humanbeing—family, friends, community,and other sources of support—canmake the difference in learning, grow-ing, healing, and well-being; however,the ultimate source of all power is con-nection with God and the Holy Spirit.

Empowering, or empowerment, re-sults from assisting the client or stu-dent to access the resources needed forrecovery from illness, or to achievehealing, learning, or growth. Depend-ing on the individual, resources mayinclude one or more of the basichuman needs for food, water, rest, fi-nances, or a place to live. But beyondphysical and material needs, it can in-clude a need for hope, faith in oneself,and insights on how to solve a prob-lem. One-on-one mentoring can inspirethis hope, as well as clarify or role-model a skill. Beyond the power ofhuman connectedness, whether it bethe nurse, educator, client, or student,when the spiritual core of the humanbeing is connected with God, the indi-vidual is empowered for healing,growth, and wholeness.

Application of the Model as a Curriculum

Framework

The significance of this integrativemodel and its constructs in relation tonursing education lies in its potentialto guide the educational process, in-cluding curriculum development, toenhance the relationship betweenteachers and students, and to rein-force the values on which curriculaare based. When integrated into aconceptual framework, these con-structs reflect an Adventist perspec-tive of nursing and nursing educa-tion, which can have a pervasiveinfluence on the entire educationalexperience of the student.

Therefore, program administratorswho seek to prepare new nursing pro-fessionals who are ethically grounded


CONNECTIN

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Figure 1. An Integrative Global Framework for Nursing Education and Practice

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in the values identified by Adventistnurses globally, who subscribe to theconstructs derived from the data inthis research project, and who desireto maintain the legacy of Adventistnursing, can examine this frameworkfor its potential to contribute toachievement of their program goals.

For example, in May 2016, the fac-ulty and administrators at SouthernAdventist University School of Nurs-ing (SAU) in Collegedale, Tennessee,U.S.A., went through the process ofreviewing the mission, philosophy,and framework of their program inpreparation for an upcoming accredi-tation. In so doing, they consideredhow the proposed new model, al-though early in its formation, wouldfit with their mission and guide theachievement of their program goalswhile simultaneously maintaining thelegacy of Adventist nursing.

The faculty found the constructs ofcaring, connecting, and empoweringto be entirely congruent with theirbeliefs about nursing and, as a result,voted to adopt this evidence-basedAdventist nursing model as the foun-dation of their new curriculum frame-work. After this step, the faculty en-gaged in the process of adapting it tothe specific objectives of their pro-gram, focusing on what is essential inthe preparation of not only an “Ad-ventist nurse” but specifically a “SAUNurse,” a step that is congruent withthe original intent of the model. Inother words, each school that adoptsthe model has the opportunity toadapt it to focus on the unique quali-ties of the professional nurse it aimsto prepare while maintaining thelegacy of Adventist nursing.

Summary

The evidence-based model pre-sented in this article represents theperspectives of Adventist nurses andnurse educators from 10 divisions ofthe world church of Seventh-day Ad-ventists. It captures the legacy andmission of Adventist nursing and pro-

vides a framework that, when ap-plied, has the potential to guide thedevelopment of Adventist nursing ed-ucation and the preparation of excep-tional professional nurses globally. ✐

This article has been peer reviewed.

Patricia S. Jones,PhD, RN, FAAN, isDistinguishedEmerita Professorat Loma Linda Uni-versity School ofNursing, LomaLinda, California,

U.S.A., and Associate Director of the De-partment of Health Ministries in theGeneral Conference of Seventh-dayAdventists in Silver Spring, Maryland,U.S.A. Dr. Jones has also taught at theAdventist University of the Philippines,Hong Kong Adventist College, and Van-derbilt University. She completed a bach-elor’s degree in nursing at Walla WallaCollege (now University), a Master’s de-gree from Andrews University, and Mas-ter’s and doctoral degrees from Vander-bilt University in Nashville, Tennessee.

Barbara R. James,PhD, RN, CNE, isDean and Professorat Southern Ad-ventist Universityin Collegedale,Tennes see, U.S.A.Her BS in nursing

was completed at Southern MissionaryCollege, her MSN at the University ofTexas, Arlington, Texas, U.S.A., and herPhD in occupational health and nursingeducation at the University of Alabamaat Birmingham, U.S.A. Dr. James hasbeen on the faculty at Southern’s Schoolof Nursing since 1991 and Dean since2005. Her research interests are in inter-professional collaborative education viasim u lation, health promotion, con temp - o rary teaching strategies, and just cul-ture. She has a strong interest in cur-riculum and faculty development withsister institutions both nationally and

internationally and has served as co-chair of the Adventist InternationalNursing Education Consortium—NorthAmerica and internationally as a sitevisitor for the Adventist Accrediting As-sociation of Schools, Colleges, and Uni-versities (AAA) and the InternationalBoard of Education (IBE).

Joyce Owino, PhD,RN/M, is a Regis-tered Nurse/Mid-wife. She hasworked as a nursefor 30 years invarious countries,institutions, and

capacities including clinical nursing,community health nursing, nursing re-search, nursing education, and nursingadministration. Dr. Owino earned herMaster’s in Health and Nursing Studiesfrom Reading University, U.K., and herdoctorate in Community Health and De-velopment from Great Lakes Universityof Kisumu, Kenya. She is a Senior Lec-turer in the School of Nursing at the Uni-versity of Eastern Africa, Baraton, whereshe currently teaches community healthnursing, leadership, and management toundergraduate students, and advancedcommunity health nursing, professional-ism, and research to post-graduate stu-dents. She has authored several booksand research articles.

Marie Abemyil,MSc, RN, RM, is aNurse Midwife witha Master’s degreein nursing fromLoma Linda Uni-versity. She has 32years of clinical ex-

perience in leadership positions both inchurch and public settings, and 17 yearsof teaching. She pioneered higher educa-tion in nursing in the Francophone partof Cameroon and Central Africa. Inrecognition for her services, she hasbeen awarded three medals by the Gov-ernment of Cameroon (Silver, Vermeil,and Gold). At present, she is the Direc-tor of the Higher Institute of Health Sci-


ence at Université Adventiste Cosendai,Nanga-Eboko, Cameroon.

Angela Paredes deBeltrán, PhD, RN,is Professor and Di-rector of the Gradu-ate School ofHealth Sciences atUniversidad Peru-ana Unión (UPeU)

in Lima, Peru. She earned her doctoratein teaching and curriculum from UPeU,and has served in several administra-tive roles such as director of the schoolof nursing, director of Adventist Inter-national Nursing Education Consor-tium, and dean of the health sciencesdepartment. Dr. Beltrán’s most recentpublication is Ética Cristiana en la En-fermería (Christian Ethics in Nursing)(Universidad Peruana Unión: Fondo Ed-itorial, 2017).

Edelweiss Ramal,PhD, RN, is an As-sociate Professor inthe graduate nurs-ing program atLLUSN. She hasbeen a nurse edu-cator for 40 years:

25 of which were spent in Mexico andBotswana, 15 in the United States.

6. Ellen G. White, The Ministry of Healthand Healing (Nampa, Idaho: Pacific Press,2004). This is a contemporary adaptation ofEllen White’s book The Ministry of Healing,which was published in 1905.

7. Ibid., 287.8. Unless stated otherwise, all Scripture

references are taken from the New RevisedStandard Version (NRSV) New Revised Stan-dard Version Bible, copyright © 1989 the Di-vision of Christian Education of the NationalCouncil of the Churches of Christ in theUnited States of America. Used by permis-sion. All rights reserved.

9. Ellen G. White, The Ministry of Heal-ing (Mountain View, Calif.: Pacific Press,1905).

10. __________, The Ministry of Healthand Healing, 145.

11. Ibid., 234, 235.12. __________, The Ministry of Healing,

301. 13. Jean Watson, “Nursing: The Philoso-

phy and Science of Caring,” Nursing Admin-istration Quarterly 3:4 (Summer 1979): 86,87; M. Simone Roach, “Caring: The HumanMode of Being,” in Caring in Nursing Clas-sics: An Essential Resource, Marlaine C.Smith, Marian C. Turkel, and Zane RobinsonWolf, eds. (New York: Springer, 2013), 165;Madeleine M. Leininger, “Transcultural CareDiversity and Universality: A Theory ofNursing,” Nursing and Health Care: OfficialPublication of the National League for Nurs-ing 6:4 (April 1985): 208; Katie Eriksson,“Caring Science in a New Key,” Nursing Sci-ence Quarterly 15:1 (January 2002): 61-65.

14. Sara T. Fry, “The Ethic of Caring: CanIt Survive in Nursing?” Nursing Outlook 36:1(January-February 1988): 48.

15. Roach, “Caring: The Human Mode ofBeing,” 165.

16. Ibid.; Tanya V. McCance, Hugh P.McKenna, and Jennifer R. P. Boore, “Caring:Theoretical Perspectives of Relevance toNursing,” Journal of Advanced Nursing 30:6(December 1999): 1388-1395.

17. Anita Wikberg and Katie Eriksson,“Intercultural Caring: An Abductive Model,”Scandinavian Journal of Caring Sciences 22:3(September 2008): 485-496.

18. Eriksson, “Caring Science in a NewKey.”

19. Ibid.20. Gail Holland Wade and Natalie Kas -

per, “Nursing Students’ Perceptions of In-structor Caring: An Instrument Based onWatson’s Theory of Transpersonal Caring,”Journal of Nursing Education 45:5 (May2006): 162-168.

21. C. A. Tanner, “Caring as a Value inNursing Education,” Nursing Outlook 38:2(March-April 1990): 70-72; Edelweiss Ramal,“Perspectives and Perceptions: Spiritual Careand Organizational Climate in ChristianSchools,” Journal of Christian Nursing 27:2(April-June 2010): 91-95.

22. Cheryl Tatano Beck, “How StudentsPerceive Faculty Caring: A PhenomenologicalStudy,” Nurse Educator 16:5 (September/Oc-tober 1991): 18-22.

23. Gail Wade and Natalie Kasper, “Nurs-ing Students’ Perceptions of Instructor Car-ing”; Joanne Duffy, “Caring AssessmentTools,” in Assessing and Measuring Caringin Nursing and Health Science (New York:Springer, 2002); Deborah Hatton, “Develop-ment of a Tool to Measure Student Percep-tions of Instructor Caring,” Journal of Nurs-ing Education 32:3 (March 1993): 142, 143.

24. Roach, “Caring: The Human Mode ofBeing.”

25. Ramal, “Perspectives and Percep-tions: Spiritual Care and Organizational Cli-mate in Christian Schools.”

26. Christopher Barber, “On Connected-ness: Spirituality on the Autistic Spectrum,”Practical Theology 4:2 (April 2011): 201-211.

27. Ibid.28. White, The Ministry of Health and

Healing, 17.29. __________, Steps to Christ (Moun-

tain View, Calif.: Pacific Press, 1892), 69.30. M. Feely and A. Long, “Depression: A

Psychiatric Nursing Theory of Connectivity,”Journal of Psychiatric and Mental HealthNursing 16:8 (June 2009): 725-737. doi:10.1111/j.1365-2850.2009.01452.x.

31. Katie Schultz et al., “Key Roles ofCommunity Connectedness in Healing FromTrauma,” Psychology of Violence 6:1 (Janu-ary 2016): 42.

32. Feely and Long, “Depression: A Psy-chiatric Nursing Theory of Connectivity.”

33. Patricia S. Jones and Afaf I. Meleis,“Health Is Empowerment,” Advances inNursing Science 15:3 (March 1993): 1-14.

34. Louise Selanders and Patrick Crane,“The Voice of Florence Nightingale on Advo-cacy,” The Online Journal of Issues in Nurs-ing 17:1 (January 2012): Manuscript 1.

35. Milisa Manojlovich, “Power and Em-powerment in Nursing: Looking Backward toInform the Future,” The Online Journal of Is-sues in Nursing 12:1 (January 2007): Manu-script 1.

36. Jaquelina Hewitt-Taylor, “Challengingthe Balance of Power: Patient Empower-ment,” Nursing Standard 18:22 (February2004): 33-37.

37. Caroline Bradbury-Jones, Sally Sam-brook, and Fiona Irvine, “The Meaning ofEmpowerment for Nursing Students: A Criti-cal Incident Study,” Journal of AdvancedNursing 59:4 (June 2007): 342-351.

38. Patricia E. Benner et al., EducatingNurses: A Call for Radical Transformation(San Francisco, Calif.: Jossey-Bass, 2009).

39. White, The Ministry of Health andHealing.

40. __________, Medical Ministry (Moun-tain View, Calif.: Pacific Press, 1932), 115.

41. Jones and Meleis, “Health Is Em -powerment.”


NOTES AND REFERENCES1. Patricia Jones, Marilyn Herrmann, and

Barbara James, “Adventist Nursing Educa tion:Mission or Market?” The Journal of AdventistEducation 71:4 (April/May 2009): 10-14.

2. Merk & Co. Inc., “Conversation MapProgram. Journey for Control Educator,”(2008): http://educator.journeyforcontrol. com/diabetes-educator; Gertrude Torres,“Curriculum Implications of the ChangingRole of the Professional Nurse,” in Faculty-Curriculum Development, Part V. TheChanging Role of the Professional Nurse:Implications for Nursing Education (NewYork: National League for Nursing, 1975).

3. Kathy Charmaz, ConstructingGrounded Theory: A Practical Guide ThroughQualitative Analysis (Introducing QualitativeMethods Series) (Thousand Oaks, Calif.:Sage Publications, 2006).

4. Ibid.5. Torres, “Curriculum Implications of the

Changing Roles of the Professional Nurse.”

B Y D O L O R E S J . W R I G H T a n d J A C Q U E L I N E W O S I N S K I


NURSINGCURRICULUM

CORECOMPONENTS

OF THE

nowledge, whether cultural or professional, ispassed from one generation to the next. This is truein families, in societies, and in professions like nurs-ing. However, knowledge of the art and science ofnursing cannot be “passed on” without some type

of structure. When formal, systematic methods are used totransmit knowledge, especially in an academic setting, theprocess and product are often referred to as the curriculum.This article will provide both novice and veteran nurse edu-cators with the core components of nursing curricula suchas stakeholders, paradigm shifts, curricular models, levels ofeducation, and evaluation. Other articles in this issue of theJOURNAL will give more attention to specific curricular contentsuch as spiritual and cultural care (see pages 20 and 26).

Definitions

Before discussing nursing curriculum, key terms need tobe defined. The American Nursing Association defines nurs-ing as “the protection, promotion, and optimization of healthand abilities, prevention of illness and injury, facilitation ofhealing, alleviation of suffering through the diagnosis andtreatment of human response, and advocacy in the care ofindividuals, families, groups, communities, and popula-tions.”1 The International Council of Nurses builds on thisdefinition by adding that nursing encompasses autonomousand collaborative care of individuals of all ages, sick or well,and in all settings; the promotion of a safe environment; re-

search; as well as participation in shaping health policy andin-patient and health-systems management.2

Education has employed curriculum definitions for al-most 200 years.3 The traditional definition includes the reg-ular course of study in a school or college or the group ofcourses of study given at a school, college, or university4; al-though, over time, the definition has greatly expanded to en-compass all of the planned learning experiences, both inschool and out of school.5

The nursing curriculum has traditionally been skills-basedand test-driven, relying heavily on behavioral objectives toassess techniques and processes. Over time, curricular goalshave changed, and nurses are now trained and prepared toengage in critical decision-making and innovative practice.As a result, nursing as a professional practice needs curriculathat can articulate learning experiences with goals, theory,and evidence-based content, as well as ethical and philosoph-ical underpinnings,6 in order to address contextualized andcurrent public-health priorities and community needs.7

Curriculum is conveyed in several different ways. Thereis the legitimate or official curriculum which Bevis and Wat-son8 assert is “the one agreed on by the faculty either implic-itly or explicitly” containing the ethical framework that in-corporates the philosophy and mission of the univer sity/ college and school/department. This framework is imple-mented through agreed-upon program- and student-learningoutcomes, competencies, individual courses, course outlines,

K

and syllabi. The official curriculum is formalized into writtendocuments that are sent to accrediting agencies and sharedwith faculty, students, curriculum committee members, andother committees as appropriate.

Beyond the legitimate curriculum, there are other types ofcurricula. In the late 1960s and into the 1970s, Jackson andSnyder observed that students often acquired unintended les-sons while in school (college or university), referring to theselessons as the latent or hidden curriculum.9 However, edu-cators recognize that students also absorb norms, values, andbeliefs from the social environment of the school, such aswhen they engage in planned activities such as service learn-ing.10 These complementary features of curriculum demon-strate the dynamic and varied aspects in the field of educa-tion in general and nursing education specifically.

Thus, several common components, both stated and as-sumed, coexist in the definitions of curriculum. There are pre-selected goals or outcomes to be achieved.Content is selected and presented in a spe-cific sequence in the program of study toachieve the desired levels of mastery ordegree. Processes and experiences that fa-cilitate learning for the traditional learneras well as the adult learner are identified.Resources must be identified and madeavailable. Responsibility for learning is de-termined by the learner and the teacher,and where and how learning occurs maybe identified.11 Because of the variety ofperspectives, another way to interpret cur-riculum may be as follows: “1) knowledgeorganized and presented in a set of sub-jects or courses; 2) modes of thought; 3)cognitive/affective content and process; 4) instructional set ofoutcomes or performance objectives; 5) everything planned byfaculty in a planned learning environment; 6) interschool ac-tivities, including extracurricular relationships; 7) individuallearner’s experiences as a result of schooling.”12 A faculty, then,in consultation with professional, accrediting, and governmentassociations, must make decisions about how each componentof the curriculum will be conveyed and implemented.

Since faculty have individual teaching styles and aca-demic freedom, there must be an operational curriculum.This is what each teacher is required to transmit in areas ofknowledge, skills, and attitudes. This is the curriculum thatis communicated to the students. The assessed curriculumis that which is tested and evaluated, and the learned cur-riculum is what the student actually learns, which is some-times not what the teachers think they taught.

In nursing, as in other fields, not everything can be taughtto students. Some content and skills are intentionally or in-advertently left out, possibly because there is not enoughtime in the schedule, or the content has not risen to a levelof significance to warrant inclusion in the curriculum, or thecontent is deemed controversial by decision makers and in-

tentionally excluded from the curriculum. Many nurse edu-cators refer to this as the “null” curriculum.13 Bevis and Wat-son14 assert that, in addition to factual content, faculty alsoattempt to teach certain behaviors such as caring and com-passion. However, dispositions such as caring and compas-sion are not quantifiable into behavioral objectives that canbe measured adequately or easily evaluated. For this reason,Bevis and Watson15 call this the “illegitimate” curriculum. Il-legitimate not because they are illegal or unsanctioned be-haviors that should not be taught, but because these dispo-sitions do not lend themselves to be described as behavioralobjectives and are difficult to measure and assess.

Stakeholders

Curriculum stakeholders include the educational institu-tion, its board of trustees, individual schools within the in -stitution, faculty, students, and the public who support the

institution. Equally important are govern-ment regulatory bodies, accrediting agen-cies, hos pitals and clinics that partnerwith nursing programs, and professionalorg aniza tions. Each of these groups maydefine curriculum differently. For exam-ple, for a number of years, state boards ofnursing in the U.S. evaluated a school’scurriculum using a behaviorist model, sonursing schools had to define their pro-jected learning outcomes using behaviorallanguage such as this: “By the end of thiscourse, the student will be able to demon-strate sterile technique.” While this is justone example, it shows that curriculumcan be influenced by government require-

ments, professional standards, societal needs, institutionalgoals, faculty plans and purposes, and students’ interests andneeds. Some of these layers of influence may unintentionallyconflict with others in curriculum development.16 Because thefaculty are usually the ones tasked with curriculum develop-ment or revision, they must consider and contend with all ofthe stakeholders and groups who influence a curriculum.

One might consider humanity at large as one such stake-holder because many issues that humans face are generatedand experienced on a global scale. These include natural dis-asters, changing demographics, increase in use of technol-ogy, emerging diseases, war and terrorism, climate change,and drug-resistant organisms. In previous times, these issueswere rarely part of any course a nursing student would take.However, nursing education must now include topics in itscourses (curriculum) that address not only local but also na-tional and international issues relating to the health of thosecared for by its graduate nurses.17

The Goals of Curriculum

Nursing faculty instruct and train on the premise that thegoal of curriculum is to facilitate the learning processes that


enable students to acquire a knowledge base and developconfidence regarding their competence to implement appro-priate strategies to adapt to the complex and shifting envi-ronment of the health-care industry.18 In other words, theybelieve nursing students and graduates need a knowledgebase from which to rationalize and verify their nursing in-terventions when providing care. However, nursing facultyalso agree, and have long since concluded, that the neces-sary knowledge base is broader than merely the nursingcourse content. It must also include foundations in naturalscience, social science, the humanities, communication, nu-trition, physical education, and bioethics and/or religion.19

Paradigm Shift

A major paradigm shift has occurred in nursing education.While nurses used to be “trained” to perform cer tain skills,they now receive an “education,” which in cludes training inhow to think critically, analyze situa tions, and collaboratewith physicians and other medical professionals in managingand making decisions about patient care. Nurses, more thanany other medical pro fessionals, are with patients 24/7. Forthis reason, they have a significant role and must be involvedin the decision-making process. The paradigm shift includesa change from the memorization of specific techniques tounderstanding the rationale behind each step of the process;from memori zation of content to developing the skills andwisdom to make appropriate clinical decisions based onsound judgment; from product thinking (focusing on the taskand process) to values-based human caring (focusing on theperson), and from maintenance-adaptation learning (doingthings the way they have always been done) to anticipatory-innovative learning (intentionally seeking creative, inno vativesolutions to problems.)20 Thus, rather than being static,modern nursing curricula are dynamic and fluid, and willcontinue to change.

Four major recommendations emerged from a recent studyfunded by the Carnegie Foundation21: (1) Students should betaught how to “think like a nurse”; (2) Classroom and clinicalteaching should be integrated in order to replicate the realitiesof nursing practice; (3) Students should be taught multipleways of thinking, including scientific reasoning, clinicalreasoning, and use of the imagination; and (4) Studentsshould learn to internalize what it means to be a professional.These recommendations, when put into practice, would focusnursing educators toward new ways to think about curricula.

Curricular Models

The organization of curriculum is usually based on oneof three models: block, concept-based, or competency-based:

1. A block curriculum is the most traditional, with contentbeing taught according to medical condition, specialty, orage of the patients.22 However, in some areas of the world,block curriculum has another meaning. Not only does it referto content organized by medical condition, specialty, ordevelopmental age, but it also refers to all content (theory)

being taught in the classroom for several weeks, after whichnursing students spend several weeks at various facilities fortheir clinical experiences. This may be necessary due to theconstraints of the available hospitals or clinics, but it is oftensimply a matter of tradition.

In keeping with the report on nursing education by Ben -ner and colleagues,23 which emphasized the integration ofnursing theory and clinical experience, some U.S. statescur rently do not accept transcripts from countries whosenursing education uses a block curricular structure. Nursesfrom these countries who immigrate to the U.S. may beasked to repeat certain nursing courses to meet the Americanrequirement for integrating theory and clinical experience.24

2. A concept-based curriculum-design model focuses onintegrating core nursing concepts into the curriculum at theplanning stage. Concepts such as pain, inflammation, elimina -tion, human development, addiction, etc., are used to developthe curriculum.25 These concepts become the foci of courses.Faculty guide students through learning experi ences thatdemonstrate how the concepts are expressed in various settingswith different populations. For example, the concept of painmay be woven through several courses, where the studentlearns about the pathophysiology of pain, the causes andprimary characteristics of pain, situations that may exacerbatepain, and how to evaluate and treat or relieve pain. Each coreconcept could likewise be woven as a thread through variouscourses in this type of curriculum.

3. A competency-based curriculum-design model has ob -servable and measurable goals that the student must reach tobe deemed competent. This type of curricular structure allowsstudents to progress at different speeds but may be dauntingfor students transitioning from a behavioral learning-theoryapproach to a more cognitive and construc tivist theoreti calperspective of learning.26 All nursing curri cula incorporate sometype of measured competencies, but the whole curriculum isnot always built around them. The World Health Organization(WHO) has chosen a comp etency-based approach for its pro -totype curricula for nursing and midwifery.27

Levels of Nursing Education

Many areas in the U.S. allow high school graduates tocomplete a short nursing program that qualifies them tobecome licensed practical or vocational nurses, who workunder the supervision of a registered nurse or a physician.28

In the U.S., these programs usually require from 12 to 14months of coursework before the student is eligible to takethe examination to become a licensed practical nurse (LPN)or licensed vocational nurse (LVN). Similar programs inother parts of the world lead to the title of nursing assistant,technical nurse, or A2 nurse. An LPN/LVN can continueeducation toward becoming a registered nurse (RN) byenrolling in hospital-based RN programs, where available,to prepare for the RN licensing exam, or in two- or four-yearnursing programs to earn an associate degree in nursing(ADN) or baccalaureate degree in nursing (BSN).


Even though the International Council of Nurses has as oneof its goals to achieve standardization in professional nursingeducation worldwide,29 significant variation still exists: In theU.S. from the 1930s to the 1970s, hospital-based RN diplomaprograms were quite common. The programs, which usuallytook three years to complete, were developed by hospitals toensure a constant supply of nurses for their facilities. However,advancement in the profession was difficult for their grad -uates, as the programs offered no transferable credit.30 Al -though most hospital-based programs have been graduallyphased out or have partnered with colleges to offer either anassociate (ADN) or a baccalaureate degree (BSN), some stillexist without any academic partner. In the U.S., diplomaprograms can obtain accreditation by the National League forNursing, making their graduates eligible to take the licensingexamination and become registered nurses.

Schools in many parts of the world still offer two- orthree-year postsecondary professional programs that do notoffer transferable credits.31 In many African countries, wherethe prevalence of chronic diseases is increasing, curriculaare shifting from a focus on curing communicable diseases

to providing care for patients with chronic illnesses.In the early 1950s, the U.S. faced a nursing shortage con -

current with a rapid increase in the number of junior orcommunity colleges.32 These were the two main factors thatprompted the development of associate degree nursing(ADN) programs. Graduates from these programs wereeligible to take the RN licensing examination. Because ADNgraduates had earned college credit, they could enroll in afour-year college or university to complete a baccalaureateor higher degree. The ADN program is often referred to as atwo-year degree. While their students do study nursing fortwo years; in order to be accepted into the program, theymust have taken certain prerequisite courses that require ayear or two to complete. Thus, although the student hasspent at least three years acquiring an associate degree, heor she will have earned only lower-division credits, acquiredduring the last two years of the program.33

Baccalaureate nursing programs have been available inthe U.S. since the 1920s but did not achieve significantgrowth until the 1950s. These programs are based in seniorcolleges or universities and generally take four years tocomplete. The student usually must complete one to one-and-a-half years of prerequisites before being accepted intothe nursing program, although some nursing schools inte -grate their general-education courses throughout the curricu -lum. After completing the designated prerequisites, thestudent studies basic nursing courses, including leadership/ management. Historically, the hallmark of the baccalaureatenursing program has been the inclusion of a course inpublic-health nursing.34

In 1999, the education ministers of the European Uniondecided to apply a credit transfer system akin to the one usedin the U.S. to the whole education system.35 After a time ofadjustment among nurse educators, BSN programs aregathering momentum across the continent for two comple -mentary reasons: (1) the undergraduate program appeals tostudents who appreciate being able to earn transferablecredits; (2) the health-care system needs more nurses due tothe aging of the current practitioners.

Since 2000, the WHO has been pushing for the worldwideupgrading of nursing and midwifery education36 as a means toimprove worldwide health. Among others, the authors of acomparative study in China and Europe have demonstratedthat baccalaureate nursing education increases the quality ofcare, cost-effectiveness, and the retention of nurses as well aspatient satisfaction.37 Thus, schools in more and more countriesaround the world offer the Bachelor of Science in Nursing(BSN) degree. As a corollary, while nursing research has beenhistorically limited to English-speaking countries, it has gainedmomentum in Asia and is on the rise in Europe and Africa.

Curriculum Evaluation

For the past 50 years, nursing educators have incor -porated an in-depth system for curriculum evaluation thattakes a broader view than simple measurement of how


Resources

American Nurses Association offers several free resourcesthat can be used in the classroom and adopted into the curri culum.Tools for Nurse Educators: http://www.nursingworld. org/ Especially ForYou/ Educators/Educator-Tools.

National League for Nursing provides curriculum resourcesand toolkits on a variety of topics such as Effective Inter pro -fessional Education, Faculty Preparation for Global Experi ences,Faculty Toolkit for Innovation in Curriculum Design, and more.For additional information, visit http://www.nln.org/professional-development-programs/teaching-resources/toolkits.

The American Association of Colleges of Nursing offersseveral resources for nurse administrators and educators thatprovide guidelines and suggestions for curriculum design anddevelopment. This includes toolkits, Webinars, courses, curri -culum guidelines, and much more. For more information, visit:http://www.aacnnursing.org/Education-Resources/CurriculumGuidelines.

Recommendations

Provide Opportunities for Advanced Training

Colleges and universities should consider providing oppor -tunities for faculty to pursue advanced studies that includetraining in curriculum and instructional design and development.This could range from short, intensive courses to full-degreeprograms. For example, Loma Linda University offers an off-cam pus Master’s program that focuses on nursing education forfaculty from sister schools around the world, and the programincludes training in curriculum development.

Retain a Consultant

Colleges and universities should consider retaining a curri -culum design and development consultant who can help trainfaculty and assist with curricular components such as imple -men tation, assessment, and evaluation.

Box 1. Resources and Recommendations forProfessional Development

many of their students become registered nurses andwhether the programs achieve ongoing accreditation. Oneof the early curriculum evaluation systems, proposed byStuffelbeam in 1971, examined the “relationship of curri -culum elements . . . reflecting the integrated nature ofnursing curricula.”38 This model, known by the acronymCIPP, looked at planning (Context), structuring (Input),implemen ting (Process), and recycling (Product). Stuffel-beam ex panded the system in 1983 to include more in eachof the four areas in order to ensure a more wholisticexamination of the curriculum from the perspective of thestakeholders, faculty, and students. Although Stuffelbeam’ssystem has been used and taught throughout the world,nursing schools can adopt a number of other approachesthat similarly ensure a systematic evaluation. Iwasiw andGoldenberg39 list 13 different models.

A specific model is useful to guide the evaluation processso that a program’s merits and weaknesses can be identifiedand due consideration given to identifying areas that needextra attention. Curriculum evaluation is time-consumingwork, so many nursing schools have adopted a process of“ongoing” evaluation.40 They identify certain aspects of thecurriculum that must be evaluated yearly, while other areasreceive attention every three to five years. For example,yearly evaluations might include students’ exam pass rates(entitling them to become registered nurses) and exit in -terviews with graduating students. Similarly, every three tofive years, schools may choose to collect information fromemployers about their satisfaction with graduates, as well asinformation from graduates about how prepared they felt fortheir first job as a registered nurse.

Curricular evaluation by faculty tends to be beneficial inseveral ways. It may increase teachers’ awareness andappreciation for the curriculum, expand their ability todesign and implement their curriculum, help them developa deeper understanding of a variety of concepts in thecurriculum, encourage their commitment to evidence-basednursing education, and give them a sense of empowerment.Taking part in the curriculum development and reviewprocess will be relevant throughout their careers as a nursingeducators.41

Nurses who earn a baccalaureate degree are qualified tocontinue their education at the graduate level.42 In the U.S.,college graduates from other disciplines may enter a nursingprogram at the Master’s level, although they may need totake certain pre-requisite courses. Several specialties areavailable for nurses seeking advanced-practice degrees at theMaster’s level including nurse practitioner (NP), nursingeducator, and nursing administrator. There are also twotypes of doctoral education in the discipline: the doctor ofnursing practice (DNP), which is seen as a practice degreethat allows graduates to pursue a specific specialty area, andthe doctor of philosophy (PhD), which is understood to bea research degree. In most situations, graduate education isnecessary to enter the field of nursing education.

Conclusion

Many nurses enter the field of nursing education havingfirst been a preceptor for nursing students or a clinicalinstructor.43 Because they have discovered a love and talentfor teaching, they look for opportunities to do more in thefield of nursing education. Other nursing faculty are re -cruited by a nursing school’s administration because of theirclinical expertise or the degree they already hold. Somenurses choose to enter the field of nursing education becausethey want to share what they have learned or because theyhave the appropriate degree. In most of these cases, theprospective faculty member has not had course work or abackground in the underpinnings of the nursing educationsystem: curriculum development.

A novice nurse educator may feel utterly lost or over -whelmed when appointed to the curriculum committee orasked to serve on some aspect of the curriculum-evaluationprocess. For this reason, opportunities for in-service edu -cation and training in the area of curriculum design anddevelopment should be made available to nursing facultywho are actively engaged in these tasks. For the veterannurse educator as well as the novice, it is hoped that thisarticle’s definition of curriculum and of key areas involvedin developing and assessing it will be helpful when devel -oping or revising a nursing curriculum. ✐


Dolores J. Wright, PhD, RN, is Professorof Nursing at Loma Linda UniversitySchool of Nursing, Loma Linda, Califor -nia, U.S.A. She teaches on the BSc, MSc,and DNP levels. She also teaches PublicHealth Nursing, Home Health Nursing,Teaching Practicum, and CurriculumDevelopment. Her research interests in -

clude nursing education and inter-professional education.

Jacqueline Wosinski, PhD, RN, is Deanof the School of Nursing at the AdventistUniversity of Central Africa in Kigali,Rwanda. Her research interests include evi -dence synthesis, grounded theory and in -ter vention research in health promo tion,living with chronic diseases, cultural com -pe tence, and nursing education. She teaches

nursing theory, health promotion, and evidence-based practice.


NOTES AND REFERENCES1. American Nurses Association, “What Is Nursing?” (2017): http://

www.nursingworld.org/EspeciallyforYou/What-Is-Nursing.2. International Council of Nurses, “Definition of Nursing” (2017):

http://www.icn.ch/who-we-are/icn-definition-of-nursing/.3. Jon W. Wiles and Joseph C. Bondi, Curriculum Development: A

Guide to Practice, 9th ed. (London: Pearson, 2014). 4. Carroll L. Iwasiw, Mary-Anne Andrusyszyn, and Dolly Golden-

berg, Curriculum Development in Nursing Education (Burlington, Mass.:Jones & Bartlett, 2015), 4.

5. John Dewey, The School and Society and the Child and the Cur-riculum (Chicago: The University of Chicago Press, 1991) (Originallypublished in 1900); Forest W. Parkay, Eric J. Anctil, and Glen J. Hass,Curriculum Leadership: Readings for Developing Quality EducationalPrograms (Boston: Allyn and Bacon, 2010), 3.

6. Fred C. Lunenburg, “Theorizing About Curriculum: Conceptionsand Definitions,” International Journal of Scholarly Academic Intellec-tual Diversity 13:1 (2011): 1-6.

7. Diane M. Billings and Judith A. Halstead, Teaching in Nursing: AGuide for Faculty, 5th ed. (St. Louis, Mo.: Elsevier, 2015).

8. Em Olivia Bevis and Jean Watson, Toward a Caring Curriculum:A New Pedagogy for Nursing (London: Jones & Bartlett, 2000), 74.

9. Benson R. Snyder, The Hidden Curriculum (Boston: MIT Press, 1973).10. Neti Juniarti et al., “Defining Service Learning in Nursing Edu-

cation: An Integrative Review,” Padjadjaran Nursing Journal 4:2 (August2016): 200-212.

11. Billings and Halstead, Teaching in Nursing: A Guide for Faculty, 80. 12. Ibid. 13. Billings and Halstead, Teaching in Nursing: A Guide for Faculty,

80; Bevis and Watson, Toward a Caring Curriculum: A New Pedagogyfor Nursing.

14. Bevis and Watson, Toward a Caring Curriculum: A New Pedagogyfor Nursing.

15. Ibid.16. Billings and Halstead, Teaching in Nursing: A Guide for Faculty.17. ICN, 2006.18. Billings and Halstead, Teaching in Nursing: A Guide for Faculty.19. Bevis and Watson, Toward a Caring Curriculum: A New Pedagogy

for Nursing.20. Billings and Halstead, Teaching in Nursing: A Guide for Faculty, 80.21. Nine entry-level nursing programs in the United States were evaluated

and compared in this ethnographic study. Data collection included classroomobservations, a syllabus interview, and student and faculty interviews fromtwo core courses in the nursing curriculum. Web-based surveys were alsoused. For more information, see Patricia Benner et al., Educating Nurses: ACall for Radical Transformation (Hoboken, N.J.: Wiley, 2010).

22. Billings and Halstead, Teaching in Nursing: A Guide for Faculty.23. Benner et al., Educating Nurses: A Call for Radical Transformation.24. Nursing Practice Act, California Code of Regulations, Section

1426 (d & g) (n.d.): http://www.rn.ca.gov/practice/npa.shtml#ccr.25. Billings and Halstead, Teaching in Nursing: A Guide for Faculty.26. Fatemeh Aliakbari et al., “Learning Theories Application in Nurs-

ing Education,” Journal of Education and Health Promotion 4:2 (Febru-ary 2015). doi: 10.4103/22779531.151867.

27. WHO Regional Office for Africa, Three-year Regional PrototypePre-service Competency-based Nursing Curriculum, Brazzaville, Congo(2016): http://hrh-observatoryafro.org/wp-content/uploads/2017/01/ PROTOTYPE-COMPETENCY-NURSING.pdf.

28. Janet M. Coffman, Krista Chan, and Timothy Bates, Trends inLicensed Practical Nurse / Licensed Vocational Nurse Education and Li-censure Examinations, 1998 to 2013 (San Francisco: University of Cali-fornia, 2015): http://healthworkforce.ucsf.edu/sites/ healthworkforce. ucsf.edu/files/Report-Trends_in_LPN-LVN_Education_and_ Licensure_ Examinations_1998-to-2013_v1.1.pdf.

29. International Council of Nurses, “The Global Nursing Shortage:Priority Areas for Intervention.”

30. Nursing Practice Act, California Code of Regulations, Section1426 (d & g).

31. Personal communication from Themba T. Thongola, principal ofthe Kanye Seventh-day Adventist College of Nursing in Kanye, Bots -wana, Africa, June 2016.

32. Elizabeth H. Mahaffey, “The Relevance of Associate Degree Nurs-ing Education: Past, Present, Future,” Online Journal of Issues in Nurs-ing 7:2 (May 2002): 11.

33. Lower-division credits are for the first two years, or freshmanand sophomore years of college leading to an associate degree. Four-year (baccalaureate) programs require not only undergraduate but alsoupper-division credits (taken during the junior and senior years) andconvey a BSN degree. One hour of classroom instruction each week dur-ing a semester or quarter equals one unit of credit. In a quarter system(10 weeks per quarter), one unit of credit indicates that a student hasspent 10 hours of in-class time; similarly, three hours of practice or clin-ical time each week (or 30 hours of practice during the term) also equalsone unit of credit. In a semester system (with 16 weeks per semester),one unit of credit would indicate that the student had spent 16 hours ina theory course or 48 hours of time in clinical practice. For more infor-mation, see Nursing Practice Act, California Code of Regulations,Section 1426 (d & g) (n.d.): https://www.google.com/search?q= https://govt.westlaw.+com/calregs/Document/+IECADF240CC+D411DF9+C2+DE816+E9BE2+880?+viewType%3DFullText+origination+Context%3Ddocumenttoc%26+transitionType%3DCategory+PageItem%26contetData%3D(sc.Default).&spell=1&sa=X&ved=0ahUKEwickZSomJLYAhVM6yYKHb1EBQcQBQgmKAA.

34. Janna Dieckman, “History of Public and Public Health andCommunity Health Nursing,” in Marcia Stanhope and Jeanette Lancas -ter, eds., Public Health Nursing: Population Centered Health Care in theCommunity, 9th ed. (St. Louis, Mo.: Elsevier, 1987): 22-43.

35. European Ministers of Education, The Bologna Declaration(1999): http://www.magna-charta.org/resources/files/BOLOGNA_DECLARATION.pdf.

36. WHO Department of Human Resources, Global Standards for theInitial Education of Professional Nurses and Midwives, Geneva, Switzer-land (2009): http://www.who.int/hrh/nursing_midwifery/ hrh_global_ standards_education.pdf.

37. Ann Kutney-Lee, Douglas M. Sloane, and Linda H. Aiken, “AnIncrease in the Number of Nurses With Baccalaureate Degrees Is Linkedto Lower Rates of Postsurgery Mortality,” Health Affairs 32:3 (March2013): 579-586. doi: 10.1377/hlthaff.2012.0504; Li-Ming You et al., “Hos-pital Nursing, Care Quality, and Patient Satisfaction: Cross-sectional Sur-veys of Nurses and Patients in Hospitals in China and Europe,” Interna-tional Journal of Nursing Studies 50:2 (February 2013): 154-161. doi:http://dx.doi.org/10.1016/j.ijnurstu.2012.05.003.

38. Iwasiw and Goldenberg, Curriculum Development in Nursing Ed-ucation, 2015, 371.

39. Ibid.40. Sarah B. Keating, Curriculum Development and Evaluation in

Nursing, 2nd ed. (New York: Springer, 2011).41. Iwasiw and Goldenberg, Curriculum Development in Nursing Ed-

ucation.42. Your Guide to Graduate Nursing Programs Brochure (Washington,

D.C.: American Association of Colleges of Nursing, 2013): http:// studylib.net/doc/8812385/your-guide-to-graduate-nursing-programs.

43. A preceptor for nursing is often a staff nurse with at least a BSNwho does not serve as teaching or adjunct faculty at a college or univer-sity. The preceptor’s role is to aid the student nurse during the transitionto an RN by modelling and guiding practice, often during a final prac -ticum course. A clinical instructor is often a full-time, part-time, or ad-junct faculty member. Clinical instructors typically have Master’s degreesand may serve as a preceptor coach. For more information, see “Preceptorand Clinical Faculty Roles With Undergraduate Students” in PreceptingGraduate Students in the Clinical Setting, Bette Case di Leonardi and MegGulanick, eds. (Chicago, Ill.: Loyola University Chicago, 2008), 131-151.


or almost a century and ahalf, Seventh-day Adventistshave provided spiritually sen-sitive health care to the sickand suffering. Providing

health care allows us to extend thecompassion of Jesus Christ, therebybringing benefit to others as well asjoy for ourselves through our service to God. In light of Adventism’swholistic understanding of beinghuman, care promoting physical orpsychological well-being inherentlyimplies supporting spiritual wellness.Consequently, in addition to the myr-iad of Adventist hospitals, outpatientclinics, skilled nursing facilities, andhome-health and hospice agenciesaround the world, there are dozens of

educational institutions training thou-sands of students to provide whole-person health care.

Among these Adventist institutionsof higher education are 75 Adventistschools of nursing. Europe and Aus-tralasia each have two; the rest aredistributed throughout Africa, Asia,and North, South, and Inter-Amer -ica.1 These schools of nursing, influ-enced by their Adventist distinctive-ness, seek to prepare their graduatesto provide wholistic nursing for body,mind, and spirit. Adventists are notunique in this regard—other Christiannursing schools (of which there aremany) likewise may teach their stu-dents to provide spiritually sensitivecare. Furthermore, many secularnursing programs (at least in severalEnglish-speaking Western countries)

are including curricular content aboutspiritual care because of professionalmandates.

Thus, the purpose of this article isto briefly describe how spiritual careis taught in and outside of Adventistnursing schools. This explorationprompts conclusions that divergefrom what some Adventist nurse edu-cators assume. Recommendations areoffered that can guide nurse educa-tors and administrators in Adventistschools of nursing as they plan cur-riculum and provide instructionabout spiritual care. First, however, inorder to provide context, nursing per-spectives about spiritual care will bereviewed.

B Y E L I Z A B E T H J O H N S T O N T A Y L O R


RECOMMENDATIONSFOR AN ETHICAL

ADVENTIST APPROACH

TEACHINGSPIRITUALLY SENSITIVE

NURSING CARE:

F

Nursing Perspectives

The work of nursing (and care ofthe sick, in general) has often oc-curred in the context of religion.2

Nursing care was provided by templeattendants in ancient times and by re-ligious orders in medieval times; morerecently, it has often been situated infaith-based health-care organizations.Indeed, nurses are often prompted byspiritual or religious motives to enterthe profession.3

It may be these religious roots innursing, in combination with othermotivations (e.g., reaction to increas-ingly technological and medicalizedcare, a desire to increase professionalboundaries, and an increase in socie-tal exploration of spirituality as it re-lates to well-being), that have lednurses to explicitly view spiritual careas within their purview. The rationaleusually offered, however, for whynurses should provide spiritual care isthat it is essential to wholistic care.4

Regardless of causes, the notion ofnurse-provided spiritual care is em-bedded deeply within the discipline.This is manifest in several ways. TheInternational Council of Nurses’ Code(ICN 2012) states that “In providingcare, the nurse promotes an environ-ment in which the human rights, val-ues, customs and spiritual beliefs ofthe individual, family and communityare respected.”5 This intention is mir-rored in nursing ethics codes in vari-ous countries, the goals of which areto preserve the rights of patients andprevent unwelcome care. Conse-quently, nursing programs must seekways to teach and model spiritual carewithin the context of these guidelines.

The inclusion of spiritual carewithin nursing care is more pragmati-cally recognized in nursing nomen-clature for identifying patient con-cerns (“diagnosis”) and labelingnursing therapeutics. For example,the North American Nursing Diagno-sis Association in its internationallisting of diagnoses—which is widelyused by nurses—includes six diag-noses that relate to patient spirituality

and religiosity (e.g., Spiritual Distressand Risk for Impaired Religiosity).6

Nurses typically understand spiritualcare to include “interventions” suchas supporting patients’ religious be-liefs and practices, facilitating valuesclarification when faith intersectswith treatment decision-making, em-pathic communication about spiritualstruggles, and so forth.7

The nursing literature is repletewith discussions about the signifi-cance of supporting patient spiritualwell-being. A November 2016 searchof the database Cumulative Index toNursing and Allied Health Literature(CINAHL) identified nearly 3,500 cita-tions for publications since 1980 thatincluded “spiritual*” OR “religio*”with “nurs*” in their abstract. (Theasterisk allowed for searches to in-clude variants of the search term suchas religion, religiosity, and religious-ness.) Some of this literature is prag-matic, describing how nurses can pro-vide spiritual care; other documents

explore spiritually related concepts intheoretical ways. Many nurses haveincluded spiritual or religious con-cepts in research studies using bothqualitative and quantitative methods.

Teaching Nurses to Provide Spiritual Care

The nursing program accreditationstandards in several nations (e.g.,Canada, United Kingdom, Australia,and the United States) include statedexpectations that pre-licensure stu-dents will learn about assessing andaddressing patients’ spiritual needs.For example, the 2006 Australian Na-tional Competencies stated that Regis-tered Nurses (RNs) ought to: “Practicein a way that acknowledges the dig-nity, culture, values, beliefs and rightsof individuals/groups.”8 It also thenadvised that RNs must learn to “collectdata that relates to . . . spiritual . . .variables on an ongoing basis.”9 The2008 American Association of Schoolsof Nursing Essentials of BaccalaureateEducation for Professional Nursing


Practice likewise expected undergradu-ate nursing education to teach stu-dents to: “Conduct comprehensive andfocused . . . spiritual . . . assessment ofhealth and illness parameters”; “Pro-vide appropriate patient teaching thatreflects . . . spirituality . . .”; “Developan awareness of patients as well ashealth care professionals’ spiritual be-liefs and values and how those beliefsand values impact health care.”10

Given the AACN mandate, the Regis-tered Nurse licensure examination testbank consequently includes questionsabout spiritual care.

Nurse educators in several coun-tries (e.g., Israel, Korea, Malta, Nether-lands, Taiwan, United Kingdom) havedocumented in published articles howthey taught nurses about spiritual care.These reports often are either descrip-tions of workshops provided to hospi-tal nurses with pre- and post-testing ordescriptions of undergraduate coursesor curriculum. Typically, content forsuch training includes a description ofspirituality (which distinguishes itfrom religion), encouragement of per-sonal spiritual self-awareness and well-being, spiritual needs of patients, as-sessment of patient spirituality, and anoverview of spiritual-care therapeutics(e.g., presence, referral and collabora-tion with spiritual-care experts, em-pathic communication, respect for reli-gious diversity). Assessment of theseeducational sessions or courses hasoften concluded that they increasenurse or student nurse spiritual well-being and improve attitudes towardproviding spiritual care.11 However,although attitudes about spiritual careare often assessed, spiritual care-related skills and/or knowledge arerarely evaluated.

Nursing schools employ a varietyof approaches for teaching spiritualcare. While some integrate it through-out the curriculum, others (probablymost) teach it during selected lecturesor assignments (often in the contextof health challenges where death isimminent).12 Diverse and creative

teaching and learning strategies in-clude journal writing, evaluating spiri-tual themes in artwork or patient casestudies, shadowing chaplains, lectures(including guest lectures from repre-sentatives of faith traditions and chap-lains), and various reading and writ-ing assignments.13 Indeed, severalbooks by and for nurses discuss spiri-tual caregiving, including three byAdventist author Elizabeth JohnstonTaylor (the author of this article).14

Although recently critiqued as lackingin this area, many core nursing text-books include chapters about patientspirituality and religiosity.15

Even though spiritual-care educa-tion may be mandated, and variousmodalities and educational resourcesfor teaching spiritual care exist, numer-ous studies document that nurses atthe bedside perceive themselves as in-adequately trained to provide it.16

These studies also find that the nurse’spersonal spirituality or religiosity iscorrelated with positive attitudes. It ap-pears, however, that there may be adisconnect between positive attitudesand implementation of spiritual care.)17

Teaching Spiritual Care in Adventist

Nursing Schools

Although a few descriptions ofhow spiritual care is taught to under-graduate nursing students within areligious school exist,18 only one pub-lication, to date, presents an Advent-ist example.19 In 2014, Taylor and col-leagues described how the LomaLinda University School of Nursing(LLUSN) baccalaureate curriculumintentionally seeks to prepare itsgraduates to provide spiritual care. Itdoes this in several ways, includingadopting a conceptual frameworkthat explicitly recognizes a spiritualdimension; integrating pertinent con-tent about spirituality throughout thecurriculum (e.g., learning spiritual as-sessment in the introductory funda-mentals of the nursing course, andhoning spiritual-care communicationskills in a capstone course); usingvarious teaching strategies (e.g., as-signing a “blessings” journal, casestudies, patient-care plans, self-reflec-tion paper); modeling of spiritual careby clinical faculty while providing di-rect patient care; biannually holding afour-hour mandatory workshop onspiritual care, and creating a spiritu-ally supportive environment (e.g.,prayers offered with and for students,weekly chapel attendance, devotionaltime at the start of each didactic orclinical class).

What may be unique about theLLUSN program is that it purpose-fully evaluates graduating students’perceptions of their spiritual-carecompetence in a brief quantitativesurvey; it also evaluates how theseexiting students perceive their univer-sity experience in terms of nurturingtheir personal wholeness (includingspirituality).

To better understand how Advent-ist nurse educators around the worldteach students to provide spiritualcare, an e-mailed query was distrib-uted to all program directors by theLLUSN Office of Global Nursing.(Since this was not a systematic in-


Diverse and creative

teaching and learning

strategies include journal

writing, evaluating spiritual

themes in artwork or

patient case studies,

shadowing chaplains,

lectures (including guest

lectures from representa-

tives of faith traditions

and chaplains), and various

reading and writing

assignments.

vestigation, no ethics committee ap-proval was necessary.) Twenty-oneschools responded from four regionsof the world (the Americas, Africa,Asia, and North America). Theschools represented had student pop-ulations that were 20-99 percent Ad-ventist (nine were lower than 50 per-cent) and (except for four schools) allhad faculty who were predominantlyAdventist. Responses suggested thatAdventist nurse educators assumethat spiritual care is taught by nurtur-ing students spiritually or religiouslyas well as by providing didactic in-struction and clinical experiences.

Adventist educators would likelyreadily agree with positions arguedby other nurse educators such asLewinson, McSherry, and Kevern20

that nurses cannot be expected to beaware and present, never mind thera-peutic, to patients’ spiritual needs ifthey are not to some degree spiritu-ally self-aware and intentional abouttheir own moral development. Thus,Adventist nurse educators providespiritual nurture through religiousand spiritual experiences duringschool time (e.g., devotional experi-ences in class, Week of Prayer); fac-ulty modeling (e.g., “I model how topray with patients by praying withstudents,” or “Sharing experiences ofGod . . . students can sense that wehave been with God for it is seen inour thoughts, actions, and words”);and encouraging religious behaviorsoutside of school time (e.g., visitingpatients as part of a church-related“outreach” activity, engaging in Voiceof Prophecy [Adventist] Bible les-sons). Illustrating all these methodsis an activity that one South Ameri-can nursing school schedules eachmonth. Students are invited to drawthe name of a classmate, pray specifi-cally for him or her for a week, andthen at a Sabbath meal provided bytheir professor, share their recentspiritual experiences or prayer re-quests and offer a gift to the class-mate for whom they prayed.

Nearly all program directors alsoindicated that their programs in-

cluded lectures on spiritual care(from nursing faculty and/or spiri-tual-care experts such as chaplainsand clergy), assigned readings aboutspiritual care, case studies, and othercourse activities that taught spiritualcare. Likewise, nearly all respondentsacknowledged having a curriculumguided by a conceptual frameworkspecifically recognizing spirituality.Most programs also had clinical as-signments that gave students practi-cal experience with spiritual care(e.g., spiritual assessment, developingcare plans, praying with patients, lis-tening to spiritual concerns withoutjudging). Many described includingspiritual care in community healthfairs or projects (e.g., having a spiri-tual talk after a lifestyle presentation,praying with those seeking health orhygiene services).

Prayer was central to much of thespiritual care taught; students wereoften taught to offer a prayer afterother nursing care was completed oras an “intervention” for those in emo-tional distress. One school teachesnursing students to instruct patientsin meditation and prayer techniques,as well as activities that allow emo-tional expression. Schools in countrieswith a strong Roman Catholic influ-ence typically include not only prayer,but also singing (“serenading”) aChristian song and reading a Bibleverse during visits with the sick.

Observations and Recommendations

These illustrations of how spiritualcare is taught in Adventist nursingschools around the globe portray howa Christian’s beliefs and behaviorsoften align, and how Adventist nurseeducators live and teach compassion-ate service. Whereas the article in thisissue by Mamier et al. (see page 26)describes what motivates Adventistnurse-provided spiritual care, this arti-cle will focus its observations and rec-ommendations on factors that en-hance and strengthen spiritual

caregiving and teaching. Although thefollowing points could be misinter-preted as admonitions to refrain fromsharing God’s love, they are actuallysuggestions about how to more sensi-tively, respectfully, and ethically liveout God’s love in practical ways.

Teach Spiritual Care in Context1. Adventist approaches to teach-

ing nursing students how to providespiritual care vary with the culturalcontext in which each school is situ-ated. In schools in Western pluralisticand individualistic cultures, contentincludes knowledge about many faithtraditions and how nurses can respectand support patients of diverse faiths.In contrast, schools in Asia, Africa,and South and Inter-America oftenequate spiritual care with sharingChristian or Adventist beliefs.

This raises the question of howcultural mores interrelate with ethicalimperatives. I recommend that all Ad-ventist schools teach students not toconfuse spiritual care with evangel-ism, and to prepare students to sensi-tively acknowledge the unique spiri-tual needs of clients from diversebackgrounds. In any cultural context,wholistic care—indeed, care that re-flects the compassion of Christ—should include laying a groundworkthrough empathetic conversation thatopens up shared spaces of trust, re-spect, and genuine caring. Only thencan a readiness be established forgenuine spiritual care arising fromthe patient’s initiative. Once the clientacknowledges an openness to receivespiritual care, the sincere ministry ofthe nurse in sharing God’s uncondi-tional love and providing hope andcomfort is more likely to be acceptedand effective.

2. Prayer is frequently an Advent-ist nursing therapeutic. Adventistnurses who have prayed with patientstell many stories about its efficacy.Adventists, like most Americans, praycolloquially. Although times of physi-cal or emotional extremis are oftenoccasions when patients most appre-


ciate prayer, they are not always con-ducive to colloquial prayer. As onenursing director reported, perhaps allnursing schools should teach stu-dents about the various ways to prayand meditate, and how to tailorprayer experiences to patient circum-stances.

Model Ethical Spiritual Care inPractice

3. Although teaching spiritualcare undeniably requires supportingstudent nurses as they mature spiri -tually, it also raises the question ofhow to do this ethically. When stu-dents enroll in an Adventist school,they implicitly agree to place them-selves in an environment where theymay be shaped by Adventist religiousbeliefs and practices. Schools oughtto state their expectations in this re-gard (e.g., about attending weeklychapels, and religious emphasis inclasses) for all prospective students.

Faculty pressure on a student (nomatter how sweetly applied) to at-tend a Friday night Bible study orother religious activity unrelated toschool expectations, however, is inap-propriate. It abuses the faculty-stu-dent relationship and suggests a self-serving religiosity. I recommend thatfaculty be sensitive to the possibilityof students feeling coerced to partici-pate in religious extracurricular activ-ities and make such invitations in away that avoids the potential for cre-ating student discomfort.

4. Nurse educators also must becareful not to coerce students throughassignments or obligations that areinconsistent with their beliefs (e.g.,grading a student on whether he orshe prayed colloquially with 10 pre-operative patients during a clinical ro-tation, if that student does not believein prayer or prays in a manner thatdiffers from the instructor’s expecta-tions).

5. Instruction about spiritual caremust include a recognition of its po-

tential for harm when it is coercive orunethical. When nurses provide care,they are in a powerful position of car-ing for someone who, inherently inthe role of being a patient, is vulnera-ble. Because of this power imbalance,some ethicists have argued thatprayer or self-disclosure of religiousbeliefs should not occur unless a pa-tient initiates a request for it.21 AsChristian theologian and nurse ethi-cist Marsha Fowler stated, “by re-fraining from offering faith where it isnot welcome, [nurses] affirm the free-dom that must exist in faith.”22 Fur-thermore, the role of nursing is to ad-dress health problems; if a patient’sspirituality contributes to the problemor if it is a resource for addressing thehealth problem, then it is within thepurview of nursing to provide carethat is spiritually sensitive and sup-portive. The role of the nurse, there-fore, is not that of a theologian, evan-gelist, or pastoral counselor.

I recommend that the goals of Ad-ventist nursing schools include notonly helping students to clarify andmature their own spirituality, but alsoteaching them to support patients’spiritual journeys in a manner thatavoids any appearance of coercion.

6. Last, if they are given such ethi-

cal instruction, graduates of Adventistnursing programs will be unlikely toface difficulty when practicing innon-religious contexts. I recommendthat students be educated not onlywith theory, but also with evidenceupon which to practice spiritual careso that they can explain their spiritualcare in “the real world.”

Although a thorough discussion ofthese issues is beyond the scope ofthis article, it is hoped that this briefdiscussion will prompt readers to re-flect further. An in-depth discussionon the ethics of religious nurses shar-ing their personal religiosity is foundin Religion: A Clinical Guide forNurses.23

Conclusion

Teaching nursing students to pro-vide spiritual care is a salient featureof Adventist nursing programs. It maybe that this emphasis as well as thereligious context of the teaching thatmake Adventist nursing educationunique. The concern arises, however,about whether the spiritual careshould be taught as evangelism. ForChristian nurses, the answer varies:“No, if evangelism means trying(even subtly) to persuade vulnerablepatients to believe the same way asdo I. Yes, if it means reflecting thecompassion of Christ in the holywork of nursing—being the hands ofJesus.”24 Indeed, Adventist nurse edu-cators will benefit from continued re-flection with their students aboutwhat it means for health-care workersto take the gospel into all the world.While it must be acknowledged thatthe distinction between spiritualityand conventional religion (and thusbetween spiritual care and religiousnurture) varies from culture to cul-ture, there are certain universally rec-ognized ethical considerations thatwill apply anywhere. ✐


Instruction about spiritual

care must include a

recognition of its potential

for harm when it is coercive

or unethical. When

nurses provide care, they

are in a powerful position of

caring for someone who,

inherently in the role of being

a patient, is vulnerable.

The author thanks Dr. Patricia S.Jones and Valerie Nusantara for theirsupport in contacting Adventist educa-tors around the world to obtain exam-ples of teaching practices. I am alsodeeply grateful for the careful reviewof the manuscript provided by Drs.Jones, Iris Mamier, and EdelweissRamal; and for the anecdotal infor-mation from their programs that wasprovided by Adventist educators, gra-ciously and generously shared for il-lustrative purposes in this article.


Elizabeth John-ston Taylor, PhD,RN, is a Professorof Nursing at theLoma Linda Uni-versity School ofNursing (LLUSN)in Loma Linda,

California, U.S.A. She has held nurs-ing faculty positions for more than 20years, and has taught at LLUSN since2000. Her area of research interest isspiritual responses to illness and nurseprovision of spiritual care. Dr. Taylorhas written three books: Religion: AClinical Guide for Nurses (Springer,2012); What Do I Say? How to TalkWith Patients About Spirituality (Tem-pleton, 2007); and Spiritual Care:Nursing Theory, Research, and Prac-tice (Prentice Hall, 2002).

NOTES AND REFERENCES1. Loma Linda University School of

Nursing, “List of International Seventh-dayAdventist Schools of Nursing” (2017):http://nurs ing. llu.edu/about-us/global-nurs ing/ international-schools-nursing.

2. Mary Elizabeth O’Brien, Spirituality inNur sing: Standing on Holy Ground, 5th ed.(Burlington, Mass.: Jones and Bartlett Learn-ing, 2014).

3. Elizabeth J. Taylor, Carla G. Park,and Jane B. Pfeiffer, “Nurse Religiosity andSpiritual Care,” Journal of Advanced Nursing70:11 (November 2014): 2612-2621. doi:10. 1111/ jan.12446.

4. O’Brien, Spirituality in Nursing: Stand-ing on Holy Ground, 5th ed.; Elizabeth J.Taylor, Spiritual Care: Nursing Theory, Re-search, and Practice (Upper Saddle River,N.J.: Prentice Hall, 2002).

5. The ICN Code of Ethics for Nurses:http://www.icn.ch/images/stories/documents/about/icncode_english.pdf.

6. T. Heather Herdman and ShigemiKamitsuru, eds., NANDA International Nurs-ing Diagnoses: Definitions and Classification,2015–2017 (Oxford, United Kingdom: WileyBlackwell, 2014).

7. Elizabeth J. Taylor, “What Is SpiritualCare in Nursing? Findings From an Exercisein Content Validity,” Holistic Nursing Practice22:3 (May-June 2008): 54-159. doi: 10.1097/ 01.hnp.0000318024.60775.46.

8. Australian Nursing and Midwifery Coun-cil, National Competency Standards for theRegistered Nurse (2006): http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professionalstandards.aspx, 4.

9. Ibid., 8.10. American Association of Colleges of

Nursing, The Essentials of Baccalau reateEducation or Professional Nursing Practice(2008): http:// www.aacn.nche.edu/ educa tion-resources/baccessentials08.pdf., 31, 32.

11. Katherine L. Cooper et al., “The Im-pact of Spiritual Care Education Upon Prepar-ing Undergraduate Nursing Students to Pro-vide Spiritual Care,” Nurse Education Today33:9 (September 2013): 1057-1061. doi:10.1016/j.nedt.2012.04.005; Elizabeth J. Tay-lor, Nancy L. Testerman, and Dynnette E.Hart, “Teaching Spiritual Care to Nursing Stu-dents: An Integrated Model,” Journal of Chris-tian Nursing 31:2 (April-June 2014): 94-99.

12. Taylor, Testerman, and Hart, “Teach-ing Spiritual Care to Nursing Students: AnIntegrated Model.”

13. Taylor, Park, and Pfeiffer, “Nurse Reli-giosity and Spiritual Care”; Kerry A. Milner,Kim Foito, and Sherylyn Watson, “Strategiesfor Providing Spiritual Care and Support toNursing Students,” Journal of ChristianNursing 33:4 (October-December 2016): 238-243. doi: 10.1097/cnj.0000000000000309.

14. Taylor, Spiritual Care: Nursing Theory,Research, and Practice; __________, What DoI Say? Talking With Patients About Spiritual-ity (West Conshohocken, Penna.: TempletonPress, 2007); __________, Religion: A ClinicalGuide for Nurses (New York: Springer, 2012).

15. Fiona Timmins et al., “Spiritual CareCompetence for Contemporary Nursing Prac-tice: A Quantitative Exploration of the Guid-ance Provided by Fundamental Nursing Text-books,” Nurse Education in Practice 15:6(November 2015): 485-491. doi:10.1016/ j.nepr. 2015.02.007.

16. Cooper et al., “The Impact of Spiri-tual Care Education Upon Preparing Under-graduate Nursing Students to Provide Spiri-tual Care.”

17. Danielle Rodin et al., “Whose Role?Oncology Practitioners’ Perceptions of TheirRole in Providing Spiritual Care to AdvancedCancer Patients,” Support Care Cancer 23:9(January 2015): 2543-2550. doi:10.1007/ s00520 -015-2611-2; Barry S. Gallison et al.,“Acute Care Nurses’ Spiritual Care Prac-tices,” Journal of Holistic Nursing 31:2 (June2013): 95-103. doi: 10.1177/089801011 2464 121; Wilfred McSherry and Steve Jamieson,“The Qualitative Findings From an OnlineSurvey Investigating Nurses’ Perceptions ofSpirituality and Spiritual Care,” Journal ofClinical Nursing 22:21, 22 (October 2013):3170-3182. doi: 10.1111/jocn.12411.

18. Jewish: Laurie H. Glick, “NurturingNursing Students’ Sensitivity to SpiritualCare in a Jewish Israeli Nursing Program,”Holistic Nursing Practice 26:2 (March/April2012): 74-78; Latter-Day Saints: Lynn C. Cal-lister et al., “Threading Spirituality Through-out Nursing Education,” Holistic NursingPractice 18:3 (May 2004): 160-166; RomanCatholic: Donia R. Baldacchino, “Teachingon the Spiritual Dimension in Care to Under-graduate Nursing Students: The Content andTeaching Methods,” Nurse Education Today28:5 (July 2008): 550-562.

19. Taylor, Testerman, and Hart, “Teach-ing Spiritual Care to Nursing Students: AnIntegrated Model.”

20. Lesline P. Lewinson, Wilfred McSherry,and Peter Kevern, “Spirituality in Pre-registra-tion Nurse Education and Practice: A Reviewof the Literature,” Nurse Education Today 35:6(June 2015): 806-814. doi: 10.1016/ j.nedt. 2015. 01.011.

21 Taylor, Religion: A Clinical Guide forNurses.

22. Marsha D. M. Fowler, Guide to theCode of Ethics for Nurses With InterpretiveStatements, 2nd ed. (Silver Spring, Md.:American Nurses Association, 2015), 85.

23. Taylor, Religion: A Clinical Guide forNurses.

24. __________, “Spiritual Care: Evangel-ism at the Bedside,” Journal of ChristianNursing 28:4 (October 2011): 194-202.


Two experiences contributed to this article. One wasa colleague’s loss of her elderly mother just beforethe close of the academic school year. During hermother’s preceding hospitalization in an Adventistmedical center, our colleague found herself torn be-

tween attending to the demands of work and her mother’sneeds. Although she faithfully checked on her mother sev-eral times a day, she was shocked when her mother died un-expectedly. During the hospitalization, her mother’s medicalneeds had taken precedence, and she had not had a chanceto explore her spiritual needs. When she heard that two ofher nursing students had prayed with her mother just priorto her passing, she found solace in knowing her mom hadbeen supported as she passed.

The second experience came from a qualitative researchstudy conducted a few years ago at Loma Linda University(California).1 The first author surveyed registered nursesworking in acute tertiary care about a significant encounterthey had experienced with spirituality while at work. Al-though most respondents reported positive encounters in of-fering spiritual care, one staff nurse expressed doubts aboutthe educational preparation she had received at an Adventistuniversity to equip her for the role of spiritual-care provider.She shared that she had been taught to offer prayer (and abackrub) during her evening rounds. This had not createdany difficulties until she started working outside of a faith-

based hospital. One day, she found herself in the uncomfort-able situation of being reprimanded by her supervisor be-cause a patient had complained.

These two situations warrant reflection. One interactionwas received as a precious gift and gratefully remembered;whereas the other, at minimum, ended in a patient’s irrita-tion and a nurse’s discouragement. Clearly, nursing studentsneed to be equipped with tools to navigate patients’ spiritualneeds in multi-faith societies. As educators, we have a re-sponsibility to prepare them to recognize spiritual cues andteach them how to invite a spiritual conversation in diversepatient-care contexts. Our students need to be sensitized topotential pitfalls and taught how to connect with people ofall walks of life in a way that ensures that each patient al-ways feels respected and honored. Therefore, teaching stu-dents about spiritual care deserves thoughtful preparationon the part of the nurse educator.

Adventist health care embraces a wholistic approach tocare, one that is inclusive of patients’ spirituality. Given itslongstanding legacy, it is easy to assume that professionalsin this field who have been educated in and work for Ad-ventist institutions are therefore trained in spiritual care. Yetthere is scant literature—aside from Ellen White’s writingsto medical professionals—that clearly explains an Adventistperspective on spiritual care and how it should be taught. Ifindeed spiritual care is core to Adventist health care, then a

BY IRIS MAMIER, EDELWEISS RAMAL, ANNE BERIT PETERSEN, and HARVEY ELDER


A LOMA LINDAUNIVERSITY PERSPECTIVE

INVITINGA SPIRITUALDIALOGUE:

more overt discussion of these questions seems warranted. The purpose of this article is to provide Adventist nurses

and nurse educators with a practical guide for inviting a spir-itual conversation. In what follows, we review two significantencounters from the Gospels and draw on advice given byEllen White in her book, The Ministry of Healing, to set thestage. Reflecting on our own experiences and the insights ofthose who have mentored us, we situate these recommenda-tions in the context of collaborative interdisciplinary practiceat Loma Linda University Health and suggest that the com-bination of experience, research, and guidance from inspiredsources provides a unique perspective on how to teachnurses to offer wholistic care. We hope to stimulate morethought and reflection in practice and academic settings.

Biblical Encounters of Wholistic Healing

Jesus’ life and ministry exemplified how spiritual care isintegral to caring for the sick. His actions in healing two par-alytic men reflected a true “whole-person-care” approachthat connected physical, mental, and spiritual well-being.

Healing at BethesdaJohn 5 reports on the restoration of a paralyzed man.

Bethesda, meaning “House of Mercy,” was a site of concen-trated misery in Jerusalem where crowds of sick, blind, lame,and paralyzed individuals awaited care and sought healing.Jesus deliberately visited this “hospital” one Sabbath, unac-companied by His disciples.2 He was drawn to a man whohad been paralyzed for a very long time. After nearly fourdecades of suffering, feeling lonely, friendless, and discour-aged, he had almost lost all hope. To get the man’s attention,Jesus stooped down, looked into his eyes, and asked a ques-tion that may have seemed obvious but that invited the manto share his story: “‘Do you want to be made well?’”3

The man’s response informs us about the lament of hissoul. “‘Sir, I have no one to put me into the pool when thewater is stirred up; and while I am making my way, someoneelse steps down ahead of me.’”4 His expectation for healingwas focused on a magical cure supposedly resulting from get-ting into the pool at the right time. He had no idea to whomhe was speaking. Jesus then summoned him to do the impos-sible: “‘Stand up, take your mat and walk!’”5 Empowered bythese words, the man complied and was healed. He thenquickly left the place and headed straight to the temple—stillcarrying his mat—intending to praise God for his recovery.

But no sooner had the jubilant man arrived at the temple


than the Jewish leaders confronted himfor breaking the Sabbath. According tothem, he had sinned again; how distress-ing this must have been to the recipientof Jesus’ miracle. But just then, Jesus ini-tiated a second encounter at the temple:Healing, part two!

Addressing the real issues, Jesusshared with the man how he could staywell: “‘See, you have been made well!Do not sin anymore so that nothingworse happens to you.’”6 Having expe-rienced physical restoration, the manhad reason to trust that Jesus had hisbest interest in mind and that His ad-vice mattered.

The question: “What keeps youfrom getting trapped and helplessagain?” remains relevant for us today.The man needed an external powersufficiently strong and reliable to keephim from sin—a power that we asChristians believe comes only from a relationship with God.The success of spiritually based programs, such as Alco-holics Anonymous and similar programs directed at otheraddictions, testify to this reality. They have been successfulbecause they connect patients to a “higher power” and re-establish spiritual values.7

As soon as the religious leaders found out who the healerwas, they confronted Jesus sternly about His healing on theSabbath. Jesus calmly responded: “‘My Father is still work-ing, and I also am working.’”8 Here Jesus explained the largerperspective of spiritual caregiving: Ever since humans choseto distrust their Creator, God has been working tirelessly—and especially on the Sabbath day9—to restore a trusting re-lationship. “The Father’s ongoing redemptive involvementon this earth is then the basis for Jesus joining the Father inHis work.”10

Because Jesus operated on the basis of following the Fa-ther, we too should focus on the signs of God’s work in a pa-tient’s life. Spiritual cues may surface as expressions of worth-lessness, shame, guilt, fractured relationships, hopelessness,etc., pointing to a spiritual need for forgiveness, acceptance,hope, or reconciliation. These will often not be evident unlessthe health-care provider first meets the physical needs in anempathetic and competent manner. Once these have been ad-dressed and trust has been established, patients may revealdeeper concerns about their lives and their illness. The ex-pressed lament of the soul then provides direction for spiritualcaregiving and/or referral to specialists (e.g., pastoral care).

Healing at CapernaumThe second story, recorded in three of the four Gospels,

is about the paralytic at Capernaum (Matthew 9:1-8; Mark2:1-12; and Luke 5:17-26). This paralyzed man was so help-

less that he depended on his friends’determination and strength to bringhim to Jesus. When they realized it wasimpossible to navigate the crowd, theyremoved parts of the roof of the housein which Jesus was preaching and low-ered him into the Master’s presence.The man’s misery was likely com-pounded by carrying the stigma ofbeing a sinner abandoned by God,11

adding mental anguish and spiritualhopelessness to an already devastatingphysical condition. Therefore, Jesus’first words to him were received as ahealing balm: “‘Take heart, son; yoursins are forgiven.’”12

We can take inspiration from thiscase. For example, when we ask pa-tients how an illness has influenced theway they view themselves or God, it isnot unusual for them to express re-morse, guilt, or shame. Some attribute

their illness to God as punishment for past misdeeds. Suchan understanding of God makes it very difficult for sufferingpeople to imagine that God will regard them with love ratherthan contempt and rejection. Guilt and shame therefore pre-vent them from accessing the most valuable resource theymight otherwise access: refuge in the loving presence of aforgiving God who knows them personally and welcomesthem into a trusting relationship with Him. For the paralyticman, Jesus’ assurance of forgiveness told him that God hadnot rejected him and instead loved him infinitely.

With a renewed identity as a beloved child of God andhis sense of self-worth restored, the man began to experienceemotional and spiritual healing. Therefore, when Jesusspoke the powerful words “‘Get up, pick up your bed, andgo home,’”13 the man was made whole spiritually, physically,and mentally. What was deemed a blasphemous act by thereligious authorities actually revealed Jesus’ divine powerand authority as the Son of Man, evidenced by the man’s re-stored physical health.

Application to Modern Health CareIn both of these accounts, Jesus is portrayed as a spiritual

caregiver. Whether or not these men were aware of theirspiritual needs before their healing, or focused mainly ontheir felt needs for physical healing and hope, Jesus viewedthem wholistically, connected with them authentically, andworked to restore them—not only physically, but also spiri-tually and mentally.

As Adventist health-care providers, we are reminded thatthe Holy Spirit works in people’s lives before, during, andafter the patient encounter. Our experience and perception ofa patient and his or her situation is limited. By contrast, Godknows each patient’s life story and current need. As nurses


Spiritual cues may surface as

expressions of worthless-

ness, shame, guilt, fractured

relationships, hopelessness,

etc., pointing to a spiritual

need for forgiveness, accept-

ance, hope, or reconciliation.

These will often not be evi-

dent unless the health-care

provider first meets the phys-

ical needs in an empathetic

and competent manner.

become aware of patients’ spiritual needs and respond tothem, they, in essence, are stepping on “holy ground.”14 Whenfollowing Jesus’ model, nurses look for evidence of God work-ing in the life of a patient. Freed of any agenda and guided bythe Holy Spirit, they listen for the lament of the soul, em-pathizing and validating underlying needs. Nurses cannotforce this process, nor should they be made to feel that theirprimary duty is the spiritual restoration and salvation of thepatient. Instead, nurses can ensure that they are personallyattuned to the Holy Spirit by surrendering to God and sub-mitting to His guidance. The foundation of spiritual caregiv-ing, therefore, lies in connecting with God through prayer andthe study of His Word to detect the felt and at times disguisedneeds of patients. This was Jesus’ method, and it can be ours.

The Savior’s example in healing the paralytic men alsodemonstrates that spiritual care is not about debating doc-trine, but about revealing the love of the Father. Ellen Whiteput it this way: “At the bedside of the sick no word of creedor controversy should be spoken. Let the sufferer be pointedto the One who is willing to save all that come to Him infaith. Earnestly, tenderly strive to help the soul that is hov-ering between life and death.”15 The wisdom needed for thisapproach to spiritual caregiving is promised to all who ask.“The Savior is willing to help all who call upon Him for wis-dom and clearness of thought. And who needs wisdom andclearness of thought more than does the physician [or nurse]upon whose decisions so much depends? Let the one whois trying to prolong life look in faith to Christ to direct his orher every movement. The Savior will give the necessary tactand skill in dealing with difficult cases.”16

How Do We Teach It?

Adventist nurse educators take pride in training competentand qualified health-care professionals. We leave little tochance. Curricula are designed to address all aspects of phys-ical and mental health. As educators, we are intentional aboutwhat we teach in the classroom; in practice environments, wetest and evaluate students’ knowledge and skills, and carefullymonitor program outcomes. We also invest much effort in nur-turing students’ spirituality because we believe that their spir-itual life and personal relationship with God will shape all as-pects of their future, including their professional practice.

Therefore, students at Adventist colleges and universitiesgenerally take a minimum of one religion course for everyyear of their professional education. We believe that as agraduate’s spiritual awareness and faith experience grow, heor she will be more sensitive to the spiritual needs of others.We must ask, however, “Is this enough for students to beequipped to provide whole-person care? Will they have theskills needed to invite a conversation about patients’ spiri-tual needs? What frameworks, tools, and principles can weprovide that nurses can use to guide their practice?” Spiritualcare is an art, and just as with development of other nursingskills and competencies, proficiency is gained as the practi-tioner grows from novice to expert.17

Approaches Explored at Loma Linda UniversityScholars at Loma Linda University have wrestled with

these questions. Drs. Harvey Elder and Wil Alexander18 havespecifically asked how we might transform an art—led by theHoly Spirit—into practical and applied principles that studentscan develop into skills, confidence, and expertise. Their ap-proach has pioneered whole-person care at Loma Linda Uni-versity Health and mentored countless health-care providersover the past decades through workshops and patient rounds.

• Spiritual Care in the Context of Whole-person Care.Rather than reducing the patient to a disease process, awhole-person care approach tries to understand patients asindividuals with their own stories, and in their complexphysical, emotional, relational, and spiritual dimensions.The spiritual core is seen as the integrating dimension of allother dimensions of personhood. Drawing on more than fourdecades of caring for patients with HIV/AIDS, Dr. Elder hasreflected extensively on practical and biblically based ap-proaches to teaching spiritual-care techniques to Christianhealth professionals.19 He recommends that educators modeland encourage students to commit to following a series ofsteps in their practice. These include (1) asking the HolySpirit for passion, love, and genuine care for one’s patients;(2) remaining committed to listening to and hearing whatone’s patients and the Holy Spirit say; and (3) inviting pa-tients to tell their stories, while staying attuned to hearingthe “anguish of their cry” or the pain associated with theirexperiences. After a patient has shared his or her story, headvises health-care providers to ask questions that invite aspiritual dialogue. In the following paragraphs, we share apractical approach to soliciting and listening for spiritualthemes that has been used at Loma Linda University Health.

• Applied Training in Spiritual-care Practice. During thepast 10 years, Drs. Harvey Elder and Carla Gober-Park, at theCenter for Spiritual Life and Wholeness at Loma Linda Uni-versity (http://www.religion.llu.edu/wholeness), have con-ducted multiple spiritual-care workshops for health-careprofessionals. These typically involve a practicum in the pa-tient-care units of the Loma Linda University medical facili-ties. The goal of the activity is to invite a spiritual conversa-tion with patients who are willing to talk to a group of twoto three health professionals.

The unit charge nurse provides direction regarding whichpatients to approach—and not to approach. Upon entering apatient’s room, the group introduces themselves as health-care professionals who are not part of the patient’s treatmentteam but who are attending a conference. The practicumleader informs the patient that the group wants to learn toreally listen to the patient’s concerns, and asks if he or she iswilling to talk with them. If the patient declines, the groupwishes him or her well and leaves. If the patient agrees totalk with the group, the leader asks if they may sit while theyspeak with him or her. (The rationale is to avoid a posture oflooking down at the patient during the conversation.) Thepracticum leader proceeds by saying: “If at any point you are


uncomfortable and do not want to continue talking to us, justsay ‘I’m tired!’ and we will leave.” These simple and practicalsteps are important in establishing consent and giving thepatient control over the interaction.

During the workshop, the participants receive a sequenceof questions to guide the conversation (see Box 1). The openingquestion: “How long have you had this illness/injury?” focusesthe conversation on the individual’s experience with the ill-ness/injury rather than the details of his or her diagnosis andits implications. It allows patients to reveal as much or as littleas desired about their medical history and take the conversa-tion in the direction they choose. They can refocus the questionto their preferred timeframe. For example, during one conver-sation, a middle-aged woman told us how she had suffered astroke while honeymooning on a houseboat in a neighboringstate. She then expressed her sense ofgratitude for her husband, who ensuredthat she received the medical help sheneeded, and supported her through theordeal.

The second question, “What aboutyour illness/injury concerns you most?”seeks to explore and understand the pa-tient’s primary lament, or the “chief com -plaint.” It is easy for nurses, like otherhealth-care professionals, to assume thatthey understand patients’ primary con-cerns. Yet asking this question has re-peatedly revealed that these concerns arenot necessarily related to the diagnosis ortreatment plan. We have discovered thata nurse can go through an entire shiftwhile remaining unaware of the patient’sprimary source of distress. For example,in one conversation, when we asked thisquestion of a muscular young man whowas sitting up in his bed, his response was, “Will God forgiveme?” Unbeknownst to the small group, he had been involvedin a shooting altercation and had lost his lower leg. Ratherthan focusing on his immediate physical suffering or loss, hisunspoken distress stemmed from feelings of guilt and condem-nation. Strikingly, when invited to share, he instantly con-veyed his spiritual lament.

This model of inquiry then asks about patients’ source(s)of strength and/or support: “What helps you get throughhard times?” At this point, patients often refer to their sup-port system: family, friends, or colleagues. Some mentiontheir church, a club to which they belong, or a particularperson. God may or may not be in the picture.

A follow-up question can probe further: “Do you have a re-ligious heritage or a faith community that is relevant to you?”Followed by, “Is that a source of support to you right now?”

While the first author (Iris Mamier) shadowed Dr. Elderin an HIV/AIDS clinic as he saw a man with Kaposi sarcoma,it became apparent that the patient was not taking his anti-

retroviral medications. During their interaction, Dr. Elderasked about his religious heritage. The patient explained thathe had grown up in a Protestant denomination but figuredthat God didn’t like him because of lifestyle choices he hadmade. This encounter illustrated how underlying spiritualbeliefs (e.g., guilt, feelings of worthlessness, a punitive pic-ture of God) can have a significant impact on patient health-care decision-making (e.g., medication adherence). In thiscase, the spiritual dimension was key to understanding whythis patient had stopped caring for himself, and addressinghis spirituality was vital for effective treatment to occur.

Likewise, when patients identify as atheist or agnostic,there is typically a story in the background, often one of dis-appointment with a particular religious person or faithgroup that explains why they have given up on God alto-

gether. Patients may find it therapeuticto be given the opportunity to sharethis without being judged. Similarly,patients who are believers may appre-ciate sharing how their faith helps themcope with life’s challenges, giving thehealth-care provider a chance to affirmtheir faith.

The fourth question asks: “How hasthis experience changed the way you seeyourself?”

This question allows patients to reflecton how the illness experience has af-fected them personally. Facing their ownvulnerability, they may share: “I’ve al-ways felt like I am strong and independ-ent. It’s scary to be so weak and helplessall of a sudden!” Or: “After this fall, I amafraid I am becoming a burden to myfamily!” Both of these responses revealthat the patient’s sense of self-worth has

been shaken, reflecting the paradigm: “I’m worthwhile onlywhen I’m strong, when I’m a productive member of the familyor community.” It is not uncommon for illness experiences togenerate questions about one’s life course, purpose, andsources of meaning. Allowing oneself to be vulnerable and toreceive gracious nursing and medical care can lead to renewedperspectives on life and what really matters, which patientsmay wish to share.

Finally, depending on whether or not the individual hasacknowledged a belief in God, we may follow up by asking:“How has this experience affected the way you see God orwhatever ultimate meaning you hold in life?” This questionopenly probes the patient’s conception or picture of God andthe existential questions in his or her life. These beliefs havethe potential to greatly shape the illness experience. In astudy aimed at exploring religious coping, Kenneth Parga-ment20 surveyed 310 Christian church members six weeksafter the Oklahoma bombing tragedy. Using factor analysis,he categorized underlying religious beliefs as “helpful” ver-


1. How long have you had [orbeen living with] this illness/injury?

2. What about your illness/ injuryconcerns you most?

3. What is your source ofstrength?

4. How has this experiencechanged the way you see yourself?

5. How has this experience af-fected how you see God/ HigherPower/life?

Box 1. Questions to Guide a Spiritually

Focused Conversation.

sus “harmful” religious coping. Whilehelpful coping drew on spiritual supportand benevolent religious reframing,harmful religious coping was character-ized by religious pain and turmoil, dis-content with God, the church, and re-framing of negative life events aspunishment from God. Pargamentfound that those who primarily engagedin helpful religious coping held benevo-lent beliefs about God and grew spiritu-ally and psychologically in the after-math of this trying life situation, whilenegative religious coping was associatedwith more callousness toward others.

For patients who welcome such a dis-cussion, these five questions can gen -erate substantive and meaningful conver-sations that validate their experiences.The sequence is not designed as a rigidstructure but rather as prompts to steer the conversation in ameaningful direction. Based on our experience, patients and/orfamily members appreciate being able to have the undividedattention of health-care providers. This in itself can be experi-enced as a gift and as therapeutic.

When patients thank us for taking the time to talk to them,we know that the conversation has meant something to them.However, generally the blessing goes both ways. For this reason,the practicum leader always thanks the patient and/or familymember for sharing with the group. If deemed appropriate, theleader may also ask: “Would it be helpful to you if we prayedwith you before we leave?” Not only do we believe that it is im-perative that patients be asked to consent before we pray withthem, we also recommend wording the offer in such a way thatthe patient knows that prayer is not driven by the health-careproviders’ needs. The suggested wording keeps the focus on thepatient and what would be supportive for him or her. The al-ternative, “Can I pray for you?” risks placing the patient in asituation where he or she worries about disappointing or hurt-ing the feelings of a well-intended health professional. Our rec-ommended phrasing allows the patient to say, “No thank you,I don’t think that would be helpful for me.” Recognizing thatprayer is an intimate, personal, as well as communal practice,we also recommend a working knowledge of world religionsand diverse faith-traditions21 to be more attuned to patients’ per-spectives. If requested or welcomed by the patient, a shortprayer such as the following may be helpful:

Dear God, thank you for the privilege of talking with [Mrs.Smith]. She is your beloved daughter—thank you for beingwith her through these trying times. We are grateful that she isrecovering from her surgery and that her son has been so sup-portive through this experience [mention things that the pa-tient named as being important]. Please be with her as shegoes to rehab tomorrow [include specific concerns or requests

that the patient mentioned]. Bless her,Lord, and continue to grant her healingand Your peace. In Your name we pray.Amen.

Once the group has left the patient’sroom, the practicum leader should takethem to a quiet corner or small confer-ence room to debrief the experience.This is an essential part of the prac -ticum, as much of the learning often oc-curs after the patient encounter. Thepracticum leader and the group reflecton what they heard and observed, anddiscuss cues they followed or missed.Suggested questions that can be directedto the group include the following: Howdoes the person who asked the ques-tions feel? What spiritual needs did thepatient identify? Should there be a refer-

ral/follow-up? The debriefing process allows students andparticipants to identify emerging spiritual themes. These ses-sions also provide an opportunity to affirm participants’ in-dividual strengths, provide feedback, and suggest alternativeapproaches. Finally, they provide a framework from whichto evaluate one’s own effectiveness.

Final Thoughts

The two stories at the onset of this article illustrate thatmeeting patients’ spiritual needs is what ought to drive anyspiritual care. While in the first case, spiritual support al-lowed the patient to pass peacefully, and this knowledgecomforted the bereaved daughter, the second scenario raisedconcerns because prayer was offered without prior assess-ment and regard for context. We suggest that the context inwhich prayer or any other spiritual care is offered matters:Has the nurse connected genuinely with the patient? As-sessed and explored the patient’s wholistic needs? And, fun-damentally, does the spiritual intervention meet the actualexpressed needs of the patient? The suggested questionsinviting a spiritual conversation can provide helpful guid-ance. The art of listening for spiritual cues can be taught bestin the clinical environment in small-group patient encountersfollowed by debriefings or post-conferences.

In conclusion, when modeling spiritual caregiving andteaching students how to become spiritual caregivers, in-structors would do well to communicate the deep joy andsense of calling that comes from intentionally engaging inthis sacred work. As we become increasingly attuned to theunique opportunity and privilege nurses have to “step onholy ground,” we are reminded that the most powerful pos-ture and truth from which we can approach our patients isto view them as beloved children of God. This love is trans-formative: “The love Christ diffuses through the whole beingis a life-giving power. Every vital part—the brain, the heart,


The debriefing process allows

students and participants to

identify emerging spiritual

themes. These sessions also

provide an opportunity to affirm

participants’ individual

strengths, provide feedback,

and suggest alternative ap-

proaches. Finally, they provide a

framework from which to eval-

uate one’s own effectiveness.

and the nerves—it touches with healing. By it the highestenergies of the being are roused to activity. It frees the soulfrom the guilt and sorrow, the anxiety and care that crushthe life forces. With it come serenity and composure. In thesoul it implants joy that nothing earthly can destroy—joy inthe Holy Spirit—health-giving, life-giving joy.”22 This is theoptimal outcome of spiritual caregiving; that through our in-teractions with patients, they experience this life-giving love,and recognize the Great Healer at work in their lives.

The authors acknowledge with appreciation the valuablecontributions to this article from Dr. Patricia S. Jones andMrs. Adelaide Caroci Durkin.


Iris Mamier, PhD, MSN, RN, is an Associ-ate Professor in the PhD program at theLoma Linda University School of Nursing(LLUSN) in Loma Linda, California, U.S.A.She holds a PhD from Loma Linda Univer-sity, a Master’s degree in nursing educationfrom Humboldt University, Berlin, Ger-many, and completed her undergraduate

nursing at Heidelberg University, Germany. She has practicedand taught nursing across programs in Germany, Switzerland,and the United States, and was the Dean of Waldfriede Schoolof Nursing in Berlin, Germany. For the past 15 years, she hasbeen involved in whole-person care and nursing spiritual carefrom practical, conceptual, teaching, and research perspectives.

Edelweiss Ramal, PhD, RN, is an Asso-ciate Professor in the graduate nursingprograms at LLUSN. She has been a nurseeducator for 40 years; 25 of which werespent in Mexico and Botswana, 15 in theUnited States.

Anne Berit Petersen, PhD, MPH, APRN -CNS, is an Assistant Professor in the grad-uate program at LLUSN. She has workedas a nurse educator in China, Tanzania,Ethiopia, and the United States. She com-pleted a bachelor’s degree in English atWashington Adventist University, a bach-elor’s degree in nursing at Andrews Uni-

versity, Master’s degrees in nursing and public health at LomaLinda University, and a PhD and postdoctoral fellowship at theUniversity of California San Francisco. Dr. Petersen is passion-ate about equipping nurses to provide wholistic care, and her

✐

current program of research focuses on tobacco control and theprevention of non-communicable diseases locally and globally.

Harvey Elder, MD, graduated from theLoma Linda University School of Medicinein 1957 and completed an internal medi-cine residency at the University of Califor-nia at San Francisco and San FranciscoGeneral Hospital. He also completed a fel-lowship in infectious diseases at HarvardUniversity. Dr. Elder developed the hospi-

tal infection-control program at the LLU Medical Center andJerry L. Pettis Memorial Veterans Ad min istration Hospital inLoma Linda. Over the past three decades, his clinical practicehas focused on the care of persons with HIV and AIDS. He pi-oneered whole-person care by clinicians at LLU by helping pa-tients find spiritual strength and courage as they dealt withlife and health-related challenges.

NOTES AND REFERENCES1. Iris Mamier, “Nurses’ Spiritual Care Practices: Assessment, Type,

Frequency, and Correlates.” PhD diss., Loma Linda University, 2009.ProQuest (AAT 3405316).

2. Ellen G. White, The Desire of Ages (Mountain View, Calif.: PacificPress, 1898), 201-213. In chapter 21, Ellen White describes Jesus walkingalone in apparent meditation and prayer when He arrived at the Pool ofBethesda.

3. John 5:6. Unless noted otherwise, all Scripture references in thisarticle are taken from the New Revised Standard Version Bible, copyright© 1989 the Division of Christian Education of the National Council ofthe Churches of Christ in the United States of America.

4. John 5:7.5. John 5:8.6. John 5:14.7. Barbara Stevens Barnum, Spirituality in Nursing: From Traditional

to New Age, 2nd ed. (New York: Springer, 2003).8. John 5:17.9. Sigve K. Tonstad, The Lost Meaning of the Seventh Day (Berrien

Springs, Mich.: Andrews University Press, 2009).10. John 5:19.11. John Mac Arthur, The MacArthur Bible Commentary (Nashville,

Tenn.: Thomas Nelson, 2005), Luke 5:17-20. 12. Matthew 9:2.13. Matthew 9:6.14. Henry Blackaby, Richard Blackaby, and Claude King, Experienc-

ing God: Knowing and Doing the Will of God (Nashville, Tenn.: B&HPublishing Group, 2008).

15. Ellen G. White, The Ministry of Health and Healing (Nampa,Idaho: Pacific Press, 2004), 58.

16. Ibid., 57.17. Patricia Benner, “From Novice to Expert,” The American Journal

of Nursing 82:3 (March 1982): 402-407.18. Carla Gober-Park, Keith Wakefield, and Brandon Vedder, A Cer-

tain Kind of Light (documentary) (Loma Linda, Calif.: Loma Linda Uni-versity Health Center for Spiritual Life and Wholeness, 2015).

19. Harvey Elder, Spiritual Care Workshop, Loma Linda University,January 30 and 31, 2009.

20. Kenneth Pargament, Psychology of Religion and Coping: Theory,Research, Practice (New York: Guilford Press, 1997).

21. Siroj Sorajjakool, Mark Carr, and Ernest Bursey, eds., World Reli-gions for Healthcare Professionals, 2nd ed. (New York: Routledge, 2017);Aurora Realin and Todd Chobotar, eds., A Desk Reference to PersonalizingPatient Care, 3rd ed. (Maitland, Fla.: Florida Hospital Publishing, 2012).

22. White, The Ministry of Health and Healing, 55.


linical teaching is as impor-tant to nursing education asclassroom teaching. Inter-personal and inter-relationalteaching-learning activities

in clinical settings create opportuni-ties to develop the clinical knowledgeand clinical reasoning competenciesof students. It is in the clinical settingthat student nurses practice theirpractical skills and develop clinicalreasoning by caring for multiple pa-tients with complex needs. Clinicalinstructors must be carefully chosenand strategically positioned to super-vise practice and to prepare studentsfor efficient, effective, and safe prac-tice as they perform and acquire newclinical skills.

Aggregate data from a 1995-2004competency assessment using thePerformance Based Development Sys-

tem involving 31,401 nurses from 180health-care agencies in the UnitedStates revealed that newly graduatedRegistered Nurses, regardless of edu-cational preparation, have adequatepsychomotor skills and good knowl-edge content but lack the ability touse clinical reasoning to deliver effec-tive and safe care.1 Benner, Sutphen,Leonard, and Day2 noted that in acutehealth-care situations, nurses are in-creasingly challenged to make quickdecisions based on sound reasoning.

Regardless of where they work,nurses need to become more responsi-ble, autonomous, and accountable forpatient care. Shorter hospital stays, ad-vances in technology, and increasingcomplexity and severity of patients’clinical conditions require nurses tothink clearly, exercise good judgment,and initiate action to resolve prob-lems. Clinical reasoning, which fo-cuses on the nurse’s use of thinking

strategies, is the precursor to decision-making and informed action. Deci-sion-making under conditions of risk,uncertainty, and complexity have be-come standard professional practice.3

Therefore, the role of clinical instruc-tors and preceptors (hospital staffnurses) in helping students developand apply clinical reasoning alongwith clinical skills is very important.

Clinical instructors should mentorstudents to quickly recognize the na-ture of the whole clinical situationand prioritize the most-pressing andleast-pressing concerns.4 Progressivedevelopment of clinical reasoningskills is critical to this ability in orderto avoid adverse events or failure tosave a patient’s life.5 Clinical reason-ing can strengthen nursing practice byimproving decision-making, reducingrisks, promoting safety (including

B Y S U S Y A . J A E L a n d L U C I L L E K R U L L


IN ADVENTISTNURSING

CLINICALTEACHING

C

fewer medication errors), and improv-ing patient outcomes, all of which canresult from good clinical teaching.6

Nurse educators have many ques-tions related to clinical teaching. Drs.Susy Jael from Adventist University ofthe Philippines (AUP) and LucilleKrull from Walla Walla University(WWU) in the United States sat downwith Dr. Patricia Jones of Loma LindaUniversity to compare and contrastkey points related to clinical teachingin nursing education from two di-verse parts of the world.

Question 1: How much clinical time is

required for the bachelor’s degree in

nursing, and how is it computed?

Dr. Jael: At AUP, the requiredclinical units in each professionalcourse are mandated by the Philip-pine Commission on Higher Educa-tion (CHED).7 The current Bachelorof Science in Nursing curriculum re-quires a total of 46 Related LearningExperience (RLE) units. RLE is com-posed of nursing-skills laboratoryhours and clinical practicum. Nurs-ing-skills laboratory requires 12.5units (637.5 hours) and 33.5 clinicalunits (1,708.5 hours), a total of 2,346hours for the whole program. Oneclinical unit is equivalent to threeclock hours a week or 51 clock hoursover an 18-week semester, whichdoes not include exam week.

Dr. Krull: In the United States, aprecise number of clinical hours isnot always explicitly mandated byour accrediting agency, but mini-mums may be set by individual stateboards of nursing. Each school is freeto design its own curriculum andnumber of required clinical hoursbased on its mission, setting, and de-sired outcomes. At this time, WWUrequires a total of 900 hours of clini-cal experience for a bachelor’s degreein nursing, although the State ofWashington mandates a minimum of600 clinical hours for the same de-gree. WWU exceeds the minimum be-cause it offers several clinical courses

not typically found in other pro-grams, including a course in criticalcare and another in chronic illness.

North American colleges and uni-versities structure their academic yearin either quarters or semesters. WallaWalla University uses the quarter sys-tem, which is usually 10 weeks plusan exam week. Therefore, one creditof clinical lab is equal to three hourseach week, for a total of 30 clockhours per term. Other universities usea 15- or 16-week semester; therefore,one unit of credit for clinical practiceis equal to three hours per week for atotal of 45 clinical-experience hours.

Question 2: Who should facilitate the

clinical instruction? What qualifications

are necessary? Do all clinical instructors

need to be Seventh-day Adventist em-

ployees?

Dr. Jael: At AUP, a clinical instruc-tor is a full-time faculty member whoteaches professional courses and takesresponsibility for both classroom andclinical instruction. He or she is re-quired to have academic and clinicalpreparation specific to his or her clini-cal assignment. Based on CHED re-quirements for BSN programs in the

Philippines, faculty members teachingprofessional courses must be a Regis-tered Nurse (RN) and have a Master’sdegree in nursing, with at least oneyear of clinical experience.

All employees, including the clinicalinstructors, must be Seventh-day Ad-ventists so that they will be able to in-tegrate and model an Adventist caringand healing philosophy. It is importantthat clinical instructors have a full-timeappointment to ensure quality and con-sistent clinical supervision of students.Hence, at AUP, clinical instructors arefull-time, regular denominational em-ployees with benefits. Benefits addvalue to service rendered and usuallycontribute to retention of faculty.

Dr. Krull: In the United States, thequalifications of clinical instructors areoften mandated by state boards ofnursing and national nursing-accredi-tation agencies. The typical expecta-tion is that clinical instructors be anRN with a degree higher than the stu-dents being taught. For example, inAssociate in Science Nursing pro-grams, clinical instructors must have abachelor’s degree in nursing; whereasin bachelor’s degree programs, theclinical instructor must have a Mas-ter’s degree in nursing. Depending onthe state in which the program is lo-cated, the clinical instructor must alsohave two to three years of full-time ex-perience in the specific clinical areawhere he or she will be teaching.

At WWU, clinical instruction isdone by both full-time and part-timefaculty. Each clinical course is taughtand coordinated by a full-time lead in-structor who has several part-time in-structors assisting with clinical in-struction. All full-time faculty must bemembers of the Seventh-day Advent-ist Church, but this is not always pos-sible for part-time clinical instructors.While Seventh-day Adventist clinicalinstructors are strongly preferred, asufficient number cannot always befound. The few non-Adventist part-time clinical instructors are carefullyselected and are often alumni or an


In the United States, the

qualifications of clinical

instructors are often

mandated by state boards

of nursing and national

nursing-accreditation

agencies. The typical ex-

pectation is that clinical

instructors be an RN with

a degree higher than the

students being taught.

employee at the agency where theclinical experience is being taught.These non-Adventist instructors mustsubscribe to a Judeo-Christian beliefsystem and be well oriented to Ad-ventist philosophy and practices.Many part-time clinical instructors arealso employed full-time as staff nursesin another health-care agency thatprovides employment benefits.

Question 3: How do you verify that clini-

cal instructors are spending the required

time in direct supervision of students?

Dr. Jael: A clinical-instruction planfor every professional course is inplace. It includes the objectives andactivities, tasks and responsibilities forboth the clinical instructor and stu-dents in their assigned clinical area.This serves as a guide to the clinicalinstructors. The nursing administra-tion of the school has a monitoring de-vice to ensure that clinical instructorsare directly supervising the students intheir clinical activities. This includesclocking in and out by both clinical in-structors and students. Moreover, thecharge nurse of the hospital or clinicalfacility is expected to evaluate the per-formance of the clinical instructor atthe end of the clinical rotation andsubmit a report to the school of nurs-ing administration.

Dr. Krull: At WWU, there is nomonitoring procedure for clocking inor out for clinical instructors. Eachclinical instructor reports directly tothe lead full-time nursing facultymember and develops a trust rela-tionship with that instructor. Mostfull-time faculty members meetweekly with the clinical instructors inperson, by phone, or electronically todiscuss student performance.

Question 4: How do you ensure consis-

tency in clinical supervision by different

clinical instructors in the same course?

Dr. Jael: The clinical instructionplan and the course syllabus describethe clinical activities for each profes-sional course, serve as a guide to theclinical instructor, and, to the extentpossible, ensure consistency in clinical

supervision among clinical instructors.During faculty meetings, all con-

cerns and policies are discussed andaccepted. Each faculty member isaware of what is expected, and worksin an environment of trust and hon-esty. However, an unannounced spotcheck or area visit by the clinical co-ordinator, department chair (or dean)happens occasionally.

Dr. Krull: Each lead instructor isresponsible for orienting, monitoring,and evaluating his or her clinical in-structors. He or she is responsible forbuilding a team and ensuring thatgrading and other evaluations aredone consistently by all clinical in-structors for that course.

Question 5: Is there a structured

orientation program for new clinical

instructors? If so, what is included?

Dr. Jael: Yes. A structured orienta-tion program is done at the start ofevery semester. When the new as-signments are announced, a shadow-ing period of at least two weeks (orhowever long the hospital requires) isarranged for immersion to theagency’s protocols and policies.

The clinical instructor should un-dergo orientation to the course and tothe clinical practicum site before beingallowed to supervise students. Thedean or the department chair shouldorient the clinical instructor to the poli-cies, standards, guidelines, activities,and expectations of the course in theclinical area. The nursing-administra-tion office of the clinical agency shouldconduct a clinical orientation to ensuresafe, effective, and quality practice byboth the clinical instructors and thestudents. This should include an orien-tation regarding the policies of the hos-pital/agency, the hospital administra-tion, the key personnel and staff of thespecific clinical area, the clinical formsto be used by the students, routine pro-cedures and activities in the specificclinical area, its facilities and equip-ment, and an orientation to the physi-cal setting. The clinical instructor

should also undergo clinical duty for atleast two weeks to have a feel for thespecific clinical area.

Dr. Krull: Orientation of clinical in-structors is done individually, and typi-cally includes three areas: orientationto the university and school of nurs-ing, orientation to the course, and ori-entation to the clinical agency whereinstruction will occur. Orientation tothe university is conducted by theschool of nursing dean, and includesinformation about Seventh-day Ad-ventist beliefs and practices if the clini-cal instructor is not an Adventist or analumnus. Policy manuals are shared,and key policies regarding payroll, ex-pectations, and evaluation are re-viewed. Orientation to the course isconducted by the lead instructor forthat course. This includes orientationto the syllabus, course, and clinical ex-pectations; as well as evaluation formsand clinical assignments to be graded.If a newly hired clinical instructor isalready an employee at the agencywhere the lab will be taught, immer-sion at the agency is not necessary. Ifnot, he or she may be requested toshadow an agency employee or thelead instructor before the class begins.

Question 6: What is the role of the

clinical instructor in integrating theory

into clinical practice?

Dr. Jael and Dr. Krull: Clinicalpracticum should be offered simultane-ously or immediately following comple-tion of theory. The clinical instructormust ensure that clinical activities arecongruent with the objectives of thecourse and implement the clinical activ-ities as outlined in the syllabus. Ideally,the faculty member teaching the didac-tic part should supervise students intheir clinical practicum. However, inthe case of team teaching, the clinicalinstructor coordinates and collaborateswith the lecturer of the course.

For supervision in the clinical area,what has been taught in lecture shouldbe enhanced or reinforced as it is ap-plied in the clinical setting. Ideally, thetheory instructor also does the clinicalinstruction; but if that is not possible,


another member of the team-teachinggroup does it and sees that the princi-ples are put into practice. An impor-tant aspect to remember is that clinicalexperience related to the theoreticalcontent of the course needs to be of-fered during the same academic termin order for it to be recognized and ac-cepted internationally.

Question 7: How should performance

in clinical practice influence the course

grade?

Dr. Jael: Credit for the completionof the course is based on the fulfill-ment of the curricular requirementsin both theory and clinical practicum.The grade for the professional courseis based on the course credit (theoryunits and clinical units). A studentwill not be permitted to enroll in thenext professional course unless he orshe has a passing grade in the prereq-uisite professional course.

Dr. Krull: Theory performance ispoints-based and graded with a lettergrade of A-F based on percentage ofpoints earned on tests, quizzes, andassignments. Clinical instruction iscompetency-based and is graded aspass/fail. Absolute minimum clinicalperformance is identified, and stu-dents must demonstrate that they cansafely care for patients according tothese standards. Standards increase inexpectations as the student progressesthrough the program. It is possible fora student who is performing well intheory to fail in the clinical portion ofthe course and vice versa.

Question 8: What happens when a

student fails in clinical practicum?

Dr. Jael: When a student fails in theclinical practicum, he or she is advisedto obtain additional supervised practiceand given a repeat performance of theskill/checklist. If still unable to pass,the student is required to repeat thewhole course—both theory and prac-tice. A student is allowed to repeat thewhole course one time. Mastery of theknowledge and skill(s) on one level

prepares him or her for more compli-cated clinical tasks on the next level.

Dr. Krull: If a student fails in theclinical practicum, he or she fails thewhole course and must repeat boththeory and clinical portions at a pass-ing level to progress in the program.Only one nursing course can be failedfor the student to remain in the pro-gram. If a student fails a secondcourse, he or she is no longer eligibleto be a nursing major.

Question 9: What policies should be in

place to promote safe clinical practice by

nursing students?

Dr. Jael: The Related Learning Ex-perience (RLE) is composed of skillslaboratory hours followed by practicein the clinical area. Before going tothe clinical area, students are re-quired to practice and perform thespecific clinical skills in the skills lab-oratory that they will be assigned inthe clinical area the following week.

A clinical pre-conference shouldbe conducted by the clinical instruc-tor before exposing the student to thespecific clinical area to ensure thatthe student is ready to safely performnursing skills on actual clients.

Dr. Krull: There should be specificpolicies about safe practice specifi-cally oriented to the area of medica-tion administration; also, certain skillsshould not be allowed for lower-levelstudents. For example: Beginningstudents cannot administer any med-ications without direct supervision.More-advanced students may admin-ister some oral medications once theirmedications are checked by their in-structor or the RN assigned to the pa-tient. No student can ever administerchemotherapy or conscious sedation.

Question 10: What is the difference

between clinical instructors and

preceptors?

Dr. Jael and Dr. Krull: Clinical in-structors are faculty members em-ployed by the nursing school assignedto supervise, guide, and implementstructured clinical-learning practicumto a group of students. Clinical instruc-tors allow students to apply knowledgegained in the didactic portion of a pro-fessional course to clinical practice.

Clinical preceptors are hospital-employed practicing nurses whomentor the clinical learning experi-ence of a specific nursing student.Most of the time, it is a one-to-oneguided clinical practice.

Question 11: What requirements of

clinical instructors can be described as

applicable worldwide?

Dr. Jael and Dr. Krull: Around theworld, the role of clinical instructorsis to supervise students in the clinicalarea during their clinical practicum.They are expected to perform pre-and post-conferences, orient studentsto the clinical area, ensure that clini-cal activities are congruent with theobjectives of the course; assist stu-dents in the performance of nursingcare, medication administration,nursing procedures, carrying out doc-tors’ orders, writing nursing careplans and nurse’s notes; and evaluatestudent performance.

The clinical instructor and the


The grade for the profes-

sional course is based

on the course credit (the-

ory units and clinical

units). A student will not

be permitted to enroll in

the next professional

course unless he or she

has a passing grade

in the prerequisite pro-

fessional course.

nursing-service personnel of the hos-pital/affiliating agencies should col-laborate in the planning, implementa-tion, and evaluation of the clinicalexperience of the students.

Question 12: What is an accepted

ratio of students per instructor in the

clinical area?

Dr. Jael: Faculty-to-student ratio,and student-to-client ratio policiesshould be in place and carefully fol-lowed. In the Philippines, the generalguidelines for ratio of faculty to stu-dents in the clinical setting dependson the year level of the students asmandated in the Philippine Commis-sion on Higher Education Memoran-dum Order. CHED limits the ratio toeight students per instructor for first-and second-year levels, 12 studentsper instructor for the third-year level,and 15 students per instructor forfourth-year-level students. The nurs-ing school and the clinical facilityhave the option to further limit theratio considering the complexity andseverity of patients’ clinical condi-tions, particularly in areas like inten-sive care, critical care, dialysis, emer-gency, operating, and delivery unitsfor quality clinical supervision.

Dr. Krull: In the United States, themaximum legal student/teacher ratiois mandated by the state board ofnursing. The State of Oregon limitsthe ratio to eight students per instruc-tor at any one time. The State ofWashington allows 10 students per in-structor. Both of these states havepolicies requiring a lower limit ifneeded to maintain patient safety.While schools are not allowed to ex-ceed the legal student/teacher ratio,the actual ratio can be further limitedby the clinical facility based on fac-tors such as number of patients avail-able, the complexity of a patient’scondition, unit staffing shortages, ornewly hired staff being oriented.From my personal experience, clinicalsupervision is much easier when stu-dents are located close to one anotherrather than spread over several floorsor units. Another factor to be consid-

ered is the level of experience of thestudent. Groups need to be smallerfor beginning students as opposed tostudents who are more advanced.

Summary

In spite of slight variations in lawsand accreditation standards from onestate or country to another, the overallapproach to clinical teaching remainssimilar around the world. With in-creasing numbers of schools of nursingwithin and outside of the Seventh-dayAdventist educational system, the de-mand for access to clinical sites forstudent practice is becoming a chal-lenge. Documentation of adequatelysupervised student practice by quali-fied clinical instructors or preceptors,and demonstration of safe perform-ance with minimum errors are stan-dard expectations by accrediting agen-cies and even more for Seventh-dayAdventist Christian nurses who arecalled to provide care. Programs maybe judged as “out of compliance” byaccrediting agencies if the adequacy orqualifications of clinical instructors, orany other aspect of the clinical instruc-tion, are deemed below what is ex-pected. The day when schools of nurs-ing could assume that hospital nursingstaff would be available to assist or su-pervise students is past. Therefore, theavailability and cost of expert clinicalinstructors needs to be consideredwhen establishing a nursing program.Clinical instructors should develop ex-pertise in clinical teaching not only toprevent loss of accreditation, lawsuits,and adverse patient outcomes, but toeducate future nurses who will exhibitsafe levels of clinical practice. ✐

Susy A. Jael,PhD, RN, is Asso-ciate Professorand Dean of theCollege of Nursingat Adventist Uni-versity of thePhilippines in

Silang, Cavite, Philippines. She is anappointed member of the accreditingteam of the Association of ChristianSchools, Colleges, Universities Accred-iting Agency, Inc. (ACSCU-AAI),2011-present, and formerly served asan appointed member of the Com-mission on Higher Education (CHED)Regional Quality Assessment Team(RQAT), 2014-2015.

Lucille Krull,PhD, RN, is Pro-fessor and Dean ofthe School of Nurs-ing at Walla WallaUniversity (WWU)in College Place,Washington,

U.S.A. In her 21 years at WWU, shehas served as an accreditation visitorfor the Northwest Commission on Col-leges and Universities, and as secre-tary for the Adventist InternationalNursing Education Consortium—North America.

NOTES AND REFERENCES1. Dorothy del Bueno, “A Crisis in Critical

Thinking,” Nursing Education Perspectives26:5 (September-October 2005): 278-282.

2. Patricia Benner et al., EducatingNurses: A Call for Radical Transformation(San Francisco, Calif.: Jossey-Bass, 2010): 21.

3. Patricia Ebright et al., “Mindful Atten-tion to Complexity: Implications for Teachingand Learning Patient Safety in Nursing,” inAnnual Review of Nursing Education, Mari-lyn H. Oermann and Kathleen T. Heinrich,eds. (New York: Springer Publishing, 2006):4:339-359.

4. Benner et al., Educating Nurses: A Callfor Radical Transformation, 26.

5. Linda Aiken et al., “Educational Levelsof Hospital Nurses and Surgical Patient Mor-tality,” Journal of the American Medical As-sociation 290:12 (September 2003): 1617-1620.

6. Barbara Simmons, “Clinical Reasoningin Experienced Nurses,” Western Journal ofNursing Research 25:6 (October 2003): 701-719. doi: 10.1177/0193945903253092.

7. Commission on Higher EducationMemorandum Order on Policies and Stan-dards for Bachelor of Science in Nursing Pro-gram, No. 14, series of 2009.


n 1999, the Institute of Medicine (IOM) published a land-mark report on the quality of health care in America, whichshocked the nation when it revealed that more than 98,000patients die each year as a result of medical error.1 A fol-low-up report, “Crossing the Quality Chasm,” discussed the

problem that educating health-care students in the isolation ofthe various “silos” (insular functioning that discourages reci-procity and communication across disciplines) of their profes-sions contributes to quality-care concerns, and outlined stepsto address the issues raised, which included the need to focuson evidence-based practice and interdisciplinary training.2 Inaddition, the World Health Organization (WHO) in 2010 issueda report, “Framework for Action on Interprofessional Educationand Collaborative Practice,” with the goal of providing guid-ance to key elements of interprofessional education (IPE) andcollaborative practice.3 Just one year later, the InterprofessionalEducation Collaborative (IPEC) identified Core Competenciesfor interprofessional collaborative practice.4

In 2012, the Institute of Medicine’s Global Forum on Inno-vation in Health Professional Education was formed (nowknown as the National Academies of Sciences Engineering andMedicine’s Global Forum on Innovation in Health ProfessionalEducation). Along with the Robert Wood Johnson Foundation,it developed reports on the importance of educational entitiesworking together in partnerships to educate health-care stu-dents on the importance of teamwork, collaboration, and dia-

logue. The Josiah Macy Jr. Foundation has taken an active rolein funding research on interprofessional education by provid-ing grant funding while disseminating information regardingbest practice in IPE for practitioner use including curriculum,modules, and professional development.5

The international community has clearly identified and af-firmed IPE as a foundation for effective health-care education,yet many challenges remain. Health-care education still pre-dominantly occurs in silos, with little day-to-day critical think-ing and problem-solving across professional boundaries, fur-ther complicated by each profession having its own language.6

Other challenges include the cost of funding such education,having a faculty trained in IPE skill sets and procedures, pro-viding adequate time and resources for IPE training for stu-dents, and the problem of collaborating amid varying aca-demic schedules and calendars.7 Finally, finding validated,reliable assessment measures of IPE has also been a concern.8

In spite of these challenges, certain factors can facilitateIPE in health-care education such as having faculty champi-ons who become catalysts for positive change, institutionalsupport, shared interprofessional vision, and faculty-develop-ment programs.9 Some universities have sent teams of inter-professional faculty to IPEC conferences to begin or furtherdevelop their IPE plans, and gain insight and support fromseasoned professionals. Adopting a foundation of equality,willingness to listen to others, and a commitment to minimize

B Y K A T H I W I L D a n d L I L I F E R N A N D E Z M O L O C H O


AT TWO ADVENTISTUNIVERSITIES

INTERPROFESSIONALEDUCATION

I

turf battles are also key contributors to IPE success.10 Encour-aging faculty to co-teach with other colleagues in clinicalsettings, modeling by colleagues with experience in the field,and being flexible when faced with challenges are also im-portant.11 Another avenue to enhance interprofessional edu-cation curriculum is for various accrediting bodies to developstandards that target IPE skills, values, and competencies.12

IPE and collaborative practice have been an area of in-quiry for more than 40 years, yet further research is neededto examine the effect of IPE and collaborative practice onhealth-specific outcomes.13 The WHO Framework for Actionon Interprofessional Education and Collaborative PracticeFramework14 outlined a process that starts with havinghealth and education systems examine the context of localhealth needs, then developing quality IPE programs that willtrain health-care workers to implementcollaborative practices. The result will becollaborative practice by health-care pro-fessionals, a strengthened health-care sys-tem, and improved health outcomes.15

Adventist universities and health-carecenters are moving forward in promotinginterprofessional education and collabo-ration among their university partners.IPE is necessary to equip future health-care professionals with skills such ascommunication, joint problem-solving,and teamwork to optimize patient safetyand enable quality service in ever-chang-ing health-care systems worldwide.

Interprofessional Education Experiences at

Loma Linda University (LLU)

Shortly after the Medical SimulationCenter opened at LLU Centennial Com-plex in 2010, a PhD in nursing student,Janice Palaganas, partnered with medical-simulation staff and representatives from other disciplinesto explore health-care simulation. This platform provided afoundation for IPE to compare the effectiveness of high- andlow-technology simulation and also provided students fromdifferent health-care backgrounds the opportunity to applycollaborative communication skills and participate in groupproblem-solving tasks.16

In working with students from a variety of health-careprograms, the team found that high-technology approacheswere more effective than non-simulated, low-technologymodalities. For example, high-technology simulations pro-vided students with immediate feedback on patients’ vitalsigns (as well as other forms of data), and allowed them tomake decisions, thus mirroring a real-world context. Today,LLU continues this effort through the Interprofessional learn-ing (IPL) experience, which is open to all of the university’sschools.

Students from the schools of nursing, medicine, phar-

macy, allied health (departments of radiology technologyand physician’s assistant), public health, dentistry (dentistryand dental hygiene), and behavioral health (child-life de-partment) participate in IPL. All of the participating studentscomplete the Readiness for Interprofessional Learning Scale(RIPLS) survey17 prior to and after their IPL experience.

During the four-hour IPL session, groups of eight to ninestudents from three to five different LLU schools rotatethrough three stations at the university’s Medical SimulationCenter. Before starting the activities at each of the three ro-tations, the students engage in a 20-minute learning experi-ence designed to prepare them to use TeamSTEPPS® commu-nication strategies18 as they encounter, problem-solve, andintervene in a variety of patient scenarios. In two of the ro-tations, students are able to take advantage of the simulation

patient suites with high-fidelity manikins. During their “im-mersive” rotation, students are able to observe and interveneas they experience a simulated patient emergency.

A second rotation is designed to expose the students to avariety of commonly encountered patient and staff issues re-quiring optimal team communication and problem-solving.In each of these rotations, students are able to debrief fol-lowing the learning experience, ask questions, and practiceand review key concepts.

In the third rotation, students review case studies of anacute-care situation and the accompanying long-term or com-munity-based follow-up. The scenarios were developed tostimulate participation from all the disciplines involved as stu-dents discuss assessments, key interventions, referrals, andconcerns that each of the professions would address. A guidedone-to-one interview also occurs during this “scope of prac-tice” rotation, which promotes sharing, understanding, andcommunication amongst the student participants.


Students from Loma Linda University’s Schools of Nursing, Pharmacy, Allied Health, and

Medicine work together to respond to a patient emergency during interprofessional experi-

ences at Loma Linda University’s Medical Simulation Center.

Each fall, LLU’s School of Allied Health coordinates a half-day interprofessional workshop that involves all the depart-ments preparing allied-health professionals (cardiopulmonarysciences, clinical lab sciences, communication sciences anddisorders, health informatics and information management,occupational therapy, orthotics and prosthetics, physical ther-apy, and radiation technology). Prior to the workshop, thestudents study a case scenario so they are prepared to sharetheir profession’s scope of practice and clinical context.

During the 80-minute rotations, the students from the var-ious departments interact to provide collaborative, whole-person care. Before the experience ends, the students receivea presentation from participants who were involved in thereal-life case the students had been studying throughout thesession. The culminating debriefing allows participants toreflect on how collaboration facilitated quality patient careas they discuss how to preserve life and maximize function.

Critical Event Response Lab

Each spring quarter, students from the schools of medi-cine, pharmacy, nursing, dentistry, and the emergency med-ical care department within the School of Allied Health par-ticipate in a half-day “Critical Event Response Lab,” whichis designed to prepare health-care professionals from vari-ous backgrounds to work collaboratively when faced withvarious disasters or multi-casualty situations. Prior to at-tending an assigned half-day lab, students complete amulti-module, online interactive course covering topicssuch as basics of disaster medicine, disaster triage, public-health response to disasters, TeamSTEPPS® communicationstrategies and mental-health concepts of disaster, alongwith specialty modules designed for each school. They alsocomplete pre-assessments prior to attending the onsitecourse and, with participants from the various schools, ro-tate through five stations—a triage station, decontamina-tion simulation, and three scenarios in the LLU’s interpro-fessional Medical Simulation Center suites where theyencounter various disaster scenarios requiring teamwork,communication, and effective interprofessional interven-tion. Following each experience, the students are given anopportunity for debriefing and reflection.

At the conclusion of the Critical Event Response Lab, thestudents take post-surveys to assess their understanding ofteamwork, communication procedures across health-caredisciplines, and the relationship between the context of theirscope of practice and problem-solving in real-world contexts.

Survey results showed that statistically significant growthoccurred in students’ ability to work in and contribute toteams and to facilitate communication. In addition, studentcomments from the survey showed that they developed morepositive perceptions regarding team communication andmanagement.19 Throughout the IPL experience, students re-ported that their own perceptions of positive interdiscipli-nary experiences were strengthened as they were able tolearn from the expertise of other disciplines.

Additional Lab Experiences

In addition to these events, schools within LLU are work-ing to provide opportunities and broader contexts in whichinterdisciplinary experiences can occur. For example, theschools of dentistry and pharmacy have created opportuni-ties for students and professors to collaborate on case studiesin order to provide a context in which students can applytheir learning. This process encourages students to reflecton how the attitudes, communication styles, and skill setsinherent to their discipline contribute to collaboration andbetter patientcare.

The LLU School of Nursing has created an Ethical DilemmaLab where groups of seven to nine nursing and pharmacy stu-dents partner to interview a “family” struggling with an eth-ical issue. Prior to the lab, each participant is assigned a role,sent a scenario overview, and given journal articles to review.After their preparation, each team conducts a 20-minute in-terview with actors portraying a family to provide guidanceand support, and aid in problem-solving. These interactionsare videotaped and reviewed prior to debriefing and reflec-tion. Teams discuss their effectiveness in guiding the ethicalconversation, showing empathy, providing evidence-based in-formation, and increasing their level of professionalism.

LLU’s Center for Interprofessional Education Research(CIPER) team has also begun to develop frameworks andmethodologies to guide interprofessional work, conduct re-search, and inform future IPL opportunities. This team, underthe guidance of Christiane Schubert, PhD, involves profes-sionals from the schools of medicine, dentistry, nursing, andpharmacy, as well as representatives from Loma Linda’s Vet-erans Administration Hospital. This work is designed to pro-mote foundational research in clinical settings in order toexamine ways that interdisciplinary professionals can colla -borate to achieve optimum outcomes for patients.20 By guid-ing work in these areas, the team hopes to encourage a higherquality of whole-person care, ensure better patient outcomes,and contribute to a more resilient health-care system.

Interdisciplinary Learning at Universidad Peruana Union (UPeU)

Interdisciplinary learning began at UPeU in 2012 with athree-year project titled: “Responsible Parents, Healthy Chil-dren,” which focused on early stimulation and healthy nu-trition of children from birth to 5 years of age who lived ina community close to UPeU. The project involved the nurs-ing, psychology, nutrition, and theology departments. To-gether, administrators and faculty developed a six-point ac-tion plan to decrease infant morbidity/mortality and improvethe quality of life for the local children:

1. Increase the level of parental knowledge and attitudesso that they can provide early stimulation to their childrenfrom birth to age 5.

2. Teach parents about the principles of nutrition and howto prepare healthful and appetizing foods for their childrenfrom birth to age 5.

3. Help ensure that parents bring their young children


(from birth to age 5) to well-baby clinics and healthy childchecks as established by the country’s Ministry of Health.

4. Enrich the affective interactions between couples to im-prove relationships among family members.

5. Improve mothers’ and fathers’ implementation ofhealthful lifestyle habits in personal hygiene and cleanlinessin their living areas.

6. Establish a Community Center for Early Stimulation. A team of faculty members from the participating depart-

ments mentioned above developed an action plan based onthe project’s objectives and the desired learning outcomesfor each participating department. Nursing, psychology, andnutrition students collaborated on the project and jointlyconducted home visits and educational programs. Similarly,psychology and theology students worked together to en-hance marital relationships in their clients.

This collaborative work experience generated a sharedinter-professional vision among the faculty and administra-tors of the participating departments, which offered im-proved outcomes in the health care of individuals and fam-ilies in the community.

The following year (2013), the School of Health Sciences,with the participation of the nursing, psychology, andhuman nutrition faculties, implemented the following proj-ect: “Healthy Girls and Boys for a Secure Future” in severalcommunities. This second joint project reaffirmed the needfor a coordinated interdisciplinary plan of action in the com-munity because previously, students in each of these depart-ments had conducted their community practice independ-ently. This led to duplication of effort and cost, andfre quently did not produce the desired outcomes in the com-munity. For this reason, since 2013, the School of Health Sci-ences has implemented an Interdisciplinary Community In-ternship for its nursing, human nutrition, and psychologyprograms. The faculty responsible for the community intern-ship meet at pre-determined times to develop a joint workplan that takes into account the desired competencies andlearning outcomes, and course content, and to arrange for aneeds assessment of the community.

During the first week of the practicum, the students par-ticipate in an induction and orientation program. Next, theyconduct a community needs assessment. Then, together

with community leaders and administrators, as well as localrepresentatives from the Ministry of Health, a multidiscipli-nary team develops an action plan. The team, in coordina-tion with faculty from the participating disciplines, plan thestudents’ clinical practice according to the competenciesthey want the students to acquire. This experience with in-terdisciplinary learning has enriched and increased the ca-pability of students, faculty, and administrators.

Students learn teamwork; acquire/develop skills relatedto negotiation and conflict resolution; learn assertive com-munication; and learn respect and tolerance for others’ opin-ions. They also develop leadership skills as they coordinatewith institutional leaders and community-center personnelwithin the municipality; acquire knowledge regarding theroles of the other professions participating in the project; andprepare for their year of government-required social serviceupon completion of their degree.

Faculty acquire expertise in curriculum development andrevision and identify courses or content that will enablestudents to develop the necessary competencies to engagesuccessfully in interdisciplinary work. They also identifymeth odologies and strategies to address community andinterdis ciplinary practice, learn terminology unique to eachof the professions involved, and build competency in areasof concentration. Above all, they learn to role-model team-work and develop practice guidelines.

As a result of this experience, UPeU is expanding student-intervention scenarios. For example, the school has estab-lished a strategic alliance with some of the hospitals and clin-ics throughout the country to work on a project called “TotalHealth” in which nursing, nutrition, and psychology studentswill participate, and as of 2018, medical students as well.

Even though the value and outcomes of interdisciplinarylearning are positive and promising, a variety of barriers andchallenges such as scheduling must be overcome. However,great benefits could be achieved from the following collabora-tions: integration of medical and nursing students into acute-care situations; engaging nursing, medical, and psychologystudents in emergency situations and disasters; and teachingnursing and psychology students to collaborate in managingadolescent pregnancies. The areas of health care where inter-disciplinary practice would increase the benefit to the client,


Figure 1. Outcomes for Quality IPE Programs

Interprofessional

Education

Collaborative

practice-ready

health workforce

Collaborative

practice

(post-licensure)

Improved Health

Outcomes (safe,

effective practice)

community, and society, while at the same time increasing ca-reer satisfaction for the health professional, are many.

These illustrations show how Loma Linda University andUniversidad Peruana Unión are creating opportunities for stu-dent interaction across disciplines to mobilize energy andfacilitate collaboration on various health issues. These oppor-tunities help students to acquire and develop effective com -munication skills, teamwork, collaborative problem solving,and reflective insights to navigate through ethical challenges.In addition, these interdisciplinary experiences enable stu-dents to broaden their skillsets as they collaborate with fellowclinicians to improve and implement patient care. The simu-lated and real-world projects modeled by these two schoolsprovide a greater insight into ways that university depart-ments can collaborate to prepare an interdisciplinary work-force with the diverse strengths and expertise to ensure amore responsive and effective health-care systems. ✐


Kathi Wild, MS, RN, is an Assistant Pro-fessor at Loma Linda University Schoolof Nursing (LLUSN). She worked as apsychiatric nurse before completing herMaster’s degree in psychiatric-mentalhealth nursing from Loma Linda Univer-sity. Ms. Wild taught community mentalhealth for five years at LLUSN, and later

worked as a public health nurse, then Program Manager forInland Regional Center’s Early Start program, which coordi-nates services for infants and toddlers at risk for developmen-tal delay. In 2012, she returned to LLUSN and most recentlyhas been course coordinator for Capstone Nursing Practicumand Capstone Leadership and Management courses in whichshe helps to develop interprofessional learning experiencesfor LLU students. Ms. Wild volunteers as an RN at Corner-stone Community Free Clinic and also serves on the board ofthe Inland Empire Healthcare Education Consortium.

Lili Fernandez Molocho, DPH (Spe-cialty: Intensive Care), is a faculty mem -ber in the undergraduate and graduateprograms in nursing at the UniversidadPeruana Unión in Lima, Peru. She has 25years of clinical experience, 23 years ofteaching experience, and spent six yearsas Dean of the School of Health Sciences

at the university.

NOTES AND REFERENCES1. Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson, eds.,

To Err Is Human: Building a Safer Health System (Washington, D.C.: In-

stitute of Medicine National Academy Press, 2000): https://www. nap. edu/ read/9728/chapter/1.

2. Committee on Quality of Health Care in America, Crossing theQuality Chasm: A New Health System for the 21st Century (Washington,D.C.: Institute of Medicine National Academy Press, 2001): https:// www. nap.edu/read/10027/chapter/1. doi:10. 17726/ 10027.

3. John H. V. Gilbert, Jean Yan, and Steven J. Hoffman, “A WHO Re-port: Framework for Action on Interprofessional Education and Collab-orative Practice,” Journal of Allied Health 39:3 (Fall 2010): 196, 197.

4. Interprofessional Education Collaborative Expert Panel, Core Com-petencies for Interprofessional Collaborative Practice: Report of an ExpertPanel (Washington, D.C.: Interprofessional Education Collaborative, 2011).

5. The Josiah Macy J. Foundation (2015): http://macyfoundation. org/ contact.

6. Afaf I. Meleis, “Interprofessional Education: A Summary of Re-ports and Barriers to Recommendations,” Journal of Nursing Scholarship48:1 (December 2015): 106-112.

7. Tanya R. Lawlis, Judith Anson, and David Greenfield, “Barriersand Enablers That Influence Sustainable Interprofessional Education: ALiterature Review,” Journal of Interprofessional Care 28:4 (July 2014):305-310.

8. Amy V. Blue et al., “Assessment and Evaluation in Interprofes-sional Education: Exploring the Field,” Journal of Allied Health 44:2(Summer 2015): 73-82.

9. Lawlis et al.,“Barriers and Enablers That Influence SustainableInterprofessional Education: A Literature Review.”

10. Meleis, “Interprofessional Education: A Summary of Reports andBarriers to Recommendations.”

11. Désirée A. Lie et al., “Interprofessional Education and PracticeGuide No. 5: Interprofessional Teaching for Prequalification Students inClinical Settings,” Journal of Interprofessional Care 30:3 (May 2016):324-330.

12. Joseph Zorek and Cynthia Raehl, “Interprofessional EducationAccreditation Standards in the USA: A Comparative Analysis,” Journalof Interprofessional Care 27:2 (March 2012): 123-130.

13. May Lutfiyya et al., “Setting a Research Agenda for Interprofes-sional Education and Collaborative Practice in the Context of UnitedStates Health System Reform,” Journal of Interprofessional Care 30:1(July 31, 2015): 7-14. doi: 10.3109/13561820.2015.1040875.

14. WHO | Framework for Action on Interprofessional Education andCollaborative Practice (n.d.). Retrieved August 20, 2017, from http:// www. who.int/hrh/resources/framework_action/en/.

15. Ibid.16. Janice C. Palaganas, “Exploring Healthcare Simulation as a Platform

for Interprofessional Education.” PhD diss., Loma Linda University, 2012.17. Angus K. McFadyen, Valerie S. Webster, and W. M. Maclaren, “The

Test-retest Reliability of a Revised Version of the Readiness for Interpro-fessional Learning Scale (RIPLS),” Journal of Interprofessional Care 20:6(December 2006): 633-639. doi:10.1080/13561820600991181.

18. U.S. Department of Health and Human Services, TeamSTEPPS:Pocket Guide: Strategies and Tools to Enhance Performance and PatientSafety, Version 2.0 (Bethesda, Md.: U.S. Department of Health and HumanServices, 2013).

19. The study comprised of 402 participants (senior allied health,medicine, nursing, and pharmacy students) who completed a discipline-specific course followed by a four-hour synchronous experience that in-cluded simulations such as resuscitation, decontamination, mass casu-alty triage in an active shooter event. For more information, see TaeEung Kim et al., “Healthcare Students Interprofessional Critical Event/ Disaster Response Course.” American Journal of Disaster Medicine 12:1(Winter 2017): 11-26. doi:10.5055/ajdm.2017.0254.

20. C. W. Schubert et al., The CIPER-Team: Conducting Patient-centeredResearch in a Complex, Interprofessional Health Care World (Loma Linda,Calif.: Loma Linda University Faculty Development Showcase 2016).


Dr. Jones: The first question I have for

each of you is in regard to the current de-

mand for graduate education in nursing.

How would you describe that demand?

Dr. Lloyd: In our graduate de -partment at Loma Linda University(Loma Linda, California, U.S.A.), weare seeing a demand for AdvancedPractice Registered Nurse programs(APRN). Most students are interestedin DNP (Doctor of Nursing Practice)roles. Many of these students arenurses from the workforce who areeager to get their doctorate to vali-date and give credibility to what theyhave been doing in practice for anumber of years and to provide addi-tional career opportunities.

Dr. Gadd: There is certainly a lotof demand here on the East Coastwhere I live as well. We know thereis a national demand for nurse practi-

tioners based on the research andepidemiologic information about theaging of America, the increased de-mand for health care, and the inade-quacy of the medical system to meetthat demand. We also experience aloss of nurses in an aging workforce.So there are many opportunities foradvanced-practice nurses. As wasmentioned previously, many nurseswho are mature in their nursing roleare anxious to move forward profes-sionally to provide primary-care serv-ices in different settings from whatthey have been used to. We seehealth care moving into the commu-nity more, so advanced practicenurses have the opportunity to meetsome of those needs. The demand isthere, and a lot of people are signingup to go to school.

Dr. Bristol: The other thing I wouldmention is that within hospital set-tings the cost of care—with an in-creased focus on quality—and

changes in how health-care institu-tions are paid are big issues. It is im-portant to have advanced-practicenurses in the health-care system whoare able to achieve or maintain accred-itation and professional criteria, suchas the American Nurses CredentialingCenter’s (ANCC) magnet status, directthe kind of programs needed to dem -onstrate quality patient outcomes, andto take the lead in working within theorganization to accomplish thesegoals. In today’s environment, eventhe viability of the organization is atstake because reimbursement for careis based on patient outcomes.

Dr. Gadd: I think it is super impor-tant to have these quality health-careproviders because research has shownfor 15 or 20 years that the survivalrates of hospitalized patients are betterwhen the nurses have higher levels ofeducation. This occurs at the under-graduate level when you compare as-sociate degree- to bachelor’s-level pre-pared nurses. The outcomes are betterfor patients cared for by a nurse with abachelor’s degree. This is also true of

BY SUSAN L. LLOYD, HOLLY GADD, SH IRLEY TOHM BRISTOL, and PATRIC IA S. JONES


AN INTERVIEW

ADVENTISTGRADUATE NURSING

EDUCATION:

Globally, there is increased demand for graduate nursing education. In this inter-view, Dr. Patricia S. Jones sits down with three administrators of graduate nursingprograms to discuss the demand for advanced programs, the need for qualifiededucators, types of certifications, and opportunities for online graduate education.

higher levels of care from nurses withMaster’s and doctoral degrees, and invarious settings. When you look at theacute-care settings, graduate-levelnursing education is very importantand really makes a difference.

Dr. Jones: Yes, that is very clear from the

remarks you have made thus far. What

would you say about the increasing need

for qualified educators?

Dr. Gadd: Here at Southern Ad-ventist University (Collegedale, Ten-nessee, U.S.A.), we do have a nurs-ing-education track in our program;but unfortunately, it has a very lowenrollment.

Dr. Lloyd: The challenge at LomaLinda University (LLU), and acrossthe nation, is that many nursing edu-cators will be retiring within the next10 years. We are working to “growour own” faculty now so that theywill be ready to carry on the work.

Dr. Bristol: In keeping with what Imentioned above, many graduates fromour Master’s and doctoral programs arechoosing to be employed in clinicalareas due to financial and other incen-tives. Educational institutions also needto recruit some of these highly qualifiedindividuals to maintain the level of edu-cation that produces qualified practition-ers. We need competent faculty at alllevels of nursing education, from the un-dergraduate level all the way throughdoctoral programs. As educators, wecurrently allow APRN faculty time outfrom their academic workload to main-tain practice skills. This collaborationbetween service and education will con-tinuously improve lines of communica-tion and enhance the educational oppor-tunities for both students and nurses.

Dr. Lloyd: Many of our studentswho enter the Master’s level Nurse Ed-ucator concentration later change tothe Clinical Nurse Specialist (CNS)concentration due to the large educa-tion component in the CNS role. Also,CNS students are able to receive ad-vanced-practice state and national cer-

tification, thus expanding their role aswell as providing increased clinical andeducational opportunities. Either con-centration can lead to a faculty role.

Dr. Jones: Yes.

Dr. Gadd: It is very well docu-mented that there is a shortage ofnursing faculty. Many nursing institu-tions take significant time to find qual-ified faculty and have a number of un-filled faculty positions. It is a problemthat affects the whole nursing practicearea because fewer educators meansyou take in fewer students and havefewer graduates. We need doctorallyprepared faculty to prepare nurse edu-cators to teach, and there are insuffi-cient numbers of those faculty. As youmentioned, retirements plus other fac-tors like discrepancies in wages andsalaries are very challenging. Nurseswho finish an associate degree canoften earn as much as I do with a PhD.But I’ve never gone hungry, and thereis a special blessing in doing what Godcalls us to do—particularly teaching inthe Adventist system. So, when I talkwith nurses who are consideringpreparing for a faculty role, I empha-size mission and what we do with thetalents God has given us. There are re-wards other than money.

Dr. Bristol: Not all students complet-ing an APRN program have the knowl-edge and skills to immediately becomea competent educator. It is, in fact, anentirely new learning curve. Early iden-tification of a student’s interest in an ac-ademic career can lead to a strong men-torship and supportive relationship fordeveloping competent faculty.

Dr. Gadd: I totally agree with that.I was educated at Loma Linda as anurse educator. I really valuedcourses related to curriculum devel-opment, classroom and clinical in-struction modalities, testing, meas-urement, and evaluation—how to dothese things correctly. There is a sci-ence to what we do as educators.

Dr. Lloyd: It’s not just “if you cando it, you can teach it.” We havefound that’s not always the case.

Dr. Gadd: That’s exactly right. I’lluse an even broader example. My hus-band began teaching accounting afterbeing an accountant and auditor foryears. He has expressed many timeshis envy of the classes I had in mygraduate program because I learnedhow to teach and wasn’t having to tryto figure it out on my own. Teaching isnot necessarily a natural thing, so it isreally important that we have thesegraduate nurse-educator programs.

Dr. Jones: Thank you. Is there anything

you would like to add regarding opportu-

nities for graduates with an advanced-

practice education?

Dr. Bristol: The nationally recog-nized programs for advanced practiceinclude the Clinical Nurse Specialist(CNS), Nurse Practitioner (NP), NurseAnesthetist (CRNA), and Nurse Mid-wife (NM). At LLU, we have the CNSconcentration, which includes Adult-Gerontology or Pediatric specialties.Within the Nurse Practitioner concen-tration, we have the following special-ties: Family Nurse Practitioner, Adult/ Gerontology Nurse Practitioner, Psychi-atric Nurse Practitioner, and PediatricNurse Practitioner. We also offer theNurse Anesthetist concentration. TheNeonatal Nurse Practitioner and theNurse Midwife, although not offered atLLU, are available nationwide.

Dr. Jones: There is also acute care, right?

Dr. Lloyd: Yes, a few schools na-tionally offer the Acute Care NursePractitioner (ACNP) specialty as well.

Dr. Gadd: Those are the fourmajor advanced-practice roles notedin the national guidelines. Withinthose roles, the nurse practitioner—and to some degree the CNS—thendivide into acute- and primary-careroles, and then further into lifespan(e.g., neonatal, pediatric, adult, geri-atric), gender (e.g., women’s health),and other specialty areas (e.g., cardi-ology, dermatology, and orthopedics).


Dr. Bristol: APRN graduates arehighly encouraged to seek both stateand national certification for all ofthose areas. In fact, APRN graduatesare considered to have a generalist de-gree. The expectation is for furtherspecialization within one’s initial spe-cialty practice, particularly for CNSes.This trend will probably continue.

Dr. Gadd: There are advantagesand disadvantages to specialization.One of the things that nurse practi-tioners have done exceptionally wellis to begin filling holes in the medicalsystem as physicians have special-ized. Physicians are filling less of thegeneral and family-practice roles.Nurse practitioners are filling many ofthose primary-care roles and meetinga very important national health-careneed. It may not be advantageous fornurse practitioners to push to becomespecialized, as that may again leavegaps in primary-care services.

Dr. Lloyd: Nationally, the FNP roleis in the greatest demand by studentsat this time. At LLU, the FNP andCRNA concentrations are the largestareas in our graduate program.

Dr. Gadd: We see that in our pro-gram demographics at Southern aswell. I would say about 90 percent ofour graduate students are enrolled inthe FNP emphasis. The next biggest de-mand is for the acute-care nurse practi-tioner emphasis, which is adult/geron-tology. Many students like this area, asthey have worked in critical-care andhigh-acuity inpatient settings and feelmost comfortable there. The acute-carenurse practitioner role is growing acrossthe country. Psychiatric-mental-healthnurse practitioner is another big de-mand area with many job openingsacross the nation. This is a very special-ized focus and attracts students withexperience in this area who are inter-ested in an expanded role in the care ofpatients with mental-health problems.

Dr. Jones: So do you also have a Psychi-

atric-Mental Health Nurse Practitioner

(PMHNP) program?

Dr. Gadd: Yes, Southern’s graduate

programs include the PMHNP track.This was added a couple years ago,and we just graduated our first stu-dents. There are tremendous gaps inmental-health care across the U.S., inTennessee, and in our local commu-nity. There are no other programs inour immediate area to address thoseneeds. So far, we have had steady in-terest and enrollment in this empha-sis, which is good.

Dr. Jones: When it comes to the level of

education for these advanced-practice

roles, is it at the Master’s-degree level or

are they rapidly expecting DNP-level

preparation?

Dr. Gadd: I think we are all awarethat there was a big push to have thedoctorate to be the entry level into ad-vanced nursing practice by 2015. Thatdate has come and gone, but the goalremains and is important. It is a com-plicated thing, however, because youhave to be able to get the certifyingagencies, the state licensing agencies,and the colleges and universities on thesame page. It’s a mammoth endeavor.

Dr. Lloyd: Nationally, major nurs-ing organizations are working towardstandardization of advanced practicebetween the states through a nationalinitiative.

Dr. Bristol: The DNP is becominga well-accepted degree. We have seena rise in the number of DNP pro-grams nationally throughout the pastseveral years. It remains to be seenjust when that absolute deadline forDNP entry into practice will occur.

Dr. Gadd: As I’ve attended meet-ings, it doesn’t seem that anyonewants to set a date right now for theDNP to be the entry level for ad-vanced practice.

Dr. Lloyd: No, we haven’t seenthat either.

Dr. Bristol: Anecdotally, studentsentering the program from a variety ofbackgrounds are recognizing the needto reach the doctorate level to achievetheir long-term goals. Although there

is still a demand for the Master’s de-gree, many more are seeking the DNP.

Dr. Lloyd: Our Master’s program isfocused on the Nurse Educator orNurse Administration concentrations.The DNP and PhD programs arestructured to admit post-baccalaure-ate and post-Master’s students. Forinformation regarding entrance re-quirements for various graduate spe-cialties, consult the school Website.

Dr. Jones: So, is it the Board of Regis-

tered Nursing (BRN) in each state or the

professional associations that grant the

certification?

Dr. Lloyd: Depending upon thestate, it may be the BRN or the pro-fessional association. Students are en-couraged to obtain both certificationsif applicable.

Dr. Bristol: It’s a competitive ad-vantage to have national certification.In fact, our most recent accreditationvisitors wanted to ensure that facultyin charge of all the clinical courseswere nationally certified as well ashaving doctoral degrees.

Dr. Lloyd: Our graduate programconsists of Master’s and doctoral de-grees.

Dr. Gadd: That is correct for enter-ing into practice. We, too, have kept theMaster’s program at Southern becausea DNP is not required for advanced-practice certification or licensure. TheMSN is a shorter program, and formany nurses that has a lot of appeal. Itis a good option for those who don’tyet have a vision for a terminal degree.

Dr. Jones: Is national certification done

by specific organizations?

Dr. Gadd: There are several certify-ing bodies. The national certificationfor Family Nurse Practitioners (FNPs)can be from the American Associationof Nurse Practitioners or the AmericanNurses Credentialing Center. There areothers for other specialties.

Dr. Bristol: The various concentra-tions are linked to their professionalorganizations, which in turn are linked


to a national accrediting agency. Forus, it is the Commission on CollegiateNursing Education (CCNE), the accred-itation arm of the American Associa-tion of Colleges of Nursing (AACN).

Dr. Gadd: Nurse Educators alsohave a certification exam.

Dr. Bristol: Yes, Nurse Educatorsmay be certified through the NationalLeague of Nursing (NLN).

Dr. Jones: Maybe we should talk about

the differences in the DNP and PhD edu-

cations.

Dr. Gadd: When we started thisconversation, we were talking aboutthe demand for advanced-practicenurses. A lot of nurses who come intoour graduate programs are very prac-tice oriented, wanting to work directlywith patients. That is where the DNPoriginated—as a practice degree. DNPprograms are generally shorter thanPhD programs and have a very differ-ent focus. Research is included in theDNP program because a good clini-cian needs to interpret and demon-strate evidence of meeting variouspractice guidelines. The PhD programis much more focused on research. Inour area, the demand for DNP educa-tion is greater because more nursesare oriented to clinical-practice set-tings than to research.

Dr. Lloyd: Yes, and the PhD degreein nursing, which currently is beingoverlooked somewhat, is essential tothe education of our nurses. The devel-opment and implementation of origi-nal research to contribute to nursingknowledge is necessary to provide evi-dence for DNP graduates to translateinto Evidence-based Practice (EBP) atthe bedside for improved outcomes.

Dr. Bristol: That’s why it’s so im-portant to have collaboration betweenthe PhD and DNP roles. There is adiscrepancy between the knowledgethat exists and what is needed for ex-pert clinicians in the implementationof EBP to improve quality patient out-comes. It is important for both roles

to work seamlessly in this process. Dr. Lloyd: At this time, it is more

difficult for us to recruit students intothe PhD program.

They are not sure what they aregoing to do; it is more expensive, ittakes longer, and it is also more chal-lenging. Traditionally, it has not beenonline or hybrid, although there were afew such programs. We started a BS toPhD program at LLU in the fall term of2017 to see if a hybrid or online formatcan raise the level of competitiveness interms of drawing students into bothprograms and keeping them going. Weare working hard on that; it’s a hard go,but we are getting there. We are hopingto start off with a few students andbuild as we go along.

Dr. Gadd: We struggle with the samethings. We have talked about our strug-gle to enroll nurse educators. We haven’tyet talked about advanced-practice rolesin nursing administration. There is alsoa dearth of Master’s and doctorally edu-cated Adventist nurses to fill leadershiproles in the Adventist health-care sys-tems. Many people go into nursing towork directly with patients and don’tdesire to step away into either educatoror administrator roles. The educationneeded to effectively accomplish thoseroles is just not part of their vision. Wehave many conversations about this atSouthern. How do we attract studentsinto these roles early in their career?How do we recognize their leadershiptraits and direct or encourage them to-ward leadership and administration?

Dr. Bristol: Hospital administra-tors have seen the need for theirnurse leaders to obtain advancednursing education. Clinical nurseleaders are required to have a mini-mum of a Master’s degree in nursingadministration.

Dr. Gadd: We have similar require-ments from health-care facilitiesaround Southern. Several of the chiefnursing officers have graduated fromour MSN-MBA program. They wereforced to seek graduate education.For those employed at magnet hospi-tals, the doctorate is additionally ap-pealing. We are making that avail-

able, and including residence time inmanagement and leadership whichwe hope will build strong leaders. Aspart of the advanced-practice roles,there are needs in these leadershipareas and certainly huge needs in ourAdventist health-care systems.

Dr. Jones: Are graduate programs pro-

moting the administration track?

Dr. Lloyd: We have a Master’s-level administration concentration atLLU. Many nurses working in ourhospital are required to have the Mas-ter’s degree for practice or for themanager’s role. We have also devel-oped a Master’s externship programin collaboration with the medical cen-ter to allow students to take theirDNP while they are also practicing ina clinical-leadership role.

Dr. Gadd: It’s hard to be everythingto everybody. We have an MBA pro-gram at Southern. So what we havedone is team up with the School ofBusiness to create a dual-degree MSN-MBA. As we have been developing ourDNP programs, we have added it asan emphasis in the DNP program aswell (DNP-MBA). Now we just needto get more students enrolled.

Dr. Jones: That should help in terms of

meeting the need for qualified adminis-

trators. Thank you very much. We have

covered almost all of our topics, but let’s

touch on the final one: What about offer-

ing graduate education online?

Dr. Lloyd: When we surveyed stu-dents in the process of doing a needsassessment for the different programs,the overwhelming response was aninterest and request for some type ofonline learning. We are using the hy-brid method for our online programs.

Dr. Jones: Can you describe the hybrid

method of online education?

Dr. Lloyd: Hybrid programs fea-ture primarily online learning with


once-per-quarter on-campus face-to-face interaction with the instructor.The length of time the students areon campus is determined by thenumber of classes they are taking. Wework to make it convenient and userfriendly for the students.

Dr. Bristol: Some courses may re-quire more personal contact with stu-dents. Courses such as health assess-ment, statistics, or clinical coursesmay require extra sessions either faceto face or by a computer Zoom ses-sion (online video-conferencing ses-sion), as decided by course faculty.

Dr. Gadd: We provide online educa-tion to meet the needs of people who donot have good access to graduate educa-tion or who prefer online learning forconvenience. Online education is not foreverybody. There are some individualswho just don’t possess the right person-ality, study skills, technical skills, sup-port, or whatever it takes to do onlineeducation. There are challenges on thestudent’s end that need to be weighedwhen the student is trying to choose aprogram. There are also huge challenges

for an institution offering quality onlineeducation. You can’t just take a classyou teach face to face and turn it intoan online class with the flip of a switch.It takes much more time and effort, anda lot of preparation. There are best-prac-tice guidelines for high-quality onlineeducation. Some of our faculty prefernot to teach online because it requires alot of daily attention and is differentfrom the classroom—sometimes difficultand challenging.

Dr. Lloyd: It takes an immenseamount of work and infrastructuresupport to do it well. There is a hugedemand for using educational technol-ogy, which will probably only increase.It just requires those of us who startedteaching a long time ago to really stepup to using the technology piece.

Dr. Jones: How do you think online deliv-

ery is going to affect our ability to edu-

cate faculty for sister schools in other

countries, since we are a global system?

Dr. Gadd: Online education is re-ally an advantage in relation to edu-cating those from other countries ifthey have the capability and technol-ogy to be a part of a class. Time-zonedifferences make asynchronous deliv-ery modes ideal. Education wherethey can learn at their own best timeof day is really helpful. Individuals inother countries can take advantage ofa wealth of educational resources.

Dr. Jones: Do you have some interna-

tional students in your programs?

Dr. Gadd: One of our recent DNPgraduates was an American nurse ed-ucator living and doing her programin Korea.

Dr. Bristol: Applicants must havetheir RN license in the United Statesto enter and complete the DNP pro-gram. That may be a hindrance to in-ternational students.

Dr. Lloyd: There is also a visaissue. All international students mustfirst be vetted according to their typeof visa and whether their country willrecognize an online degree prior toacceptance into the program. LLUrequires all student visas to beprocessed through the campus inter-national student office, and difficul-ties arise for some students who wantto register for online programs.

Dr. Gadd: There are definitely a lotof challenges with student visas andother immigration laws. However,distance-education programs, if to-tally online, circumvent most of theseissues and provide an advantage.

Dr. Jones: Is there anything that was not

touched on that you would like to share?

Dr. Gadd: I would just like to saythat there are a lot of exciting opportu-nities for students and faculty in grad-uate education. I often say I have thebest job on campus here at Southern. Iwork with mature students who arehighly motivated and really want toachieve professionally, and who haveso many opportunities, given our cur-rent health-care climate. There are


Institution Country Graduate Degrees

Programs

Adventist University of Health Sciences United States Master’s MSNA1

Adventist University of the Philippines Philippines Master’s MSN, MN

Andrews University United States Doctoral DNP2

Antillean Adventist University Puerto Rico Master’s MSN

Avondale College of Higher Education Australia Master’s, Doctoral MN, MPhil, PhD3

Babcock University Nigeria Master’s MSc

Loma Linda University United States Master’s, Doctoral MS, DNP, PhD

Lowry Adventist College India Master’s MSc

Peruvian Union University Peru Master’s, Doctoral MSc, Doctorate4

Sahmyook University Korea Master’s, Doctoral MSc, PhD

Southern Adventist University United States Master’s, Doctoral MSN, DNP

University of Eastern Africa, Baraton Kenya Master’s MSc

Washington Adventist University United States Master’s MS, MSN

1. Master of Science in Nurse Anesthesia2. Doctor of Nursing Practice (Practice focus) 3. Doctor of Philosophy (Research focus)4. Doctoral degree (Research focus)

Adventist Graduate Programs in Nursing

many challenges involved in what wedo in the graduate area as profes-sors—to keep up with clinical practice,teaching and educational modalities,and to engage in and promote schol-arly activities. We need to continue todevelop and promote cutting-edge pro-grams that meet the needs of nursingpractice, nursing education, and ad-ministration for our local and churchconstituents as well as for those in ourglobal society. It is both personallyand professionally rewarding.

Dr. Bristol: As students enter theirundergraduate program, faculty mayassist them in their career planning toidentify potential mission opportuni-ties and those who might be inter-ested in becoming nursing faculty oradministrators.

Dr. Lloyd: Advanced-practicednurses have great potential to make adifference within their sphere of in-fluence. An advanced-practice educa-tion résumé tops any employer’sstack of applications. Our purpose isto train students to take the Seventh-day Adventist message to their com-munities and the world.

Dr. Jones: Thank you so much. ✐

Susan L. Lloyd,PhD, RN, CNS, isAssociate Professorat the Loma LindaUniversity Schoolof Nursing, LomaLinda, California,U.S.A. She also

serves as Associate Dean for AcademicAffairs and Graduate Programs. Dr.Lloyd has a combined 42 years ofnursing experience in both clinicalpractice and academic education. As aclinical nurse specialist (CNS), she hasworked in maternal child/pediatricprimary-care settings, particularly withpregnant adolescents. As an educator,she has taught nursing at the under-graduate and graduate levels at PanAmerican University, Pacific UnionCollege, Victor Valley College, Califor-

nia State University San Bernardino(CSUSB) and Loma Linda University(LLU). She has worked to developMaster’s and DNP programs at bothCSUSB and LLUSN. She received herbachelor’s degree in nursing fromWalla Walla College, her Master’s de-gree in nursing from Loma Linda Uni-versity, and her PhD degree in nursingfrom University of San Diego.

Holly Gadd, PhD,RN, FNP, is Profes-sor and GraduateProgram Coordina-tor at Southern Ad-ventist Universityin Collegedale,Tennessee, U.S.A.

Dr. Gadd completed an AS degree innursing at Atlantic Union College inSouth Lancaster, Massachusetts,U.S.A., a BS in nursing at AndrewsUniversity in Berrien Springs, Michi-gan, U.S.A., and an MS in nursing,with emphases in Nursing Educationand Adult Health from Loma LindaUniversity, Loma Linda, California.She also completed a post-Master’sFamily Nurse Practitioner certificatefrom Midwestern State University inWichita Falls, Texas, U.S.A., and aPhD from Texas Woman’s University inDenton, Texas. Dr. Gadd has 40 yearsof nursing experience in a variety ofsettings, more than 30 years of nurs-ing-education experience, and morethan 20 years in nurse-practitionerroles. She currently remains active inboth primary-care and emergencynurse-practitioner employment. Dr.Gadd is a member of the American As-sociation of Nurse Practitioners, Ameri-can Nurses Association, Sigma ThetaTau, National League for Nursing, andNational Organization of Nurse Practi-tioner Faculties. She teaches PrimaryCare of Adults I and II, Nursing Re-search for Advanced Practice, and Bio-statistics for Advanced Practice.

Shirley TohmBristol, JD, MS,DNP, CNS, is anAssociate Professorat Loma LindaUniversity Schoolof Nursing, LomaLinda, California,

U.S.A. She also serves as Program Di-rector for the Master’s and Doctorate ofNursing Practice (MNP/DNP) graduateprograms. Dr. Bristol has a combined42 years of nursing experience in bothclinical practice and academic educa-tion. Clinically, this experience includesnumerous inpatient nursing, advancedpractice, and management positions.As an educator, she has taught med-ical-surgical and critical-care nursingon the undergraduate levels at severaluniversities. Most recently, she hasbeen responsible for developing, imple-menting, and teaching in the Master’sand doctoral programs at Loma LindaUniversity. She received her bachelor’sdegree in nursing from Andrews Uni-versity, her Master’s degree in nursingfrom Loma Linda University, her JurisDoctor degree from the University ofLaVerne College of Law in Ontario, Cal-ifornia, and her DNP from WesternUniversity of Health Sciences inPomona, California.

Patricia S. Jones,PhD, RN, FAAN,is DistinguishedEmerita Professorat Loma LindaUniversity Schoolof Nursing, andAssociate Director

of the Department of Health Ministriesin the General Conference of Seventh-day Adventists in Silver Spring, Mary-land, U.S.A. Dr. Jones has also taughtat the Adventist University of thePhilippines, Hong Kong Adventist Col-lege, and Vanderbilt University. Shecompleted a bachelor’s degree in nurs-ing at Walla Walla College (now Uni-versity), a Master’s degree from An-drews University, and Master’s anddoctoral degrees from Vanderbilt Uni-versity in Nashville, Tennessee.


line delivery of nursing education provides learnerswith access to academic content through a virtuallearning environment. Learning experiences also in-clude activities that take place under supervision inclinical settings such as hospitals and clinics. While

academic content and clinical experiences provide the foun-dation for most online nursing curricula, programs offered bySeventh-day Adventist schools build on an additional foun-dation—the development of faith in Christ. Educators in theSeventh-day Adventist system recognize that integrating faithwith learning is a primary goal, a vital consideration whendeveloping online programs and courses. In this article, twouniversities provide a description of how this primary goal isapproached within their nursing programs.

Reflections From Southern Adventist University (Southern),

Collegedale, Tennessee, U.S.A.

The School of Nursing at Southern Adventist Universityhas several fully online programs, including one for BScompletion, a Nurse Educator Master’s degree, an MSN/ MBA, and a Doctor of Nurse Practice. As Seventh-day Ad-ventist educators, regardless of the context or program inwhich we work, our primary goal is to point learners toChrist and encourage them on their path toward spiritualmaturity as members of the body of Christ (Ephesians 4:11-14). Spiritual growth is realized through prayer, daily en-counters with Scripture, and the power of the Holy Spirit.1

The ultimate goal is complete restoration to the image of

our Creator.2

We, the authors, believe that: “In the highest sense thework of education and the work of redemption are one, forin education, as in redemption, ‘no other foundation cananyone lay than that which is laid, which is Jesus Christ’ 1Cor. 3:11.”3 For this reason, teaching processes should leadstudents to trust the Author and Finisher of our faith, JesusChrist. The curriculum, then, must be Christ-centered. Thistype of curriculum—one based on a biblical foundation—isa critical aspect of planning and instruction that we believemakes our nursing programs unique and valuable. By coop-erating with the Holy Spirit, instructors and their learnerscan become instruments that share heavenly solutions withpeople and societies that comprise this broken, fallen world.This can be accomplished by inviting the Holy Spirit to in-fluence the planning and teaching of each course. Learningexperiences are designed to help learners reflect on big ideas;to recognize, accept, and act on truth; and to invite and wel-come others into a relationship with Jesus Christ. Use of thisapproach in traditional face-to-face education has demon-strated its ability to transform the lives of students.4 Such acurriculum is based on a biblical worldview that orients in-struction to probe questions such as these: Why am I here?What is my purpose in life? What does the Lord require ofme? Where am I going? Who can I help along the way? Howcan I spread the gospel of Jesus Christ? To these questions,the Bible provides direction, guidance, and answers: “He hastold you, O man, what is good; and what does the Lord re-

49

BY PEGI FLYNT, FLOR CONTRERAS CASTRO, and TAMMY OVERSTREET

http:// jae.adventist.org The Journal of Adventist Education • October-December 2017

DEVELOPINGPRESENCE AND

FAITH IN

ONLINE TEACHING

O

quire of you but to do justice, and to love kindness, and towalk humbly with your God?” (Micah 6:8, ESV).5

Community of Inquiry

Chickering and Gamson6 outlined seven research-basedprinciples of good practice in higher education. Effectiveteachers:

1. Interact with their students; 2. Encourage their students to interact and cooperate with

one another; 3. Purposely plan for active learning and encourage their

students to think and talk as well as to write and question; 4. Accentuate the importance of staying on task; 5. Provide quality and timely feedback; 6. Expect the best from their students and model what

that looks like; and7. Appreciate the diverse talents and learning styles of

their students. When teachers attempt to apply these principles in online

education, they face some unique challenges.7 Research hasindicated that learning occurs most effectively within a com-munity of inquiry.8 Theorists Garrison, Anderson, andArcher9 created a framework of “presence” (teacher pres-ence, social presence, and cognitive presence) to describehow communities of inquiry can be used to increase learningeffectiveness in online learning.

• Teacher presence is an umbrella term that refers to theentire learning experience from planning through execution.This includes the design and facilitation of the course andthe careful, intentional, and purposeful planning of interac-tive components.10 Interaction—the currency of online learn-ing environments—occurs with the content, with otherlearners, and with the instructor.11

• Social presence in an online course provides a way forlearners to concretely identify with the instructor and oneanother in ways that empower all participants to feel knownand significant.12 Because people are social beings, the de-velopment of social presence allows the learners to work to-gether as actual human beings rather than as a collection ofusernames or e-mail addresses. 13

• Cognitive presence in online courses refers to the teach-ing methods used in the online classroom to intellectuallyengage the learner in ways that encourage understandingand the creation of meaning.14 Garrison, Anderson, andArcher15 pointed out that this is done through sustained re-flection and discourse—an absolute necessity in onlinelearning. Through the mental processes of inquiry, deepthinking, and reflection, learners maintain engagement andstrengthen their intellectual ability.16

The Living Faith Presence

In faith-based institutions, where both curriculum and in-struction are rooted in a biblical worldview, a fourth pres-ence can be considered foundational to course development.At Southern Adventist University’s Online Campus, we call

that presence the “living faith” presence. According to EllenWhite: “A living faith means an increase of vigor, a confidingtrust, by which, through the grace of Christ, the soul be-comes a conquering power.”17

Professors at Southern Adventist University are trainedby members of the Online Campus team to develop thethree presences through university-wide, department/ school-level, and individual training sessions. The OnlineCampus team provides professors with information regard-ing best practices; and their use of those practices is facili-tated by the work of an online coach, one of whom is as-signed to each professor. Online coaches are members ofthe Online Campus team and they provide training and pro-fessional development in the use of instructional technolo-gies, academic course planning and creation, academic andtechnical support for teaching faculty and students, andmedia and course design assistance. The coaches are trainedin online learning, instructional technology, curriculum andinstruction, and media and Web design; they also possessyears of experience working in their fields of expertise andteaching in their areas of specialty.

Each summer, Southern holds training sessions for profes-sors, which help them develop courses with a biblical foun-dation. When the university’s professors are assigned to de-velop an online course, they are assisted with all aspects ofcourse development, including the living faith presence.

The experience gained from years of offering fully onlinecourses and programs for nursing learners has enabledSouthern’s Online Campus to identify a number of best prac-tices for building the living faith presence. First, curriculumdevelopers utilize intentional planning to establish a biblicalfoundation for the course, and throughout the course assign-ments, biblical principles relating to the academic disciplineare reinforced and developed. Next, weekly devotionals arecreated that connect to the subject content. Through onlinevideo-conferencing, learners are encouraged weekly to reg-ularly connect with God as the Creator and Author of truththrough prayer and Bible study. Perspectives from variousChristian scholars in the field of nursing are used to shapeintegrative questions for reflection.

Other intentional practices include active prayer forumsand referencing Scripture in projects, assessments, andgroup work. Throughout the learning experiences, learnersare encouraged toward greater civic responsibility with thegoal of promoting social justice from a Christian point ofview. An example of this type of learning experience occursin a course in which students work with patients who wishto make lifestyle changes, assessing and coaching themthroughout the semester. This work is based on studentlearning outcomes that include teaching learners to examinebiblical themes that support the use of a coaching approachfor motivating and educating patients to adopt lifestylechange. During the final week of the course, the learnersare encouraged to reflect upon their spiritual growth andways that the course has influenced their faith, as well as


their plans for implementing truth prin-ciples in their current and future prac-tice.

Forum discussions and live virtualmeetings encourage learners to reflect,apply, analyze, and/or synthesize con-tent from a biblical point of view. Thelearning activities in the course encour-age them to think deeply and to evalu-ate sources of information. Studentsmay be asked to critique content re-sources, comparing and contrasting theinformation with the Adventist healthmessage. Ellen White stated that“There is nothing more calculated toenergize the mind, and strengthen theintellect, than the study of the word ofGod. No other book is so potent to ele-vate the thoughts, to give vigor to thefaculties, as the broad, ennoblingtruths of the Bible.”18

Recently, the university conductedan informal survey of Southern Adventist University’s onlinenursing professors to learn how they are establishing the liv-ing faith presence in their teaching. They provided the fol-lowing statements:

• “I honor and value being a Seventh-day Adventist Chris-tian professor and consider it a privilege and a responsibilityto promote biblical principles in all of the courses I teach.”

• “We spend significant time with the inspired text. I alsomake an effort to model a Christlike spirit in the way that Irelate to my students. The goal is not simply the accumula-tion of information, but life transformation.”

• “The discussion questions in my online course relatethe content to Christian calling and service. The assignmentsgive opportunity to plan how learners will encourage othersto develop a relationship with God through nature and Scrip-ture, and to serve Him as a way of life.”

• “The online video conference each week is a vital com-ponent for building and nurturing a community of faith.”

• “Students often comment on the spiritual blessings thatthey receive from the learning experiences in the onlinecourse that I teach. The assignments call for practical meth-ods of creating a Christ-centered curriculum and opportuni-ties for character development and service.”

• “Last week a student mentioned that the online course,more than any of the face-to-face courses she had ever taken,was helping her focus on making Christ the center of herlife.”

• “More than anything else, I intend to let students knowthrough all of my interactions that I am a serious and grate-ful disciple of Jesus.”

Included in each end-of-semester digital course evalua-tion instrument are several open-response questions thatallow students to provide feedback regarding the learning

experiences and how the course trans-formed their lives.

• “To everyone involved in thiscourse—Thank you for sharing yourhearts. Not only have I learned from theprofessor and the content, but I havealso learned from YOU, my classmates.”

• “This online course gave [me] op-portunity to know the Lord more inti-mately. I am grateful.”

• “Taking this online class has beenone of the most rewarding experiences Ihave ever had. A university with a foun-dation in Christ makes all the differencein the world.”

• “I have opened my eyes and heartmore since taking this course. Little didI know that an online college coursecould lead to my salvation. That’s price-less tuition.”

• “I cannot begin to tell you howmuch the assignments in this online

course are challenging not only my worldview but my viewas an Adventist Christian. I have never had to give so muchthought to my work, to think this deep, or challenge otherpoints of view.”

By partnering with the Holy Spirit, instructors and theirlearners can be instruments that carry solutions to a brokenand fallen world. This can be accomplished by inviting theHoly Spirit to direct the planning and teaching of eachcourse. Learning experiences should be designed to helplearners reflect on big ideas; to recognize, accept, and acton truth; and to welcome others into a relationship withJesus Christ.

Reflections From Universidad Peruana Unión (UPeU), Lima, Peru

At UPeU, part of our educational mission is the integrationof faith in the teaching-learning process. The Master’s in Nurs-ing program at UPeU, the only such program in the SouthAmerican Division, was designed for online delivery to makeit accessible to the vast territory it serves. Students in this pro-gram interact with their instructors and classmates through asynchronous virtual platform. In the multimedia environmentof the virtual classroom, where the instructor and students arein different locations, integration of faith and learning (IFL) ismore challenging than in the traditional classroom.

Nevertheless, we agree with Korniejczuk19 that the inte-gration of faith in the teaching-learning process should beevident in all aspects of the curriculum, and involve the en-tire academic community and beyond. However, achievingthis goal in virtual Christian education requires extra effort.

Integration of Faith

Each cohort begins with a 15-day face-to-face sessionduring which national and international students are in-


By partnering with the

Holy Spirit, instructors and

their learners can be in-

struments that carry solu-

tions to a broken and

fallen world. This can be

accomplished by inviting

the Holy Spirit to direct the

planning and teaching of

each course.

structed on the use of the virtual classroom, practice usingthe technology, and complete two assignments. They arealso introduced to the institution’s Adventist philosophy ofeducation, which will be integrated throughout the curricu-lum. This gives the students an opportunity to share theiropinions and ideas with faculty and classmates. Duringthese sessions, students often express gratitude for the in-stitution’s attempts to strengthen the spiritual dimensionof their education.

A 10-minute devotional based on a Bible text related to theday’s topic is presented at the beginning of each online class.Students discuss the application of the text to the topic andshare their prayer requests. Students who are not Seventh-dayAdventists have the opportunity to observe how the power ofprayer and faith in God can help to solve problems. At the be-ginning of the program, non-Adventist students rarely makeprayer requests; however, as they see the fervor of their Ad-ventist classmates, little by little, they also begin to expresstheir requests based on their needs. These devotional andprayer experiences reaffirm the power of prayer and faith inGod in all students—Adventist and non-Adventist alike. Asthe semester progresses, the instructor consistently allowstime for the students to comment on some lived experiencerelated to a previous class prayer request.

On one occasion during the prayer request time, a studentof another faith commented on her sadness and anguish be-cause of the sudden death of her physician husband due to acerebral aneurism. Adding to her pain was the attitude of heroldest son, who had become rebellious and angry at God. Dur-ing each virtual class, the instructors and classmates prayedfor her and her family. The nursing team supported her duringthe grieving process by calling her and praying with her overthe phone, e-mailing her inspiring and comforting Bible texts,and mentoring her so she could successfully complete hercourse work. Later, she expressed her profound gratitude forthe prayers and the help received. She reported that her heartwas filled with peace, and that her son had asked for forgive-ness and promised to improve his behavior. She completed herdegree and is now defending her thesis.

It is important to mention that prayer is not only offeredby the instructor, but also others participating in the coursesuch as the program coordinator, the informatics engineer,and students, giving the opportunity for all to participate inthis privilege.

Throughout the program, as the classes and workshopsprogress, many occasions arise when it is appropriate to con-sider God and His Word. For example, students in smallgroups analyze portions of Scripture along with scientific lit-erature to extrapolate conclusions regarding the topic beingstudied. The parable of the Good Samaritan (Luke 10:25-37)is used to analyze the characteristics of caring of the Christiannurse. The story of Abigail (1 Samuel 25) is used to analyzeassertive leadership in nursing, and the relationship betweenChrist with His disciples exemplifies the management ofhuman resources.

Participation in the Week of Spiritual Emphasis at UPeU

During the campus week of spiritual emphasis at UPeU,special attention is given to spiritual growth. This specialevent provides an opportunity to rest from the daily aca-demic activities and to reflect upon personal communionwith God. We include our virtual classroom students byinviting them to participate online in the events of theweek.

The program coordinator takes time to explain the im-portance of the week of spiritual emphasis to the onlinestudents’ lives and provides a link that enables them toaccess the presentations’ live stream. At the end of theweek, the students are invited to reflect in writing on thethemes that had a major impact on their lives, and somestudents share their experiences verbally during the vir-tual class time.

Christian education provides faculty and students with anopportunity to strengthen their faith in God, our Creator andRedeemer. Therefore, we must ensure that neither technolog-ical nor pedagogical challenges inhibit this mission. To do so,we must ask for wisdom and claim God’s promises. This willenable us to put aside our anxieties and show genuine interestin the problems of our students, as we individually pray withand for them, and strengthen their trust in God.

Christian faculty have the responsibility of leading theirstudents to Christ. Both the bricks-and-mortar and the vir-tual classroom in an Adventist university can provide thisopportunity, so that students will be able to say with JohnFowler,20 “Adventist education made me aware that life hasmeaning and a destiny,” and that prepared them for suc-cess in their professional lives both now and throughouteternity.

Conclusion

As Seventh-day Adventist Christians, we believe EllenWhite’s assertion that “Every human being, created in theimage of God, is endowed with a power akin to that of theCreator—individuality, power to think and to do. . . . It isthe work of true education to develop this power, to trainyoung people to be thinkers, and not mere reflectors of otherpeople’s thought.”21 Educators who embrace this ideologypurposefully and iteratively will examine each aspect ofteaching and learning, and build a community of inquiry tocapitalize on every method possible to open learners’ mindsto the influence of the Holy Spirit.

Thus, designing an online course represents both an op-portunity and a responsibility because it also allows us toshare our faith with people who cannot access face-to-facegraduate programs, in addition to offering excellent qualityacademic instruction. The challenge of teaching otherhuman beings to think, explore, and accept new ideas/val-ues, and to allow their lives to be transformed is great inany educational setting and even greater in the virtualclassroom.

Christian faculty, whether in a face-to-face setting or an


online classroom, have the opportunity to lead their learn-ers to Christ. This indeed requires wisdom and creativity.Let us all claim the promise in James 1:5: “If any of youlacks wisdom, let him ask of God, who gives to all liberallyand without reproach, and it will be given to him”(NKJV).22


Pegi Flynt, EdD, is Associate Professorand Director of Academic Technology andOnline Learning at Southern AdventistUniversity in Collegedale, Tennessee,U.S.A. Dr. Flynt is a recognized leader indistance education, whose research inter-ests include improving critical thinkingand increasing engagement in online

courses. She has served Adventist ed u ca tion for more than 30years, both as a teacher and an administrator. Dr. Flynt holdsa doctorate in educational technology from Nova Southeast-ern University in Fort Lauderdale, Florida. You can follow heron Twitter @pegiflynt.

Flor Contreras Castro, DrPH, is Profes-sor of Nursing and Director of GraduatePrograms in Health Sciences at Universi-dad Peruana Unión in Lima, Peru. Sheholds a doctorate in public health and aspecialty in intensive care. Dr. Contrerashas 33 years of clinical experience and14 years of teaching experience, six of

these as director of the graduate programs in the School ofHealth Sciences. She teaches courses in nursing care foradults and the elderly, and this is also her primary area ofresearch interest.

Tammy Overstreet, PhD, is an Associ-ate Professor at Southern Adventist Uni-versity’s Online Campus. She holds aMaster’s degree in literacy educationand a doctorate in curriculum and in-struction. A lifelong Adventist educatorand administrator, Dr. Overstreet hasmore than two decades of involvement

in education, with an emphasis in literacy education. Herexperience in online education includes serving as the pro-gram director for a fully online graduate program as wellas her current work as the associate director at Southern’sOnline Campus. In her current position, she provides sup-port to professors as they use technology in their face-to-faceand online classrooms, helping them to maximize technol-ogy and pedagogy to teach more effectively and to increasestudent engagement.

✐

NOTES AND REFERENCES1. Hosea 6:3; Malachi 4:2; Ellen G. White, True Education (Nampa,

Idaho: Pacific Press, 2000), 21.2. George R. Knight, Educating for Eternity: A Seventh-day Adventist

Philosophy of Education (Berrien Springs, Mich.: Andrews UniversityPress, 2016).

3. White, True Education, 21.4. Calvin G. Roso, “Faith and Learning in Action: Tangible Connec-

tions Between Biblical Integration and Living the Christian Life,” Justice,Spirituality, & Education Journal 3:1 (Spring 2015): http://education. biola.edu/static/media/downloads/roso.pdf.

5. Quoted from the ESV® Bible (The Holy Bible, English StandardVersion®) copyright © 2001 by Crossway Bibles, a publishing ministryof Good News Publishers. The ESV® text has been reproduced in co-operation with and by permission of Good News Publishers. Unau-thorized reproduction of this publication is prohibited. All rights re-served.

6. Arthur W. Chickering and Zelda F. Gamson, “Seven Principles forGood Practice in Undergraduate Education,” Biochemical Education 17:3(July 1989): 140, 141. doi: 10.1016/0307-4412(89)90094-0.

7. Tresa Kaur Dusaj, “Seven Principles for Good Practice in OnlineTeaching and Course Development,” Online Journal of Nursing Infor-matics 19:3 (November 2015): 1.

8. D. Randy Garrison, “Online Community of Inquiry Review: Social,Cognitive, and Teaching Presence Issues,” Journal of AsynchronousLearning Networks 11:1 (April 2007): 61.

9. D. Randy Garrison, Terry Anderson, and Walter Archer, “CriticalInquiry in a Text-based Environment: Computer Conferencing in HigherEducation,” The Internet and Higher Education 2:2-3 (2000): 87-105.

10. Terumi Miyazoe and Terry Anderson, “The Interaction Equiva-lency Theorem,” Journal of Interactive Online Learning 9:2 (Summer2010): 94-104.

11. Cynthia Buchenroth-Martin, Trevor DiMartino, and Andrew Mar-tin, “Measuring Student Interactions Using Networks: Insights Into theLearning Community of a Large Active Learning Course,” Journal ofCollege Science Teaching 46:3 (January 2017): 90-99.

12. Peter Leong, “Role of Social Presence and Cognitive Absorptionin Online Learning Environments,” Distance Education 32:1 (May 2011):5-28.

13. Garrison, “Online Community of Inquiry Review: Social, Cogni-tive, and Teaching Presence Issues.”

14. Grant Wiggins and Jay McTighe, “Put Understanding First,” Ed-ucational Leadership 65:8 (May 2008): 36-41.

15. Garrison, Anderson, and Archer, “Critical Inquiry in a Text-basedEnvironment: Computer Conferencing in Higher Education.”

16. D. Randy Garrison and Norman D. Vaughan, Blended Learningin Higher Education: Framework, Principles, and Guidelines (San Fran-cisco: Jossey-Bass, 2008).

17. Ellen G. White, The Ministry of Healing (Mountain View, Calif.:Pacific Press, 1905), 62.

18. __________, Fundamentals of Christian Education (Nashville,Tenn.: Southern Publ. Assn., 1923), 126.

19. Raquel Korniejczuk, Integración de la fe en la enseñanza apren-dizaje: Teoría y práctica [Integration of Faith in Teaching and Learning:Theory and Practice] (Nuevo Leon, México: Publicaciones Universidadde Montemorelos, 2005).

20. John M. Fowler, “Why Support Christian Education? A PersonalTestimony,” The Journal of Adventist Education 70:2 (December 2007/ January 2008): 3.

21. White, True Education, 13.22. Scripture quoted from the New King James Version®. Copyright

© 1982 by Thomas Nelson. Used by permission. All rights reserved.



sionals? Will the education we provide transform the lives ofstudents and prepare them to be transforming agents inhealth care? Can we innovate by demonstrating interprofes-sional education and practice? Or will we take the easy routeand continue our separate approaches to the detriment ofmore effective health care?

As we consider these challenges, our global network of Ad-ventist schools of nursing continues to expand rapidly, nowtotaling 75 from Papua New Guinea to Africa, Asia, and Northand South America. The global shortage of nurses ensures ademand for nursing education, and Adventist universitiesaround the world are quickly adding nursing to their aca-demic offerings. In many of these colleges and universities,there is no history of Adventist health care, and no Adventistnursing tradition on which to build. While these new pro-grams faithfully follow government standards for accredita-tion, there may be little that is identifiably Adventist otherthan requiring courses in religion.

These conditions generate vital questions such as “Whatis unique about Adventist nursing education and practice?”and “What is our mission?” This issue of the JOURNAL includesresearch by Jones and Ramal et al., involving 212 nurses andnurse educators from 33 countries and 10 of the 13 world di-visions of the church. From them, we learned what they de-scribed as the core elements of Adventist nursing, and wecrafted a distinctive framework that can guide both the edu-cational process and practice of Adventist nurses in providingcare (p. 4). Johnston Taylor (p. 20) and Mamier et al. (p. 26)discuss the church’s responsibility to prepare nurses to pro-vide ethical spiritual care.

Because national requirements and culture influence cur-riculum content and structure, Wright and Wosinski addressprinciples of curriculum development that are relevantacross geographic and cultural boundaries (p. 14). Clinicalinstruction also varies greatly in different parts of the world,so Jael and Krull address issues related to clinical teachingthat reveal differences and similarities in two diverse settings(p. 33). With interprofessional education the theme of thefuture, Wild and Molocho share examples of how it is doneat the Loma Linda University School of Nursing and at Uni-versidad Peruana Unión (UPeU) (p. 38). As distance educa-tion takes the place of face-to-face instruction, the questionof how to transform the lives of students through the inte-gration of faith and learning via the Internet becomes evenmore urgent. The need for graduate study to prepare for ad-vanced practice, research, or teaching presents a complexchallenge with many different paths to take. Lloyd, Gadd,Bristol, and Jones describe these options (p. 43).

Adventist nursing continues to be a dynamic force forchange in the church and in the world. The question, how-ever, remains: Will we again be leaders of change? Are weready to develop and engage in transformative, interdiscipli-nary education while maintaining our distinctive focus andvalues? The global nature of our large and diverse networkpresents an opportunity to be a dynamic, globally connected

system building upon an outstanding legacy, a shared mis-sion, and a passion for service.

Our heritage summons us to demonstrate courage, com-mitment, and innovation as we consider these issues. Ourresponse needs to be equally passionate.

Patricia S. Jones, PhD, RN, FAAN, is Distinguished EmeritaProfessor at Loma Linda University School of Nursing(LLUSN) and Associate Director of the Department of HealthMinistries in the General Conference of Seventh-day Adven-tists in Silver Spring, Maryland, U.S.A. Dr. Jones has alsotaught at Adventist University of the Philippines, Hong KongAdventist College, and Vanderbilt University. She completeda bachelor’s degree in nursing at Walla Walla College (nowUniversity), a Master’s degree from Andrews University, andMaster’s and doctoral degrees from Vanderbilt University inNashville, Tennessee.

Edelweiss Ramal, PhD, RN, is an Associate Professor in thegraduate nursing program at LLUSN. She has been a nurseeducator for 40 years: 25 of which were spent in Mexico andBotswana, 15 in the United States.

The coordinators for this special issue, Patricia S. Jonesand Edelweiss Ramal, acknowledge the contribution of CarlaJones, PhD, at the University of Colorado for reading earlierversions of some of these manuscripts.

Drs. Jones and Ramal undertook the responsibility ofplanning this issue with enthusiasm and vision, from se-lecting topics and soliciting authors to recommending re-viewers and providing input and feedback to questions. TheEditorial Staff of the JOURNAL express heartfelt appreciationfor their assistance throughout the planning and productionof the issue.

NOTES AND REFERENCES1. Muriel Elizabeth Chapman, Mission of Love. A Century of Sev-

enth-day Adventist Nursing (Hagerstown, Md.: Review and Herald,2000), 1-3.

2. Ibid., 2.3. Josephine Goldmark, Nursing and Nursing Education in the

United States: Report of the Committee on the Study of Nursing Education(New York: Macmillan Co., 1923).

4. Margaret Bridgeman, Collegiate Education for Nursing (New York:Russell Sage Foundation, 1953); Esther Lucile Brown, Nursing for theFuture (New York: Russell Sage Foundation, 1948).

5. The National Academies of Sciences, Engineering, and Medicine,The Future of Nursing: Leading Change, Advancing Health (Washington,D.C.: Institutes of Medicine, 2011):http://nationalacademies. org/hmd/ reports/2010/the-future-of-nursing-leading-charge-advancing-health. aspx.

6. Patricia Benner et al., Educating Nurses: A Call for Radical Trans-formation (San Francisco: Jossey-Bass, 2009).

7. Julio Frenk et al., “Health Professionals for a New Century: Trans-forming Education to Strengthen Health Systems in an InterdependentWorld,” The Lancet 376:9756 (December 4, 2010): 1,923-1,958.

Editorial Continued from page 3

Guest Editorial continued from page 3


Table 1. Degree programs accredited by the AAA2

Division Institution/Country/State Degrees

ECD Adventist University of Central Africa, Rwanda Bachelor’s ECD Adventist University of Lukanga, Democratic Bachelor’s

Republic of Congo (DRC)ECD Bugema University, Uganda Bachelor’s ECD University of Eastern Africa Baraton, Kenya Bachelor’s, Master’sEUD Friedensau Adventist University, Germany RN to Bachelor’s IAD Adventist University of Haiti, Haiti Bachelor’sIAD Antillean Adventist University, Puerto Rico Bachelor’s, Master’s IAD Central American Adventist University, Bachelor’s

Costa RicaIAD Colombia Adventist University, Colombia Bachelor’sIAD Dominican Adventist University, Bachelor’s (C)3

Dominican Republic IAD Linda Vista University, Mexico Bachelor’sIAD Montemorelos University, Mexico Bachelor’sIAD Navojoa University, Mexico Bachelor’s IAD Northern Caribbean University, Jamaica Bachelor’sIAD University of Southern Caribbean, Bachelor’s (C)

Trinidad and TobagoNAD Adventist University of Health Sciences, Florida Bachelor’s, Master’s4

NAD Andrews University, Michigan Bachelor’s, DoctoralNAD Kettering College, Ohio Bachelor’sNAD Loma Linda University, California Bachelor’s, Master’s,

Doctoral NAD Oakwood University, Alabama Bachelor’s NAD Pacific Union College, California Associate, Bachelor’sNAD Southern Adventist University, Tennessee Associate, Bachelor’s,

Master’s, DoctoralNAD Southwestern Adventist University, Texas Bachelor’sNAD Union College, Nebraska Bachelor’sNAD Walla Walla University, Washington Bachelor’sNAD Washington Adventist University, Maryland Bachelor’s, Master’sNSD Sahmyook Health University College, Korea Bachelor’sNSD Sahmyook University, Korea Bachelor’s, Master’s,

DoctoralNSD Saniku Gakuin College, Japan Bachelor’s (C)SAD Bolivia Adventist University, Bolivia Bachelor’sSAD Brazil Adventist University, Brazil Bachelor’sSAD Chile Adventist University, Chile Bachelor’s SAD Northeast Brazil College, Brazil Bachelor’sSAD Parana Adventist College, Brazil Bachelor’sSAD Peruvian Union University, Peru Bachelor’s, Master’s,

DoctoralSAD River Plate Adventist University, Argentina Bachelor’sSID Adventist University Zurcher, Madagascar Bachelor’s SID Rusangu University, Rusangu Bachelor’sSPD Avondale College of Higher Education, Bachelor’s, Master’s,

Australia Doctoral SPD Pacific Adventist University, Papua New Bachelor’s

GuineaSSD Adventist Medical Center-Illigan City, Bachelor’s

PhilippinesSSD Adventist University of the Philippines, Bachelor’s, Master’s

PhilippinesSSD Asia-Pacific International University, Bachelor’s

Thailand

SSD Central Philippine Adventist College, Bachelor’sPhilippines

SSD Indonesia Adventist University, Indonesia Bachelor’sSSD Klabat University, Indonesia Bachelor’sSSD Manila Adventist College, Philippines Bachelor’sSSD Mountain View College, Philippines Bachelor’sSSD Northern Luzon Adventist College, Philippines Bachelor’sSSD South Philippine Adventist College, Bachelor’s

PhilippinesSUD Lowry Adventist College, India Bachelor’s, Master’sSUD METAS Adventist Hospital, Ranchi, India Bachelor’sSUD METAS Giffard Memorial Hospital, India Bachelor’sWAD Adventist University Cosendai, Cameroon Bachelor’sWAD Babcock University, Nigeria Registered Nurse,

Bachelor’s, Master’s (C)WAD Valley View University, Ghana Bachelor’s

Table 2. Degree programs that have not yet received AAA accreditation

The following programs may apply for evaluation and accreditation by the AAA.

SAD Paraguay Adventist University, Paraguay Bachelor’sSSD Karachi Adventist Hospital College of Bachelor’s

Health Sciences, PakistanSUD Ottapalam Seventh-day Adventist Bachelor’s

Hospital, IndiaSUD Scheer Memorial Hospital, Nepal Bachelor’s WAD Adventist University of West Africa, Liberia Bachelor’s

Table 3. Certificate and diploma programs

In October 2017, the AAA approved criteria for accreditation of postsecondary cer-tificate and diploma programs in nursing, among other areas. The following pro-grams may now apply for evaluation by their respective Division Commission onAccreditation (DCA), and if approved, be accredited by the AAA.

ECD Heri Nursing School, Tanzania Nurse TechnicianECD Ishaka Adventist Hospital, Uganda Enrolled NurseECD Kendu Adventist Hospital, Kenya Registered NurseECD Songa Adventist Hospital, DRC Registered Nurse EUD Waldfriede Berlin Hospital, Germany Registered Nurse SAD Misiones Adventist College, Argentina Registered NurseSID Malamulo College of Health Sciences, Nurse Technician

MalawiSID Mwami Adventist Hospital, Zambia Registered NurseSID Kanye Seventh-day Adventist College Registered Nurse5

of Nursing, BotswanaSID Maluti Adventist Hospital, Lesotho, Registered Nurse5

South AfricaSSD Adventist College of Nursing and Health Registered Nurse (C)

Sciences (ACNHS) Penang, Malaysia SSD Bangladesh Adventist Nursing Institute, Registered Nurse (C)

BangladeshSSD Surya Nusantara Adventist College, Indonesia Registered NurseSUD METAS Adventist College, India Registered Nurse

1. Tertiary-level nursing programs owned and operated by the Seventh-day Adventist Church.2. The Accrediting Association of Seventh-day Adventist Schools, Colleges, and Universities (AAA).3. (C) indicates candidacy status for AAA accreditation.4. Subject to a regular visit scheduled for 2018.5. Site visited and recommended by the DCA for AAA accreditation.

Seventh-day Adventist Nursing Programs1

adventist education · by patricia s. jones and edelweiss ramal 4 a distinctive framework for...

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