Dr. Jones is Professor and Director of International Nursing, Dr. Van Cleve is Professor Emerita, Dr. King is Dean Emerita, Dr. Bossert is Associate Dean and Director of Graduate Programs, and Dr. Herrmann is Dean, Loma Linda University, School of Nursing, Loma Linda, California.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Patricia S. Jones, PhD, FAAN, Professor, Loma Linda University, School of Nursing, Loma Linda, CA 92350; e-mail: firstname.lastname@example.org.
Migration of nurses from their countries of origin to countries offering higher incomes is a long-standing phenomenon. Less well-recognized is the effect this has on the supply of nursing faculty in the countries where those nurses are educated. Nursing instructors with current experience are often the first to be recruited for staff nurse positions in the United States and elsewhere. Rapid development of new nursing programs, with the specific intent of exporting nurses in countries such as India, Africa, and the Philippines, exacerbates the shortage of faculty in those countries.
In response to the global need for qualified faculty, Loma Linda University School of Nursing, a private university in the United States, offered an off-campus master’s degree program at two international sites to prepare nurse educators who would commit to remaining in their home countries for several years following graduation. To avoid introducing them to the United States, which might tempt them to immigrate, we decided to offer the program outside of the United States. This article describes the program and lessons learned that may be helpful to others considering international off-campus programs.
The guiding framework for our international off-campus program was adapted from the model of the Commission on Community-Engaged Scholarship in the Health Professions (2005). This adapted framework (Figure) incorporates three overlapping spheres representing the integration of education, practice, and research, all of which are globally focused. It provided an organizing thread for offering and evaluating a U.S.-based curriculum in a multicultural setting. Ongoing assessment of the appropriateness and cultural relevance of the curriculum occurred continuously throughout the program.
Figure. Conceptual Model for Loma Linda University School of Nursing Off-Campus Master’s Degree Program.
The program was designed to serve nursing education programs within the global Seventh-day Adventist education and health care system. In addition, the program was offered to nurse educators from Myanmar and Vietnam, where graduate education for nurses was limited and the potential impact of a master’s-prepared nurse educator was great. Program administrators visited national universities and Ministries of Health in those countries to explain the program and extend an invitation for qualified students to apply to the program.
Loma Linda University School of Nursing administrators sought external funding from foundations and individual donors to cover expenses for travel, books, and living, and the university waved the tuition costs. Students, institutions, or both paid a small fee that helped to cover miscellaneous expenses. After funding was assured, the school decided to move ahead.
Two sites were selected: one in Thailand to serve countries in Asia and one in Argentina to serve countries in South and Central America, Eastern Europe, and Africa. Criteria for selecting the best sites included:
- A place where students from any country could obtain a visa for entry.
- Availability of student services, such as access to an adequate library and reliable Internet service.
- Safe and efficient modes of travel to the site.
- Modestly comfortable accommodations available for students and faculty.
To meet our own accreditation standards, it was necessary to establish a partnership and contract with the two institutions. Administrators in these institutions assisted us in obtaining legal authorization to conduct our program in that country.
Recruitment of Students
Letters introducing the projected program were sent to the administrators of all Seventh-day Adventist educational institutions outside of the United States. In return, they were invited to send the names of potential students, who were then contacted by letter, e-mail, and telephone, to encourage their application to the program. In addition, program administrators traveled widely to visit Adventist nursing programs, national universities, and Ministries of Health to explain the program and extend an invitation for qualified students to apply to the program.
Academic Approval Process
The faculty approved the project, in principle, in spring of 2001. Although they could see that implementation of the program would mean extra work and stretching resources, they were motivated by the possibility of making a significant contribution in countries where access to graduate education was limited. Initial work included developing admission procedures specific for the international program, adapting delivery of the curriculum for international relevance, and refining the financial plans.
To comply with our accrediting agencies, the curriculum remained the same as it was on-campus in the United States. Course content also remained the same, with a couple of exceptions where adaptation to their cultural and social contexts was necessary. This is described more specifically later.
Following approval by the various university academic committees and the Board of Trustees, the proposal was submitted to the Western Association of Schools and Colleges, which granted approval in June 2004, with permission to offer the program in both English and Spanish at the Argentina site. Communication with the Commission on Collegiate Nursing Education indicated that no further approval would be needed if the program was approved by Western Association of Schools and Colleges.
Differences in standard admission processes in the United States and other countries led to unique challenges. For example, obtaining official transcripts proved to be difficult. In some countries, it is not the policy to send transcripts directly to another institution; rather, the individual has the responsibility of obtaining and mailing the transcript. Applicants to our program often waited long periods and made repeated requests for official copies of their records to be sent.
Once received, all transcripts were forwarded to the American Association of Collegiate Registrars and Admissions Officers for evaluation of credits and verification of the bachelor’s degrees. In some instances, the bachelor’s degree earned by students in their home country was not considered equivalent, and they had to enroll in additional undergraduate courses in their own country. Another challenge was that not all institutions post the final degree on the transcript, so copies of the awarded diploma were also necessary. All students who took the program in English rather than Spanish took a test to determine English proficiency. As expected in an international group, there was considerable variation in the ability to speak and read English, resulting in an ongoing challenge in instruction.
The first session for Cohort I was held in Thailand with students from China, India, Indonesia, Japan, Malaysia, Myanmar, Nepal, Pakistan, Philippines, Thailand, and Vietnam. Cohort II began 6 months later in Argentina with students from Argentina, Bolivia, Botswana, Cameroon, Croatia, Jamaica, Kenya, Malawi, Mexico, Nigeria, Peru, and Puerto Rico.
Delivering the Program
The students and faculty met for 1 month each year for 4 years. An intensive format of two 2-week sessions was chosen, with students taking two courses concurrently. After the 4 weeks of instruction, students were given time to complete assignments and submit them online through Blackboard®, a software application that allowed individual posting and interaction among the class.
Our goal was to provide the same program of instruction by our faculty off-campus as on-campus. This was balanced with the practical concerns of time away from families, time needed to develop and maintain a learning community, cost of international travel, and avoidance of major national holidays observed in other cultures. Face-to-face engagement of the faculty in the teaching process was deemed important to promote active faculty-student interaction, demonstrate appropriate role modeling, and encourage student interaction and collaboration.
Faculty interspersed assignment timelines with examinations to assess learning during the 2-week intensives. Assignments were staggered among courses so that none were due the same week. Most course deadlines for students’ major written assignments were set for the end of the following academic quarter, allowing a 4-month period to complete the coursework when letter grades were assigned. Courses that included practice in the clinical setting required joint planning by the faculty member and student. For example, the teaching practicum was accomplished by working with the student to set appropriate learning objectives and outcomes that could be accomplished in their own work setting. Group discussions and evaluations were done using Blackboard.
The study load was strenuous while at the sessions, and when students returned home they were faced with the distractions and responsibilities of home, families, and full-time work. Faculty and students worked together through births, family deaths, tribal unrest, and environmental disasters.
Internet access was required for ongoing communication, sending and receiving assignments, and access to the Loma Linda University Campus Library. At the beginning, a few students did not have convenient Internet access. This became a challenge in the second year of the program, when Blackboard was introduced as a platform for instruction. Reliable Internet access continued to be a problem, especially for those from war-torn areas, rural institutions, and areas experiencing natural disasters.
The six Spanish-speaking students from Central and South America met with the rest of the class and learned through simultaneous translation. Translation was conducted primarily by one of our regular nurse faculty members, who had a degree in education and years of experience teaching in Spanish, assuring the accuracy of the content. Assignments were translated by the bilingual faculty member and graded in collaboration between the translator and the faculty of record.
Differences in culturally appropriate classroom behavior and expectations were evident. For example, the faculty expected students to participate in class discussion and small group work, whereas the students expected to listen quietly to a lecture. Once they understood that expression and discussion of their ideas was expected and valued, dynamic exchanges between students and faculty occurred.
The faculty approach to teaching demonstrated sensitivity, caring, and great respect for the students’ contribution to discussions in the classroom and on Blackboard. Faculty learned that students from hierarchical cultural systems tended to be hesitant to ask for clarification or help. Over time, the students learned to communicate if help or additional time was needed to submit assignments, yet they were accountable for timely completion of their work. Students expressed amazement and appreciation for these approaches to learning.
Faculty worked long hours during these 2-week teaching sessions. They taught during the day, met with the students for individual conferences in the evening, ate meals together in the cafeteria, attended church, and participated in sight-seeing and shopping excursions together. It was total immersion for both students and faculty. Although the pace was fatiguing, the motivated and grateful spirit of the students encouraged and energized the faculty.
The goal of the program was to enhance the knowledge of nurse educators teaching in the Seventh-day Adventist system of higher education around the world. Outcomes of the project were evaluated based on the three foci of the guiding framework: globally focused education, practice, and research. Apart from the framework, the same evaluation processes were used as on-campus.
Globally Focused Education
The primary purpose of the project was to prepare faculty to teach in their home countries. This goal was reached. Forty-five of the 49 students who started the program completed the coursework, and all are filling leadership roles in their home countries. Forty-two graduates are nurse educators in academic settings. Three came from and returned to nurse educator positions in health care.
The intensive teaching format in this program, a new experience for most of the faculty, proved to be more conducive to learning than expected. As the program progressed and Web-based learning was added to traditional face-to-face instruction, the integration of both traditional and innovative teaching modalities served to transform our own pedagogy, as described by Skiba, Connors, and Jeffries (2008). One graduate found what she learned about teaching strategies to be so helpful that she started teaching a class to share what she had learned with her colleagues.
Maintaining the global focus meant that we continually evaluated the content for relevance to students’ cultural contexts. For example, in a theoretical foundations course, theories were applied to cases studies and scenarios mutually developed by the students and teacher. Similarly, teaching of health policy included a U.S. textbook but addressed health policy issues in the countries represented rather than in the United States. Courses in pharmacology discussed drugs used for diseases prevalent in that part of the world.
In many countries, faculty teach only the theory portion of nursing courses, whereas clinical practice is supervised by staff nurses. For us, integration of theory and practice was a core value. Therefore, it was essential that our program strengthen the students’ foundation for both clinical practice and clinical instruction. The curriculum included two choices of clinical specialty content: care of adult and aging clients and their families or caring for the young and growing families. Four clinical courses addressed the specialty, ending with a practicum course that was completed in their own setting. Students who were academic faculty were constantly reminded of the need to remain clinically current, and those in health care positions were reminded of the importance of the educator and coaching role of clinical leaders.
The students demonstrated a strong motivation to become engaged in research. They were determined to improve nursing by developing projects that would contribute to evidence-based practice in their home countries. Once they returned home, they contacted the authors of published tools to determine whether the tool had been validated in their respective language and gain permission for use. When necessary, they adapted and translated the research measures and began psycho-metric evaluation for use in their cultures. Several students plan to implement their research proposals and are seeking collaboration from Loma Linda University faculty.
The faculty reported a changed world view and expressed openness to continuing projects of this type, despite the additional workload and personal inconvenience. Their understanding of and support for on-campus international students also changed as a result of this experience.
As for the students, they remain connected with their classmates across Africa, Central and South America, and Eastern Europe, and throughout Asia from Japan to Pakistan. The Internet allows ongoing sharing of resources, ideas, and personal support during times of crisis and of celebration. The group in Asia decided to meet for a reunion 3 years after completion of the program and invited the faculty to join them.
As we prepare for another cohort of off-campus master’s degree students, we are guided by lessons learned the first time around. We learned that the admissions process takes longer than anticipated because transcripts must be evaluated in more detail than those from the United States, and universities in other countries are slow to issue them. Visas and travel arrangements may also take longer than expected. Computer access is a hurdle that must be considered when students are expected to apply online and then meet deadlines for assignments in the program. Teaching in two languages requires extensive effort with translation. In some countries, recognition of a U.S. master’s degree requires a thesis. This needs to be clearly understood beforehand. Also, in some countries, recognition of a distance education program may need to be discussed with authorities before students enroll in the program.
The overwhelming satisfaction of the students with the program and the enrichment of the faculty from the cross-cultural experience left us with the knowledge that the program had affected both the graduates and the faculty.
The cultural diversity in both cohorts enriched classroom discussions, as well as social interaction and student-faculty conversations, providing one of the greatest learning outcomes of the program for both faculty and students. Individual comments of changed lives, changed practice as educators, and changed world views have demonstrated the success of the program.
The opportunity to obtain an internationally recognized graduate education was “a dream come true” for the students. They studied hard, asked excellent questions, and eagerly absorbed everything given to them. It was a challenge to face new intellectual demands, for which some initially felt unprepared. Friendships developed as they studied together and mastered challenging assignments. They learned from each other, saw things from new perspectives, and developed a broader world view and supportive international network of colleagues.
Following completion of the program, the faculty continued to hear from the graduates and were gratified by reports of how they were using what they learned. One graduate in Africa reported on a community health project. When asked by a colleague how this project differed from others he had done previously, he reported that now he had a conceptual framework that guided his planning, involved the community, and helped in the evaluation of the project.
Our bold adventure with delivering an off-campus international master’s degree program to students from diverse cultural and educational backgrounds in nursing turned out to be a life-changing experience for all involved. For students, high expectations, along with the supportive and nonauthoritarian approach of the faculty, resulted in professional growth. For faculty, it broadened their world view, enriched their cultural awareness, and opened their minds to the potential for innovation to transform nursing education, while helping to meet the global need for nursing faculty.
- Commission on Community-Engaged Scholarship in the Health Professions. (2005). Linking scholarship and communities: Report of the Commission on Community-Engaged Scholarship in the Health Professions. Seattle, WA: Community-Campus Partnerships for Health.
- Skiba, D.J., Connors, H.R. & Jeffries, P.R. (2008). Information technologies and the transformation of nursing education. Nursing Outlook, 56, 225–230. doi:10.1016/j.outlook.2008.06.012 [CrossRef]