The Integration of Art and Health: A Descriptive Study of the Arts in Baccalaureate Nursing Education by Heather Hardin A dissertation submitted to the Graduate Faculty of Auburn University in partial fulfillment of the requirements for the Degree of Doctor of Philosophy Auburn, Alabama May 3, 2014 Keywords: art, art education, health, liberal arts, humanities baccalaureate nursing education Copyright 2014 by Heather Hardin Approved by Maria Martinez Witte, Chair, Associate Professor of Educational Foundations, Leadership and Technology James Witte, Professor of Educational Foundations, Leadership and Technology Frances Kochan, Professor of Educational Foundations, Leadership and Technology Leslie Cordie, Assistant Professor of Educational Foundations, Leadership and Technology ii Abstract The purpose of this study was to explore the integration of the arts within baccalaureate nursing programs across the southeast. A literature review explored the historical relationship between art and health and nursing education. Because of the multiple facets included within art and health, the American Association of Colleges of Nursing endorsed the inclusion of the arts into nursing education in its publication The Essentials of Baccalaureate Education for Professional Nursing Practice (AACN, 2008). The study was undertaken to provide an organized, descriptive assessment of the inclusion of the arts in nursing education and to uncover the nurse educator leadership perceptions of arts integration. The findings of this study suggested that the integration of the arts were not considered a priority in the baccalaureate nursing program curricula by the majority of respondent schools across the southeast. The study revealed a need for innovative andragogy in healthcare practitioner education to address the changing landscape of healthcare related to demographical shifts, heightened informatics, and advancing technologies. Additionally, the recommendations of the study suggest a need for the advancement of art and health as a specific discipline to promote research, theory, and practice that surround this intersection. iii Acknowledgments This study could not have been completed without the help and support of Dr. Maria Witte, the chairperson of the advisory committee, Dr. James Witte, Dr. Frances Kochan, Dr. Leslie Cordie, and Dr. Kathy Jo Ellison. I would also like to express my gratitude towards my graduate professors and colleagues with particular gratefulness to Dr. Debbie Faulk and Dr. Ramona Lazenby. Additionally, this study would not have been possible without the numerous researchers, including Dr. Maureen Leen, that have made significant contributions to the growing body of knowledge surrounding art and health. I thank you. A special thanks to all of my precious family who have individually made profound contributions to this research through their support, unique talents, advice, personal and professional experience, and love. Their unique contributions have been synthesized here. I am especially grateful to my husband and best friend, John, for his encouragement, endless support, intellect, and love. Finally, I would like to thank our beautiful and amazing children, Katherine Campbell, Claire, and Lovie for their patience, kindness, and inspiration. I love you. I pray that the Lord will bless you and guide you along your unique paths, and your life will be filled with love, hope, and, of course, the arts. iv Table of Contents Abstract ................................................................................................................................ ii Acknowledgments................................................................................................................ iii List of Tables ....................................................................................................................... ix List of Figures ...................................................................................................................... xi List of Abbreviations .......................................................................................................... xii Chapter One Introduction .....................................................................................................1 Overview ...................................................................................................................1 Expanding Technology .............................................................................................2 Nursing Education ....................................................................................................4 The Arts ....................................................................................................................6 Arts and Health .........................................................................................................7 The Arts and Nursing Education ...............................................................................9 Research Problem ....................................................................................................11 Purpose of the Study ................................................................................................13 Research Questions ..................................................................................................14 Assumptions .................................................................................................14 Limitations ...................................................................................................15 Definition of Terms..................................................................................................15 Overview of Study ...................................................................................................17 v Summary??????????????????????? ???. ?.. 17 Chapter Two Review of the Literature??????????????? ????.. 19 Introduction????????????????????? ?????? 19 Purpose of the Study.............................................................................................. 20 Research Questions................................................................................................ 21 Nursing Education???????????????? ?? ??????. 22 Nursing Licensure????????????????? ????.. 23 Articulation Agreements??????????????? ???? 26 Standards of Baccalaureate Nursing Education??????? ???. 29 Domains in Nursing Education???????????? ????.. 33 The Historical Evolution of the Arts and Health???????? ????... 35 Dimensions of Arts and Health??????????????? ????.. 38 Arts and Health: Forms???????????????? ???. .42 Arts and Health: Types??????????????? ????.. 42 Arts and Health: Patients??????????????? ???... 43 Psychological and physiological benefits for patients? ???... 43 Environmental benefits for patients???????? ???... 46 Arts and Health: Caregivers????????????? ????... 46 Intuition??????????????????? ???. 49 Uncertainty?????????????????? ???. 49 Arts and Health: Community?????????????? ???. 51 Arts and Health: In-Patient Settings?????????? ????.. 53 Arts and Health: Environment????????????????... 53 vi Arts and Health: Medical and Nursing Education????........ ............. 55 History???????????????????? ??? 57 Benefits??????????????????? ???.. 60 Challenges????????????????? ????.. 62 Student Response??????????????? ???... 63 Transference????????????????? ???... 63 Quantifying????????????????? ???? 64 Curriculum?????????????????? ???. 65 Humanities in Health Education???????????? ???? 69 Conclusion??????????????????????? ????. 75 Chapter Three Methods????????????????.????? ????. 80 Introduction??????????????????????? ???? 80 Purpose of the Study???????????????????????. 80 Research Questions?????????????????? ?????... 82 Design Overview????????????????.????? ???.. 83 Population???????????????????.???? ????. 84 Instrumentation?????????????????.????? ???. 87 Leen Nursing Program Essentials and Effectiveness Survey??? ????? 87 Catalog Survey?????????????????????????... 90 Variables????????????????????????? ??? 92 Data Collection?????????????????????? ???.. 93 Leen Survey Data Collection?????????????? ???. 93 Catalog Survey Data Collection?????????.??? ???? 95 vii Carnegie Classification? ?????????????? ????.. 96 Sample??????????????????????.??? ???.. 96 Data Analysis??????????????????????? ???. 99 Summary???????????????????????????. 100 Chapter Four Results?????????????????????? ???? 102 Introduction??????????????????????????. 102 Purpose of the Study??????????????????????? 102 Research Questions???????????????????????. 103 Characteristics of Arts Coursework?????????????? ???. 107 Semester Credit Hours?????? ????????????. ? 107 Prescriptive Status????????????????????... 111 Arts Integration??????????? ?????? ????... . 113 Leadership Perceptions of Art Coursework?????????? ????. 114 Demographics of Respondents??? ????????? ???? 114 Curricular Review?????????????????? ??? 116 Integration of the Arts??????????????.? ????. 116 Arts Integration Setting??????????????.? ???... 119 Leadership Perceptions of Effectiveness of the Arts Integration?? ???? 120 Extent of Art Coursework?????????????????? ??? 124 Relationship between Demographics and Perceptions??????? ??? 127 Carnegie Basic 2010 Classification and Semester Hours??? ??? 127 Carnegie Classification Size and Semester Hours???? ????... 128 Carnegie Classification Control and Semester Hours??? ????.. 130 viii Carnegie Basic 2010 Classifications and Likert Questions???????????. 131 Summary? ??????????????????????????.. 137 Chapter Five Conclusion, Implications, and Recommendations?????????. 142 Introduction??????????????????????????.. 142 Purpose of the Study??????????????????????? 142 Research Questions???????????????????????.. 143 Findings???????????????????????????? 144 Conclusions??????????????????????????.. 146 Implications??????????????????????????.. 148 Theory-Practice Gap???????????????????? 148 Compartmentalization???????????????????.. 149 Specificity???????????????????????? 151 Recommendations???????????????????????? 152 Recommendations????????????????????? 152 Comprehensive Recommendations??????????????.. 154 Summary???????????????????????????.. 156 References????????????????????????????? .... 157 Appendices?????????????????????????????... 175 Appendix A. Permissions?????????????????????. 176 Appendix B. Institutional Review Board Information??????????. 180 Appendix C. Examination of the Population?????????????... 187 Appendix D. Surveys??????????????????????... 190 ix List of Tables Table 1 Southeastern State Articulation Agreements ........................................................28 Table 2 Comparison of NLNAC and CCNE Accreditation...............................................30 Table 3 Nine Essentials of Baccalaureate Education for Professional Nursing ...............31 Table 4 Categories of the Convergence of Art and Health Within the Literature .............40 Table 5 History and Development of Arts and Healthcare ................................................59 Table 6 Studies Surrounding Art and Professional Practitioner Education .......................67 Table 7 Studies Regarding the Humanities in Professional Practitioner Education ..........74 Table 8 Study Population by State .....................................................................................85 Table 9 Study Population by Carnegie Basic 2010 Classification ....................................86 Table 10 Constructs and Survey Questions .......................................................................89 Table 11 Fourth Section of The Leen Survey ....................................................................90 Table 12 Variables, Sources, and Related Research Questions .........................................92 Table 13 Population and Respondents by State .................................................................97 Table 14 Stratification of Population and Sample by 2010 Carnegie Classification .........99 Table 15 Respondent Schools by State ............................................................................106 Table 16 Description of Semester Credit Hour Findings.................................................108 Table 17 Average Semester Credit Hours by State .........................................................110 Table 18 Average Semester Credit Hours for BSN and NCLEX? Pass Rate .................111 Table 19 Prescriptive Status by State...............................................................................110 x Table 20 Prescriptive Status by State in Percentage of Respondent Schools .....................112 Table 21 Horizontal and Vertical Arts Integration .............................................................114 Table 22 Titles of Position of Respondents and Average Time in Position .......................115 Table 23 Count of the Arts Review ....................................................................................116 Table 24 Leadership Perception of Arts Integration ...........................................................117 Table 25 Findings of Leadership Perception of Arts Integration .......................................118 Table 26 Nurse Educator Leader Perceptions of Arts Integration Setting ..........................119 Table 27 Likert Questions from Leen Survey.....................................................................120 Table 28 Responses from the Likert Questions in the Leen Survey by State .....................122 Table 29 Summary of Open-Ended Survey Question Regarding Greatest Strength ..........123 Table 30 Summary of Open-Ended Survey Question Regarding Greatest Weakness .......124 Table 31 Description of the Extent of Arts Course Semester Credit Hours .......................126 Table 32 Carnegie Basic Classification and Number of Arts Courses ...............................128 Table 33 Carnegie Classification Size and Number of Arts Courses .................................130 Table 34 Carnegie Control Classification and Number of Arts Courses ............................131 Table 35 Carnegie Classification and Likert Scores ...........................................................132 Table 36 Carnegie Classification and Each Likert Question Score ....................................133 Table 37 Carnegie Classification with Small Classes & Interdisciplinary Integration ......136 Table 38 Control of Institution within the Population ........................................................188 Table 39 2000 Carnegie Classifications of Population .......................................................188 Table 40 Count of Undergraduate Program Classification .................................................189 xi List of Figures Figure 1 Concept Map of Art and Health???????????? ????. ??. 41 xii List of Abbreviations AACN American Association of Colleges of Nursing ADN Associate Degree in Nursing BSN Bachelor?s of Science in Nursing EBP Evidence Based Practice NCLEX? National Council Licensure Examination 1 Chapter 1 Introduction Overview The field of medicine extends beyond the mechanism of disease; therefore, the education of medical professionals should reach beyond purely scientific phenomena. According to Fried, Madar, and Donley (2003), education in the arts allows students to explore ideas thereby increasing the comprehension of complex issues. Further literature suggests that training in the arts improves observation, illuminates cultural awareness, fosters ethical consideration, encourages empathy, and develops communication skills (Bardes, Gillers, & Herman, 2001; De la Croix, 2011; Dolev, Friedlaender, & Braverman, 2001; Kirklin, Duncan, McBride, Hunt, & Griffin, 2007; Naghshineh, Hafler, Miller, Blanco, Lipsitz, Dubroff, & Katz, 2008; Pellico, Friedlaender, & Fennie, 2009; Phillips & Fragoulis, 2012; Shapiro, Rucker, & Beck, 2006; Elder, Tobias, Lucero- Criswell, & Goldenhar, 2006;Wikstr?m, 2011; De la Croix, Rose, Wildig & Willson, 2011). The complexities of healthcare in combination with a call for quality improvement heighten the challenges associated the with preparation of professional healthcare providers. Medical practitioners must have the ability to provide care for humans; therefore, healthcare provider education should negotiate a delicate balance between the science of medicine and an awareness of the human condition (Pellegrino, 1984). 2 Expanding Technology While nursing informatics and nursing education simulation have a real and necessary presence in baccalaureate education, there is a potential for ?opposition between the medical and humanities epistemologies? (Wachtler et al., 2006, p. 9). Expanding technology, scientific and medical advancements, and a drive for increased quality of care have led to a technology saturation (Hermann, 2004). Robots perform surgery in the operating room while computers and cell phones, in many cases, have replaced the pen and paper. This depersonalization and lack of human contact could lead to devastating consequences in the healthcare arena (Frydman, 2010). The medical humanities fulfill a social responsibility; however, the reality is that these programs require resources and, perhaps more importantly, recognition, and validation (McClay, 2010). Meanwhile, the ever expanding complexities in health care delivery call for the search and realization of innovative teaching strategies in medical practitioner education. The utilization of simulation in nursing labs across the country has prompted a plethora of data to support the replacement of clinical rotations with clinical labs (Leighton, 2007). This reduces, and potentially omits, the hospital setting in which healthcare students gain the experience of speaking to an actual patient. This prioritization for technology over the human may continue into practice. Zuger (1999) indicated that many American doctors were so dazzled by ingenious technology that they were no longer skillful in physical assessments and diagnosis. Nevertheless, because of the ability to control patient situations and capitalize on nursing skills, simulation has created a niche in nursing education that has previously 3 been untapped. As benefits of simulation are explored in the current literature, there is a realization that meeting the objectives of a liberal arts infusion into a primarily science- oriented discipline requires more than just content and anecdotal support. While the technology exists to provide students with safe experiences in technique, the delivery of the content and the ability of the educator to promote critical reflection takes on a new and higher level of importance (Hermann, 2004). In 2009, the American Recovery and Reinvestment Act (ARRA) created incentives to practitioners and hospitals for the adoption of electronic medical records. This was a move toward creating Electronic Health Records (EHR) which was set forth as a goal by George W. Bush in 2004 (Braunstein, 2013). While the incorporation of technology reached for a goal of improving safety and quality, promoting the human aspect of medicine could easily be overlooked. EHR etiquette emerged with ideas that included teaching medical practitioners to look at patients in the eye while inputting health data into the electronic health record (Frydman, 2010). In order to encourage health information technology and meet the goals for the adoption of electronic health records, the ARRA delineated 20 billion dollars in funding. Meanwhile, it was stipulated that physicians who did not adopt an EHR by 2014 would face financial penalties. However, there were still barriers to EHR adoption which included the human concerns such as; diminished eye contact between the practitioner and the patient, time with the patient, clinical workflow, and other unintended consequences (Stewart, Kroth, Schuyler, & Bailey, 2010). Literature confirmed that art improved observational skills, empathy, and communication, but with such emphasis on solidity of simulation technology and EHR 4 adoption, the utilization and recognition of the fluidity of the arts as an avenue towards observational skills, communication, and empathy may be overlooked (Bardes, Gillers, & Herman, 2001; De la Croix, Rose, Wildig & Willson, 2011; Dolev, Friedlaender, & Braverman, 2001; Elder, Tobias, Lucero-Criswell, & Goldenhar, 2006; Kirklin, Duncan, McBride, Hunt, & Griffin, 2007; Naghshineh, Hafler, Miller, Blanco, Lipsitz, Dubroff, & Katz, 2008; Pellico, Friedlaender, & Fennie, 2009; Phillips & Fragoulis, 2012; Shapiro, Rucker, & Beck, 2006; Wikstr?m, 2011). Moreover, measuring the achievement of learning goals associated with the arts in nursing education was lacking (Hermann, 2004). An organized assessment of the inclusion of the arts into baccalaureate nursing education would reach beyond testimonial support for the presence of the arts and provide an overview of the current state towards achieving the arts Essential of nursing education. Nursing Education Recognizing the importance of the fine arts, performing arts, and the humanities to the development of the baccalaureate prepared nurse, The American Association of Colleges of Nursing (AACN) identified the arts as an Essential element in baccalaureate education; however, the AACN did not create specific recommendations for the application of this study. Because there were no explicit regulations, nursing schools differed in the infusion of the arts into the curriculum. The intrinsic value of the arts provided an opportunity to facilitate a shift in healthcare education from dogmatic scientific practice while promoting education beyond clinical or vocational training. Furthermore, Macneill (2011) cautioned that art provided more than a mere instrument toward efficacious practitioners, but rather art contributed to 5 a holistic education. This was particularly important in nursing education because of the multiple entry points into nursing practice. Sitting for the nursing license exam requires one of three entry points in most states. An individual may apply and take the licensing exam with either a baccalaureate of science in nursing (BSN), an associate degree in nursing (ADN), or a diploma certificate. The American Association of Colleges of Nursing (AACN) is the ?national voice for baccalaureate and graduate nursing education? (American Association of Colleges of Nursing, 2013, p.1). This national body consists of over 725 member schools and provides education, research, federal advocacy, and programs to promote quality nursing education. In 1986, through a deeply rigorous process, a panel was created within the AACN to outline the Essential elements in nursing education for competency in professional nursing. This organization defined the essential knowledge for professional nursing education. The Essentials of Baccalaureate Education for Professional Nursing Practice came to be known as The Essentials or The Essentials Series (AACN, 2008). The document that arose from this provided a framework for nursing education at the baccalaureate level. In 2008, The Essentials were revised as healthcare education shifted to meet and embrace the challenges of the new millennia (AACN, 2008). The AACN committee developed nine Essential elements for baccalaureate nursing education. The first element for baccalaureate generalist nursing practice called for a ?solid base in liberal education? (AACN, 2008, p. 3). This was further defined into two distinct categories which described a liberal education as ?both the sciences and the arts? (AACN, 2008, p. 10). The arts were acknowledged as the fine arts such as, painting and sculpture, performing arts, such as dance and music, and the humanities, such as 6 literature and theology (AACN, 2008). In the end, the task force set the standard for the inclusion of the arts in baccalaureate nursing schools which acknowledged the integration of the fine arts, the performing arts, and the humanities. Additionally, the outcomes associated with The Essentials were outlined (AACN, 2008). According to the AACN, a liberal education allowed the graduate to ?integrate knowledge, skills, and values from the arts and sciences to provide humanistic, safe quality care?? (AACN , 2008, p. 12). More specifically, the AACN Essential for liberal education in professional nursing practice strived to prepare the baccalaureate graduate to tolerate ambiguity, improve decision making by utilizing multiple facets, engage in effective communication, and synthesize and integrate interdisciplinary theories to inform practice. The Arts According to the American Association of the Colleges of Nursing (AACN), the arts include fine arts, performing arts, and the humanities (AACN, 2008, p. 10). Some three hundred fifty years before Florence Nightingale pioneered the art of nursing, Leonardo da Vinci, the first medical illustrator, was busy as a master artist, sculptor, and painter. His studies sat at the convergence of art and science and were catalyzed by creativity as early as the 15th century (Gelb, 1998). The Mona Lisa, painted by Leonardo da Vinci in the early 1500?s exhibited uncertainty because art, like medicine, is inherently ambiguous (Wilsher, 2005). Edwards (1999) suggests, ?We see what we expect to see or what we decide we have seen? (p. XXV). The convergence of art and health is multifaceted. Regardless of the point of inclusion, a cognitive shift is necessary to overcome a conceptualized 7 observation. Study in observation related to art may allow the young artist to find more realism in his work, but for the healthcare student, the study of art produces a fascinating shift that could be a crucial diagnostic tool as a result of improved observation, critical thinking, empathy, and communication. Arts and Health There is a synthesis of knowledge and experience beyond conscious thought that transforms a nurse from a novice to an expert (Wright, 2006). Nursing integrates art with science. The construct of art in nursing provides a framework for the challenges and rewards in the profession. Through the arts, uncertainty, fear, and human awareness are recognized and appreciated. Art is a valuable tool for the novice, as well as, the experienced nurse as art provides an opportunity to find a phenomenological perspective. Art reaches beyond the science of knowing and creates a cognitive space for how something feels (Wright, 2006). The science of nursing is logical and defined while the humanism in nursing stretches beyond a lingual justification into a mode of controversial intuition and knowing (Paniagua, 2004). The link between the arts and nursing programs can only be understood once the intersection of the arts and health has been explored. The American Association of Colleges of Nursing (AACN) sets the curriculum standards, competency expectations, and quality indicators for research in baccalaureate and post baccalaureate nursing programs (American Association of Colleges of Nursing, 2013). The AACN defined the fine arts to include painting and sculpture, performing arts to include dance and music, and the humanities to include literature and theology (2013). 8 Dileo and Bradt (2009) identified four broad intersections between art and health which included; practice, recipients, settings, and disciplines indicating that the application of art in healthcare is multidimensional. Moss, Donnellan, and O?Neill (2012) also addressed the intersection of art and health with five categories which were identified as aesthetics, therapeutic interventions, treatments, cultural participation, and the medical humanities. Additionally, The Society for the Arts in Healthcare (2011), now the Global Alliance for Arts and Health, also identified five focus areas surrounding art and health: Patient care, environment, caregivers, community, and medical, and, more specifically, nursing education (Global Alliance for Arts & Health, 2013). Exploring each focus area reveals concepts that are associated with these connections. Because both are filled with uncertainty, the application of art to patient care promotes an increase in the acceptance of ambiguity and intuition. Next, the ability to see and manipulate space promotes the creation of a healing environment when art is applied to healthcare design. Beyond the realities of patient care, healthcare providers are faced with providing support to grieving family members. The application of art to promote the wellness of caregivers promotes empathy and the humanity of nursing. Finally, the convergence of art and health meet with the promotion of well-being in the community. For the healthcare practitioner, this promotes a connection between the self and the context of the population. Meanwhile, the arts build a necessary awareness of culture and cultural consideration. Art is a platform for health education because the application of art in each focus area creates an environment rich in opportunities for developing comprehension and identification of the self, the subject, and the patient. Creativity is a crucial part of 9 intelligence and problem solving; so, cultivating creativity is essential to making connections. It encourages innovation, reflection, synthesis, and evaluation. The Arts and Nursing Education A call for nursing education reform has emerged as a result of demographic and political influences combined with a quest for quality and safety in healthcare (Morris & Faulk, 2012). Moreover, the challenges of the 21st century include scientific advancements, increasing technological advancements, healthcare policies and mandates, an increase in chronic disease, and an aging population (Braunstein, 2013). The development of innovative nursing education pedagogies that include the arts is one way to attempt to address the emerging dissatisfactions related to the depersonalization of medicine associated with the current healthcare system while developing critical thinking through a humanistic approach (Hermann, 2004; Sonke, Rollins, Brandman, Graham- Pole, 2009). In addition to the call by national nursing associations and accrediting agencies, the Association of American Medical Colleges (AAMC) also directly addressed the need for compassion, empathy, and respect for patients among students. According to Schwartz et al. (2009), in 1984, the Association of American Medical Colleges called for reform of the premedical curricula to stress the value of the humanities in addition to the sciences, and by 2004, 88 of 125 American medical schools in the United States required humanities courses. In 2004, Rodenhauser, Strickland, and Gambala described a study in which questionnaires were mailed to all United States medical schools to inquire about arts-related activities within the curricula. The researchers extrapolated four distinct improvements resulting from the employment of the arts in medical education: (a) student 10 well-being, (b) clinical skills, (c) reflection and contemplation, and (d) teaching, particularly within community outreach (Rodenhauser et al., 2004). While the AACN set forth clear expectations regarding the infusion of the arts into nursing education, Burton, Horowitz, and Abeles (2000) discussed the transfer of information from the arts to other subjects. Cognitive capacities such as creativity, imagination, and critical thinking were found to be transferable from art to non-art subjects; however, practicing these skills in another domain required that the skill be presented in a way that transference was addressed (Burton, Horowitz, & Abeles, 2000). Infusing the Arts into medical practitioner education programs is inherently interdisciplinary (Halperin, 2010). However, the term interdisciplinary could potentially be misleading when referencing the science and humanities. Transference is necessary; however, reducing the role of the humanities to transplanting theory, content, or methods into medical education may devalue the essence of them. Offering courses in the arts is not sufficient; students need active, intentional learning opportunities woven into their study of medicine (Marnocha, & Marnocha, 2007; Pardue, 2004). The intersection of the arts, which includes the fine arts, performing arts, and the humanities, is not mutually exclusive to the more traditional didactic course of instruction incorporated in nursing education. However, there are important positive consequences for the incorporation of the arts in nursing education. The infusion of the arts into the nursing curricula acknowledges that art advances students clinical and critical thinking skills in a profession that operates at the convergence of science and art (Frei, Alvarez, & Alexander, 2010). In a world where technology provides instant information, the human element of nursing maintains an important role in caring (Hermann, 2004). While 11 simulation provides a rich learning experience and electronic health records improve the quality of care, it is the human that drives the true art of nursing (Wright, 2006). Research Problem The synthesis of the arts into a science curriculum requires commitment. Nursing education curricula are full of scientific concepts necessary for passing licensure exams. The massive amount of coursework is highly content driven, and faculty members are motivated to deliver concrete and overtly relevant information (Pavill, 2011). Professors may fail to integrate the arts into the classroom because there is a lack of recognition for the ability of the arts to enhance student creativity, critical thinking, and, ultimately, success on state board examinations. Paniagua (2004) suggests that the art of nursing is linked to the intuitive practice of nursing, and because this type of knowing cannot be explained, it is not valid. Meanwhile, the literature reveals that faculty members may not always feel comfortable with teaching a subject outside of their expertise (Pavill, 2011). In particular, educators with a primary background in patient care delivery may enter graduate teaching programs that tend to focus on scientific content as opposed to teaching strategies, techniques, and theories. This perpetuates a lack of expertise or motivation in developing alternative teaching strategies (Pavill, 2011). Nevertheless, studies have demonstrated that integrating the humanities into the clinical experiences improves healthcare delivery (Bleakley & Marshall, 2013; Fried, Madar, & Donley, 2003; Marnocha & Marnocha, 2007). The National League for Nursing (NLN), the American Association of Colleges of Nursing (AACN), and the Association of American Medical Colleges (AAMC) addressed the importance of 12 education in the arts for medical professionals. Regardless of the controversy surrounding the importance of the arts in medicine, because these membership bodies also have accrediting agencies associated with them, the requirements to infuse the arts into medical practitioner education cannot be overlooked. While literature supports the incorporation of art into the education of baccalaureate prepared nurses and national agencies set standards that include the arts, there remain several challenges to this call (Hermann, 2004). Among these is a lack of research that recognizes both the art and science of nursing education programs. Creating an environment where science and art have equal recognition is a foundational challenge. Defining the necessity of art in a primarily science-based curricula should be addressed. Next, underscoring the importance and equality of art and science must reach beyond anecdotal support. Explorations of the current state of the infusion of the arts into nursing education provides recognition for potential inequalities, as well as, exposing opportunities for shared curricular space (Wachtler, Lundin, & Troein, 2006). Varying schools of thought on the implementation, the manner of curriculum incorporation, and the contributions of art in practitioner education were inherent obstacles to overcome. Student reservation related to a lack of appreciation was noted to diminish enthusiasm for this type of pedagogy (Robinson, 2007). The challenge of preparing nurses for the uncertain future of the healthcare arena necessitates a search for the most efficacious andragogy for the education of future nurses. Preparing nurses to critically think, unassumingly observe, concisely and correctly communicate, and adapt to technology cannot override the sheer necessity of promoting empathy and humanism. Nevertheless, the infusion of art into an already 13 saturated curriculum may push the arts into electives that are detached from clinical experiences which undermines the opportunity for transference (Marnocha & Marocha, 2007). Purpose of the Study The purpose of the study was to explore the nursing curricula of AACN affiliated nursing schools in the southeastern United States and to describe the amount and structure of the arts, as defined as, the fine arts, performing arts, and the humanities, within their programs. Additionally, data were collected from nurse educator leadership to uncover their perception of the effectiveness in meeting the AACN liberal arts standard outcomes related to the arts. Studies have been conducted on medical school adaptation of the incorporation of the visual arts, performing arts, and the humanities; however, no study exists to determine the extent of the incorporation of the arts (fine arts, performing arts, and the humanities) into curricula of the American Association of Colleges of Nursing (AACN) affiliated programs in the southeast (Leen, 1990). Two surveys were used to address the goals of this research which included identifying the current state of AACN nursing school curricula and the perceptions of the nurse educator leaders regarding arts integration. A survey of nursing education leadership explored their perceptions with regard to the intended outcomes of the arts infusion within nursing programs. An additional survey revealed the curricula for individual programs within the sample. The intention of the research was to broadly explore the intersection of the arts and nursing education for the purpose of identifying potential value surrounding The Essentials (AACN, 2008). Moreover, a review of the literature explored art and health and captured 14 the current state of the incorporation of art into nursing and medical education. Finally, a compilation of the survey results was utilized to create a descriptive picture of the infusion of the arts into baccalaureate nursing programs across the southeast. Research Questions The following Research Questions were used in this study: 1) What are the characteristics of arts coursework (fine arts, performing arts, and humanities) found in baccalaureate nursing curricula in southeast United States institutions? 2) What are the leadership perceptions of art coursework (fine arts, performing arts, and humanities) found in their baccalaureate nursing program curricula? 3) What are the leadership perceptions of the effectiveness of arts coursework (fine arts, performing arts, and humanities) in meeting The Essential outcomes within their baccalaureate nursing program curricula (AACN, 2008)? 4) To what extent is art coursework (fine arts, performing arts, and humanities) being incorporated into baccalaureate nursing curricula in southeastern United States institutions? 5) What is the relationship, if any, between demographic characteristics and leadership perceptions (essentials and effectiveness)? Assumptions The following assumptions were made: 1. The participants answered questionnaires honestly. 2. College and university nursing curriculum descriptions were current and accurately described the nursing curricula. 15 3. Each responding nursing school had a baccalaureate program, and they were in good standing. 4. The leadership responding to the questionnaire were aware of the liberal arts requirements and outcomes for baccalaureate nursing students, and they were capable of rating the efficacy of the program related to the standards and outcomes. Limitations This was not an exploration of art therapy, art education, or art appreciation in nursing education. The intent was to explore art and health, determine the extent of the integration of the arts into the nursing curricula, and to determine the current state of the integration of the arts into baccalaureate nursing education. A survey was delivered to every AACN affiliated nursing school in the southeastern United States without regard to the stratification according to the Classification of Institutions of Higher Education (The Carnegie Foundation for the Advancement of Teaching, 1987). The study was further limited to the availability of nursing school curricula and the description of the arts requirements for graduation. Definition of Terms 1. AACN According to their website, The American Association of Colleges of Nursing (AACN) ?is the national voice for baccalaureate and graduate nursing education? (American Association of Colleges of Nursing, 2013). The AACN sets curriculum standards, competency expectation, and quality indicators for research. The AACN has an eleven member Board of Directors and several standing committees. 16 2. Art The American Association of Colleges of Nursing (2008) defined art as fine arts, which include painting and sculpture, performing arts, which include dance and music, and the humanities which include literature and theology. 3. BSN Registered nursing has multiple points of entry. A Bachelors of Science in nursing is a four year degree and is considered a professional nursing degree while an Associate Degree in Nursing (ADN) is a two year nursing degree and is considered a clinical degree (Hermann, 2004). Both degrees prepare students for licensure as a registered nurse (RN education from LPN Programs to Doctoral Degrees, 2013) 4. CCNE The Commission on Collegiate Nursing Education (CCNE) is an independent arm of the AACN which is a leading national accreditation agency for baccalaureate and graduate nursing education programs (Commission on Collegiate Nursing Education, 2013). 5. Humanities The humanities include aspects of the social sciences which contain humanistic content and utilize humanistic methods. They include the study and interpretation of language, literature, history, philosophy, archaeology, religion (McClay, 2010). For the purposes of this study, the humanities included; literature, theology, and ethics while the social sciences included psychology and sociology (AACN, 2008). 6. Medical Humanities Medical humanities is defined as the application of traditional humanities fields to the phenomena within medical education (Evans, 2002; Wachtler, Lundin, and Troein, 2006). 17 7. Nursing Informatics Nursing informatics is the combination of nursing science, computer science, and informatics to manage and communicate information (Kearney-Nunnery & Aucoin, 2012). 8. Evidence-based Practice Evidence-based practice is the integration of research with clinical expertise for optimum care, learning, and research (Kearney- Nunnery, 2012; Melnyk & Fineout-Overholt, 2011). Overview of Study This was a descriptive study to explore the incorporation of the arts in AACN member nursing schools in the southeast. The data gathered was analyzed to determine patterns in the length, structure, and coursework related to the arts (visual arts, performing arts, and the humanities) in nursing curricula, as well as, the perceived effectiveness by nursing leaders in achieving the outcomes related to the liberal arts Essential as outlined by the AACN (2008). This study provided information on the present state in an effort to progress planning, curricular activities, and nursing education standards. Summary The intersection of art and nursing begins with a multidisciplinary understanding of the links between art and health. While the infusion of the arts into healthcare education has challenges, the arts contribute to the humanity of medicine in a time when informatics and technology have shifted the landscape of health care delivery. There is a growing body of qualitative and quantitative research that contributes to the understanding of the importance of art and health to our communities, country, and the world (Halperin, 2010). 18 The intersection of art and health has been identified as Essential in nursing education (AACN, 2008). Understanding the body of evidence that surrounds the importance of the infusion of art into medical education is one step in answering this call. Next, the exploration of the current state of these concepts into the nursing curriculum provides an evidence-based picture of the application of art to nursing education. Evidence based practice (EBP) is the incorporation of the best evidence to inform practice (Kearney-Nunnery, 2012). An exploration of southeastern schools that are members of the American Association of Colleges of Nursing provided a glimpse into the current state of the integration of the arts into nursing education. 19 Chapter 2 Review of the Literature Introduction Florence Nightingale theorized, although not formally, that nursing was both an art and a science (Wright, 2006). Nightingale embraced the idea of utilizing the knowledge obtained through keen observation, such as that of an artist, to better the lives of humankind. While the spirit of the humanities has pervaded the discipline since its inception, the scientific front has been the prominent focus (Hermann, 2004). With an increase in technology, scientific advancements, and diversity in clients and disease processes, the infusion of the arts into nursing education has become vulnerable. Advances in biomedical science has placed curing patients ahead of comfort and reduced suffering (Sonke, Rollins, Brandman, and Graham-Pole, 2009). The complexities of the 21st century call for renewed praxes and pedagogies to inform it which should include an increased awareness of the importance of the humanity of nursing. Sonke, Rollins, Brandman, and Graham-Pole suggested that the purpose of the arts in healthcare was to promote health and well-being and ease suffering (2009). Further literature suggested that the inclusion of the liberal arts in nursing education illuminated cultural awareness, fostered ethical consideration, encouraged empathy, and developed communication skills (Bardes, Gillers, & Herman, 2001; De la Croix, Rose, Wildig, & Willson, 2011; Dolev, Friedlaender, & Braverman, 2001; Elder, Tobias, Lucero-Criswell, & Goldenhar, 2006; Kirklin, Duncan, McBride, Hunt, & Griffin, 2007; Naghshineh, Hafler, Miller, Blanco, Lipsitz, Dubroff, & Katz, 2008; Pellico, 20 Friedlaender, & Fennie, 2009; Phillips & Fragoulis, 2012; Shapiro, Rucker, & Beck, 2006; Wikstr?m, 2011). Medical practitioners provide care for human beings; therefore, practitioner education should negotiate a delicate balance between the science of medicine and the awareness of the human condition (Pellegrino, 1984). A review of the literature brought awareness to the history and current state of nursing education, the history of art and health, the various dimensions of art and health, and more specifically, art and professional medical education which included nursing and physician education. Exploring the literature that surrounded the historical and current states of nursing education revealed how transitions in the healthcare marketplace have impacted nursing education curricula. Meanwhile, the history of art and health provided the groundwork for the significance of the infusion of the arts (visual arts, performing arts, and the humanities) into nursing education. The exploration of the arts and health uncovered a multi-faceted perspective of the arts in healthcare which included the infusion of the arts into medical and nursing education. Purpose of the Study The purpose of the study was to explore the nursing curricula of AACN affiliated nursing schools in the southeastern United States and to describe the amount and structure of the arts, as defined as, the fine arts, performing arts, and the humanities, within their programs. Additionally, data were collected from nurse educator leadership to uncover their perception of the effectiveness in meeting the AACN liberal arts standard outcomes related to the arts. Studies have been conducted on medical school adaptation of the incorporation of the visual arts, performing arts, and the humanities; however, no study exists to 21 determine the extent of the incorporation of the arts (fine arts, performing arts, and the humanities) into curricula of the American Association of Colleges of Nursing (AACN) affiliated programs in the southeast (Leen, 1990). Two surveys were used to address the goals of this research which included identifying the current state of AACN nursing school curricula and the perceptions of the nurse educator leaders regarding arts integration. A survey of nursing education leadership explored their perceptions with regard to the intended outcomes of the arts infusion within nursing programs. An additional survey revealed the curricula for individual programs within the sample. The intention of the research was to broadly explore the intersection of the arts and nursing education for the purpose of identifying potential value surrounding The Essentials (AACN, 2008). Moreover, a review of the literature explored art and health and captured the current state of the incorporation of art into nursing and medical education. Finally, a compilation of the survey results was utilized to create a descriptive picture of the infusion of the arts into baccalaureate nursing programs across the southeast. Research Questions The following Research Questions were used in this study: 1. What are the characteristics of arts coursework (fine arts, performing arts, and humanities) found in baccalaureate nursing curricula in the southeastern United States? 2. What are the leadership perceptions of art coursework (fine arts, performing arts, and humanities) found in their baccalaureate nursing program curricula? 22 3. What are leadership perceptions of the effectiveness of arts coursework (fine arts, performing arts, and humanities) in meeting The Essentials outcomes within their baccalaureate nursing program curricula (AACN, 2008)? 4. To what extent is art coursework (fine arts, performing arts, and humanities) being incorporated into baccalaureate nursing curricula in the southeastern United States institutions? 5. What is the relationship, if any, between demographic characteristics and leadership perceptions (essentials and effectiveness)? Nursing Education In the early 1800?s, there was no formal training for nurses. Nurses were primarily taught through apprenticeships, working with physicians, or experience (Erickson, 2012). While the care of the ill or infirmed began long before the 1800?s, modern nursing began with the writings of Nightingale in 1859 and the Nightingale training school in 1860 (Peet, 1995). By the 1870?s, in an effort to improve practice, formal nursing schools began to develop in the United States (Finke, 2012). The first nursing school ?was expected to educate and morally uplift the coming generation? (Boyer, 1990, p. 4). Then, a shift occurred. With the Morrill Act of 1862 and the Hatch Act of 1887, service provided by educators became a public expectation and educating for the common good became a priority (Finke, 2012). Nursing programs were being established in hospitals, and the primary concern of nursing was improvement in public health. These nursing programs mandated that nursing faculty meet the service needs of the hospital 23 while teaching nursing students, and nursing students were asked to provide a service to the hospital while they were learning. The third phase began as higher learning institutions made a commitment to the development of research and science (Boyer, 1990). This was the embodiment of what Boyer (1990) identified as the three phases of higher education development which included education, service, and research. Nurse educators in baccalaureate programs added two additional roles to their teaching requirements. Service and research, along with teaching, created a trifecta for nurse educators (Hendrix, 2009). This trifecta became increasingly important with the emergence of recognition for evidence based practice. By the 1930?s, physicians began to recognize the efficiency of seeing patients in an in-patient setting which produced a need for more nurses (Bentley, 2004). This became heightened in the late 1940?s. National data began to be collected surrounding the nursing needs and resources which were pivotal to the analysis of the state of the profession (Gortner, 2000). During a critical post World War Two nursing shortage, a need for rapid nursing preparation of nurses emerged (Hess, 1996). The technical nursing education was to be completed within two to three years to fill this need. Nursing education became layered as technically prepared nurses and professionally prepared nurses co-habited the healthcare space (Hess, 1996). Meanwhile, faculty were taking on new academic roles, and nursing education was evolving to meet the demands of the acute healthcare needs of the United States population. Nursing Licensure There were three routes to becoming a licensed nurse. The technical nurses were educated with an associate degree in nursing (ADN) or a diploma degree while the 24 professional nurse had a baccalaureate (BSN) degree (Hess, 1996). Sitting for the nursing licensure exam required one of three entry points in most states; graduates of any of the three programs were able to take the National Council Licensing Examination (NCLEX- RN?) to become a registered nurse. The diploma program, the oldest type of nursing education was typically a three year program in which students took one year of coursework and spent two to three years in hospital training. Between 2005 and 2006, diploma programs experienced a 13 percent loss enrolling less than 12,000 students even though opportunities to obtain nursing education were limited (Kaufman, 2008). This entry point has been losing ground since 1965 when the American Nurses Association called for these programs to be moved to educational institutions (Raines & Teglaireni, 2008). Moreover, many students began to flock to two year programs that offered transferable courses into a four-year baccalaureate program. By the millennia, the primary forms of nursing education were the associate prepared nurse (ADN) and the baccalaureate prepared nurse (BSN). With a one state exception, either preparation required the student to take the same licensing exam. North Dakota was the only state that had implemented a separate licensure exam for BSN prepared graduates (George, 2010). In all other states, for example, a student could have an associate degree in nursing (ADN) from a community college or a bachelor?s degree (BSN) in nursing offered by a university, sit for the licensing exam, and receive the exact same licensure. There was a long-running debate regarding the competencies as a result of the layered education into licensure (George, 2010). Davis-Martin (1990) found that 25 healthcare institutions rarely recognized the duality of nursing roles with regard to education; however, the same study found that baccalaureate prepared nurses had a broader and more in-depth range of competencies. Unlike diploma and baccalaureate programs, ADN programs had an emphasis on education, not service. While no further education was required to sit for nursing licensure, in 1978, the American Nurses Association proposed that ADN programs should be a part of an upward-mobility plan as opposed to a terminal program (Zerwekh & Claborn, 2006). In 2007, there were over approximately 606 entry-level BSN programs, and approximately 31 percent of the nursing workforce had a BSN (Raines & Taglaireni, 2008). Meanwhile, in this same year, approximately 42 percent of the nursing workforce were ADN prepared from one of the 940 associate degree programs. This was not an exploration of the debate between ADN and BSN prepared nurses; however, the impact of this dual entry on nursing education must be acknowledged. While BSN prepared nurses took classes that included extensive theoretical and liberal arts training over four years, the ADN student was highly focused on the logistical and technical skills associated with the delivery of nursing care over the two year curriculum. The baccalaureate degreed nurse, possessing theoretical and empirical knowledge was charged to lead, plan, and guide the care of the patient. Meanwhile, the technical nurse was dedicated to the physiological care of the patient with identified nursing diagnoses (Bentley, 2004). Benner (1996) acknowledged the importance of education that extended beyond rote clinical skills. Recognizing that theory guided the framework for clinically situated motor tasks provided avenues for clinical judgment. This was fundamental to 26 baccalaureate nursing education, and this was not included in the technical training of ADN students. Articulation Agreements The American Association of Colleges of Nursing (AACN) acknowledged multiple factors within the social, environmental, cultural, and informational systems have led to a fragmented and adaptive healthcare system (AACN, 2013). Because of this, nurse practice arenas have become increasing complex related to ethical, informational, and resource allocation dilemmas. Nursing educators must insist on promoting the highest quality in nursing care. The Southern Regional Education Board states (SREB) addressed the connections between two and four years college to ensure that students understood the policies that impacted the transfer of course credits. According to the focused report by the SREB, there were only three states (Delaware, Georgia, and Mississippi) that did not have specific legislation regarding transfer policies and procedures (Creech & Lord, 2007). The remaining states that have agreements have identified common core curricula courses with mutual course titles or course numbers in order to help students through the process of transferring from a two year institution to a four year institution (Creech & Lord, 2007). Just as the preparation for nursing licensure had at least two entry points, there were also two entries toward obtaining a baccalaureate in nursing science degree (BSN). It could be achieved through a four year baccalaureate program, or associate-degreed registered nurses (RN) could complete an RN to BSN program (DeBrew, 2010). Both programs had liberal arts components. According to McKie (2012), the associate- 27 prepared nurse would obtain the liberal arts portion of the degree after obtaining the registered nursing licensure in association with the RN to BSN program while the traditional BSN graduate would complete the liberal arts portion of the nursing curricula during the four years of the baccalaureate degree. In accordance with this position, the AACN has identified Educational Mobility as the process for addressing the need for continuing education in nursing. Programs called mobility or bridge programs are nursing program options that ?allow learners educational mobility within the profession? (Boland & Finke, 2012, p. 127). Typical mobility programs include the ADN to BSN option and the Diploma to BSN option. There are also some second degree programs for those students who hold a baccalaureate degree in a non-nursing profession and desire to return to school for a BSN (2012). One essential facet of educational mobility is articulation agreements which were arrangements between ADN institutions and BSN institutions to promote the access to baccalaureate level nursing education (AACN, 2013). There were three general categories of agreements which include Mandated Articulation, Statewide Articulation, and Individual Articulation. Statewide Articulation are the majority of articulation agreements. These types of agreements included articulation plans for all programs within the state university and community college systems. Credits from an associate degree in nursing were applied to a baccalaureate degree to facilitate the nursing education progression from associate degree to a baccalaureate and even a graduate level. Most states allow 60 semester credit hours to transfer which was consistent with other disciplines (AACN, 2013). Because credits were being accepted by universities that offered a baccalaureate degree in nursing, the ADN and BSN programs were often 28 required to have renewable arrangements in order to facilitate the transfer of credit hours. This deeply impacted the mandatory coursework required by each institution within the statewide, individual, and mandated articulation agreements. Participating schools must maintain a core curriculum equivalent to other institutions within the state or agreement model (See Table 1). More specifically, the articulation agreements for each state were important regarding arts coursework because with an articulation agreement in place, students were required to have a mandatory number of dedicated liberal arts coursework hours. Table 1 Southeastern State Articulation Agreements State Articulation Agreement Type Alabama Statewide Arkansas Statewide Florida Mandated Georgia Statewide Kentucky Individual Louisiana Statewide Mississippi Statewide North Carolina Mandated South Carolina Mandated Tennessee Statewide Virginia Individual West Virginia Individual According to the AACN (2013), Individual Articulation agreements were made between schools without a state agreement. A Mandated Articulation was the result of state law regulation regarding the transfer of credit between public institutions (AACN, 2013). Meanwhile, a Statewide Articulation agreement applied to all public programs and was often adopted by private programs in the university and community college systems within these states. 29 Standards of Baccalaureate Nursing Education There are multiple, and sometimes competing, constituents interested in the education of nursing professionals (Boland & Finke, 2012). First, each state regulates nursing practice through a state board of nursing. Public accountability and social responsibility are crucial for the nursing profession because of the action of the care provider on behalf of the infirmed (Boland & Finke, 2012). The National Council of State Boards of Nursing (NCSBN) maintains a competency statement to ensure consistency and accountability across the states. In addition to the state regulatory bodies, the accrediting bodies influenced program development, curricula design, and program evaluation (Zerwekh & Claborn, 2006). Historically, the National League for Nursing (NLN) was the professional accrediting body for baccalaureate nursing programs until the National league for Nursing Accrediting Commission (NLNAC) was established in 1996 (Boland & Finke, 2012). Soon after, American Association of Colleges of Nursing began professional accreditation under the Commission on Collegiate Nursing Education (CCNE). Essentially, the National League for Nursing Accrediting Commission (NLNAC) and the Commission on Collegiate Nursing Education (CCNE) were the two accrediting bodies for nursing education outside of state regulation (Adams, 2012). The National League for Nursing Accrediting Commission (NLNAC) accredited practical nurse, associate degree, diploma, baccalaureate, masters and clinical doctorate programs. The Commission on Collegiate Nursing Education (CCNE) accredited programs that offered baccalaureate, masters, and doctoral education. The NLNAC had six 30 accreditation standards. The CCNE accreditation standards were based on core values in addition to four standards (Adams, 2012). Along with these standards, each program had a set of essential guidelines. Programs were required to incorporate The Essentials, which loosely guided the program and specified the expected outcomes associated with the guidelines (AACN, 2008; Adams & Valiga, 2009). Table 2 Comparison of NLNAC and CCNE Accreditation NLNAC Accreditation CCNE Accreditation Created 1996 Created 1998 Member body: National League for Nursing (NLN) Member body: American Association of Colleges of Nursing (AACN) Initial accreditation 5 years Continuing accreditation 8 years Initial accreditation 5 years Continuing accreditation 10 years Six standards Four standards and the eight Essentials Note. This is a comparison of the National League for Nursing Accrediting Commission (NLNAC) and Commission on Collegiate Nursing Education (CCNE) accreditation information (Adams, 2012). The Essentials of Baccalaureate Education for Professional Nursing Practice (AACN, 2008), was commonly referred to as The Essentials document. To successfully prepare nursing graduates for the healthcare arenas, nine essentials were outlined to be integrated into nursing curricula (See Table 3). Evidence of the infusion of these curricular Essentials was necessary for accreditation by the CCNE, and institutions were charged with utilizing The Essentials to provide a foundation for a curriculum that was ?congruent with a university?s mission, philosophy, and core values (Mailloux, 2011, p. 385). 31 Table 3 Nine Essentials of Baccalaureate Education for Professional Nursing Practice (AACN, 2008) Note: Adapted from the American Association of Colleges of Nursing (2008). The Essentials of Baccalaureate Education for Professional Nursing Practice. Because of the changing healthcare reforms, political environment, and public scrutiny, the roles of nurses and nursing faculty have been impacted again in this century (Boland & Finke, 2012). While nursing care evolved into a community-based and consumer-driven system, nursing faculty have been called to meet the demands of this changing landscape. Additionally, changes in curriculum and teaching strategies, as well as, the introduction of distance education have deeply impacted nursing education. According to Porter-O?Grady (2003), the nursing profession was undergoing a shift from a focus on the process and action of work to the outcomes and value of work. Each Essential in The Essentials document described and addressed nursing practice in relation to the current state of the United States healthcare system. The Essentials document was provided as a guide for curricular elements by the AACN, and it was not intended for each Essential to be an individual course (AACN, 2008). The trifecta of nursing education which includes service, research, and education also continued into the 21 century. The significance of evidence-based practice exploded with the informational age and incrementally increased access to current best practices. AACN Essentials Essential 1 Liberal education Essential 2 Organizational and systems leadership for patient quality and safety Essential 3 Scholarship for evidence-based practice Essential 4 Healthcare Informatics Essential 5 Policy, finance, and regulatory affairs Essential 6 Interprofessional communication for improving patient care outcomes Essential 7 Prevention and population health Essential 8 Professionalism Essential 9 Generalist nursing practice 32 Nevertheless, McKie (2012) suggested that the importance of the scientific paradigm need not undermine the significance of the incorporation of the arts into nursing education. While the scientific paradigm remained dominant, the arts also provided a preparation for the complexities of millennial healthcare (McKie, 2012). DeBrew (2010) found several themes that emerged from the infusion of the liberal arts into baccalaureate nursing education. Those themes included improved communication, global thinking, academic growth, cultural competence, critical thinking, personal and professional growth. The first Essential, or Essential I, of The Essentials documents was ?liberal education for baccalaureate generalist nursing practice? (AACN, 2008 p. 10). This Essential focused on the sciences and the arts which included the fine arts, the performing arts, and the humanities. The internet and other information technology systems have increased international communications. Allen and Ogilvie (2004) recognized that globalization required a greater understanding of cultural, economic, and social variables. An educational framework that explored worldviews and encouraged cultural competence was necessary (Allen & Ogilvie, 2004). The Association of American Colleges and Universities supported the initiatives through Essential I that have emerged from many colleges and universities based on the idea that the arts helped students become more effective problem solvers and address societal needs. Essential I was to be integrated throughout the nursing curriculum in order to successfully integrate liberal education, which included the arts, and nursing education thereby serving to develop cultural competence and clinical reasoning (AACN, 2008). 33 The AACN (2008) defined nine outcomes associated with the liberal arts in baccalaureate nursing education. These outcomes included the ability to integrate and synthesize theories and concepts, utilize analysis and information literacy, incorporate diverse forms of communication, maintain cultural and social competency, engage in ethical reasoning, integrate interdisciplinary knowledge, demonstrate tolerance, and embrace life-long learning. While specific recommendations of curricula or courses were not offered, sample content included ?selected concepts and ways of knowing from the arts? (AACN, 2008, p. 12). Domains of Nursing Education The Institute of Medicine (IOM) published a report in 1999 and, again, in 2001 that revealed the status of patient safety and medical errors in healthcare. In 2008, the IOM, along with the Robert Wood Johnson Foundation, called for an initiative to respond to the need for a transformation in the nursing profession (Fleeger, & Connelly, 2012). The response to these publications led to a call to action in an effort to improve the safety of the United States healthcare system. The recognition of the gap in quality healthcare, produced a critical need for nursing education reform. Two main ideas emerged which included, first, a shift to a competency-based educational approach and, second, an identification of core competencies for nursing professionals (Chenot & Daniel, 2010). These ideas represented a shift in nursing education that included a vision for safe healthcare delivery, personal responsibility, and attention to adequate professional risk management preparation (Chenot & Daniel, 2010). The Quality and Safety Education for Nurses (QSEN) project was funded by the Robert Wood Johnson Foundation in an attempt to address the challenges in patient care 34 quality and safety that were encountered by nurses (Brown, Feller, & Benedict, 2010). The QSEN faculty and advisory board defined quality and safety competencies through three domains: Knowledge, skills, and affect or attitudes (2010). McKie (2012) described these competencies as ?minds-hearts-actions? (p. 804). The three domains were applied to specific content areas within nursing education. Moreover, there was an acknowledgement of The Essentials of nursing education that exposed the need to stretch beyond technical skills and knowledge; and therefore, the affective domain was validated as a necessary contribution to the quality and safety of nursing care. Furthermore, the call for improved nursing education necessitated the affective domain for the pursuit of patient safety. This provided leverage to warrant the exploration of innovative teaching strategies which included the arts to address critical thinking and problem solving (Chenot & Daniel, 2010). According to Miller (2010), the affective domain has been difficult to define, but it included the attitudes, values, and the development of appreciations in students. The difficulty in terms and issues made identifying and comparing information within this domain even more complex. Nevertheless, according to Shephard (2008), the affective domain included an ability to interact with others, to demonstrate consideration, and transform thinking without making assumptions. This may be, in essence, what has been referred to as the elusive ?art of nursing.? There was a synthesis of knowledge and experience beyond conscious thought that transformed a nurse from a novice to an expert (Wright, 2006). Nursing integrated art with science because the art in nursing exposed the challenges, fears, rewards, and compassion that emerged from act of caring for human 35 beings. Art was a valuable tool for the novice, as well as, the experienced nurse because art reached beyond the science of knowing and told how something felt (Wright, 2006). The Historical Evolution of the Arts and Health The core competencies that were called for by the QSEN were in place by both the nursing accrediting bodies (NLNAC and AACN). The AACN defined these competencies in The Essentials (AACN, 2008) documents. In Essential I, the American Association of Colleges of Nursing (AACN) defined the arts as the fine arts which included painting and sculpture; the performing arts which included dance and music; and the humanities which included literature and theology (AACN, 2008). The history of the convergence of art and health was far-reaching. Even though the arts have been inherent in medicine since the beginning, it was not until the 20th century that accrediting bodies, such as the AACN, began to mandate the infusion of the arts into the medical and nursing curricula (Hermann, 2004). The history of art and science has deep historical roots. More recently, the Renaissance in Italy between the 15th and 17th centuries was a time of profound influence on art and architecture as the arts were interwoven into an emerging science (Johnson, 2010). The three primary contributions to the development of Renaissance art were the use of oil paints, the invention of perspective, and the use of cadavers in the exploration and understanding of human anatomy which included muscles and skeletal structure (Stork, 2004). In the early 16th century, the crowds gathered at human dissections by the hundreds (Johnson, 2010). In 1543, Andreas Vesalius published a seven volume book with his revolutionary illustrations and ideas regarding human anatomy (Johnson, 2010). 36 The intricacies of the illustrations within these volumes influenced artists, as well as, physicians of the time. Leonardo da Vinci had a reliance on direct observation in scientific investigations and experimentation, and he recorded his findings through the visual arts (Johnson, 2010). Art and science during the Renaissance almost became interchangeable as the line between works of art and scientific study became blurred with artists such as Da Vinci and Michelangelo. (Goldstein, 1980). Da Vinci sought scientific understanding in order to analyze the natural form, and he was adept at holistically connecting observations and ideas from different disciplines in his research (Capra, 2007). Vesalius and da Vinci were skilled in the art of observation, and they used it to explore their curiosities by exploring the connections between the art and sciences. However, following the Renaissance, the scientific revolution had a significant impact on the Enlightenment period. A noticeable shift occurred within the Enlightenment Period as art became less influenced by the role of science. In fact, Johnson (2010) cited the Enlightenment as the reason for the separation between science and art. The emphatic division between art and science after the Enlightenment exposes an essential need for medical practitioners to undergo objective and scientific training (Johnson, 2010). This trend continues. Despite a recognition of the arts as a necessary component of practitioner education, literature suggests that the scientific focus remains predominant (Valiga & Bruderle, 1997). A focus on knowledge and skills rather than the affective domain continues because of a lack of clear definition and an emphasis on tasks in nursing care (Miller, 2010). Moreover, comfort has been relegated to a secondary role in the 21 century as evidenced by current trends in terminology such as, healthcare 37 provider and healthcare consumer which are more indicative of the business of modern medical practice than caring (Sonke, Rollins, Brandman, & Graham-Pole, 2009). In 1950, the American Music Therapy Association was formed which was followed by similar organizations that focused on the visual arts, poetry, and dance in health. Boland and Finke (2009) contended that the integrative curriculum which incorporated knowledge from more than one discipline, gained attention in the 1970?s. According to Sonke, Rollins, Brandman, and Graham-Pole (2009), this was primarily related to the socio-political and cultural climates. Nevertheless, in 1965, the National Endowment for the Arts was formed with a mission to increase accessibility to the arts (Ivey, 2005). After this formation, numerous other groups began to emerge in an effort to infuse the arts into healthcare (Sonke, Rollins, Brandman, & Graham-Pole, 2009). Several universities around the country beginning with Duke, and later the University of Iowa, created programs that supported and promoted the arts in healthcare. This recognition of the importance of the arts in healthcare spurred the development of academic, as well as, non-academic programs across the country. Scientific rationale has taken the dominant goal with the current and on-going advancements in the biomedical sciences and technology (Sonke, Rollins, Brandman, & Graham-Pole, 2009). Nursing curricula may marginalize the arts in a quest to remain primarily committed to the scientific and technical aspects of nursing. While the discipline must focus on the logistics of patient care, there is a recognition that the arts and health maintained a symbiotic relationship for centuries. In an effort to sustain the arts within the evolution of nursing education, the AACN has identified the need for the incorporation of the arts in nursing education as defined in Essential I (AACN, 2008). 38 Dimensions of Art and Health The link between the arts and nursing programs can only be understood once the intersection of the arts and health has been explored. There were multiple intersections between art and health that have been defined by various organizations and researchers (Brenner, 2003; Dileo & Bradt, 2009; Global Alliance for Arts and Health, 1990; Moss, Donnellan, and O?Neill, 2012). The American Association of Colleges of Nursing (AACN) was one agency that set the curriculum standards, competency expectations, and quality indicators for research in baccalaureate and post baccalaureate nursing programs (AACN, 2013). Art was defined as fine arts, which include painting and sculpture, performing arts, which included dance and music, and the humanities which include literature and theology (AACN, 2013). Dileo and Bradt (2009) explored the definition of art and health. They described the intersection as four broad categories with multiple and overlapping applications. In a report by Brenner (2003), the arts in healthcare included a number of different practices. This report included end of life care and gerontological considerations (art with the aging) in the practices of art and health. The four broad categories as defined by Dileo and Bradt (2009) related to art and healthcare included: disciplines, practices, settings, and recipients. While many of these categories and their precipitants overlapped, an exploration of each focus area provided an opportunity to further define the arts and health. Additionally, the arts and health intersect with multiple disciplines which include architecture, therapies, education, and gerontology (Dileo and Bradt, 2009). Next, art and healthcare impacted a wide variety of settings including community settings, health settings, educational settings, and 39 therapeutic settings. The recipients of art in healthcare, according to Dileo and Bradt (2009), included the patient, family member, caregivers, medical practitioners which include direct and indirect patient care providers, and healthcare students. Finally, there were several types of art practices included in the application of the arts and health such as; the visual arts, performing arts, creative writing, horticulture, architecture, and video arts. The Society for the Arts was a Washington D.C. based corporation that was founded in 1990 to promote the arts in Healthcare. It has since been renamed as the Global Alliance for Arts and Health (2013). In an attempt to define the multidimensional aspects art and health, this organization identified five focus areas surrounding art and health: Patient care, environment, caregivers, community, and medical, and, more specifically, nursing education (Global Alliance for Arts and Health, 1990). Art was viewed as a platform for health education because the application of art in each focus area created an environment rich in opportunities for developing comprehension and identification of the self, the subject, and the patient. According to the Alliance, creativity has been defined as a crucial part of intelligence and problem solving; therefore, cultivating creativity was fundamental to making critical and therapeutic connections. It encouraged innovation, reflection, synthesis, and evaluation (Global Alliance for Arts and Health, 1990). Meanwhile, Moss, Donnellan, and O?Neill (2012), acknowledged five categories of art and health which included: Aesthetics, therapeutic interventions, treatments, cultural participation, and the medical humanities. The aesthetics category included healthcare designs and environment. There is a responsibility to evaluate these aspects of 40 healthcare and the arts especially in light of the government spending associated with the arts. The following table identifies several of the various approaches, according to the research, of the arts and health convergence (See Table 4). Table 4 Categories of Convergence of Art and Health within the Literature Once the four broad categories were explored, as defined by Dileo and Bradt (2009), each focus area and their precipitant, as defined by the Alliance (1990), were incorporated for an in-depth perspective of the arts and health connection. In nursing education, concept maps are often created in order for students to visually grasp the complexities of disease processes, symptoms, interventions, and patient care management. The following synthesis of this research provided a broad visual representation of the convergence of art and health. It included the four broad categories that lead to the dimensions and their associated precipitates according to the research. A partial list of examples of applications further defined each category. Figure 1 represents these relationships. Literature Number of Categories Categories Dileo & Bradt, 2009 4 Disciplines, Practices, Settings, and Recipients Global Alliance for Arts and Health, 2013 5 Patient Care, Environment, Caregivers, Community, and Professional Medical Education Moss, Donnellan, & O?Neill, 2012 5 Aesthetics, Therapeutic Interventions, Treatments, Cultural Participation, and the Medical Humanities 41 Figure 1. This concept map depicts the intersection of art and health based on the literature, the four broad categories lead to the eight dimensions, applications, and their precipitates which are found on the bottom row (Dileo & Bradt, 2009; Global Alliance for Arts and Health, 2013; Moss, Donnellan, & O?Neill, 2012.) 42 A literature search was conducted surrounding each dimension within the four broad categories. The dimensions were forms and types, patients and caregivers, community and in-patient settings, healthcare environment, and education. An exploration of each dimension led to a holistic view of the intersection of art and health which developed a fuller understanding of the AACN Essentials (2008) to include liberal education, and more specifically, the arts which were defined as the fine arts, performing arts, and the humanities into baccalaureate nursing education. Arts and Health: Forms Art-based interventions and art therapy occurred in multiple forms of art. Art forms could have been primarily visual arts which included; painting, drawing, collage- making, or other types of art which included; dancing, theater, music, poetry, creative writing, and singing. Research indicated that the perceived benefits of art for patients included social interaction and support, distraction, pain management, and expression (Meyer, 2012). Arts and Health: Types Art-based interventions, art therapy, and art education were not interchangeable. Art therapy was a formal discipline. Meyer (2012) surmised that art therapists were trained in theories and perspectives to utilize art to solve or treat patients through artistic creation. Many art therapists were shown to have a focus on the relationship between mind and body through psychoanalysis based on the works of Freud and Jung (Meyer, 2012). However, art-based interventions were found to be interdisciplinary, and they were intended to promote health through a holistic view of health and wellness (Meyer, 43 2012). While art therapy was a tool for healing as an endpoint, art-based interventions utilized the process of art to facilitate health. Licensed art therapists were less concerned with aesthetic criteria than multi-disciplined art educators. Art and Health: Patients The four broad categories within art and health, as defined by Dileo and Bradt (2009); practice, recipients, settings, and disciplines, all directly or indirectly impacted patients. Art education, art-based interventions, and art therapy each have an impact on varying patient populations. While the impact has been recognized, the research on the impact of art on specific patient populations was limited (Moss, Donnellan, & O?Neill, 2012). Psychological and physiological benefits for patients. Cohen (2005) identified a capacity for creativity and positive change in the last half of life; this challenged the assumptions of an essential cognitive decline with age. Folk art was cited as an example of ?the inherent capacity for creative expression through the entire life cycle? (Cohen, 2006, p. 8). Moreover, the promotion of health was found to be heighted when the potentials with aging were recognized. In fact, artists such as Pablo Picasso, Marc Chagall, Georgia O?Keeffe, and Grandma Moses were all famously artistically active into their old age (Kim, 2010). Cohen (2006) researched the mind-body connection in which positive emotions were found to benefit patient immunity. Carey (2002) also found that individual response to medical treatment and the immune system were impacted by the brain. Neurotransmitters such as dopamine, serotonin, and endorphins impacted happiness, peacefulness, and motivation (Kulisevsky, Pagnabarraga, & Marinez-Korral, 2009). 44 Dopamine was also involved with in Parkinson?s disease. Patients with Parkinson?s disease (PD) have decreased dopamine related to the reduced activity of dopamine-secreting cells in the brain. When treated with dopamine, patients experienced an increase in motivation and emotion. According to Kulisevsky, Pagnabarraga, and Marinez-Korral (2009), dopamine was associated with the appreciation of beauty such as that found in the arts. Furthermore, dopamine was stimulated in the presence of art therapy and increased the emotional experience of the art-making process in PD patients (Kulisevsky, Pagnabarraga, & Marinez-Korral, 2009). Kim (2010) provided additional research that suggested art-based intervention activities established new connections in the brain and changed the uptake of neurotransmitters thereby encouraging happier and healthier aging. The convergence of art and health in older adults rested in the context of creativity and aging. The arts contributed to feelings of empowerment, mindfulness, social engagement, and laterality (Cohen, 2006). The Creativity and Aging Study at George Washington University Center on Health, Aging, and Humanities examined the influence of art on health and observed positive health outcomes associated with art. The arts improved hand-eye coordination and flexibility. Moreover, the communication between the right and left hemispheres of the brain was improved during artistic expression and drawing (Kim, 2010). Additional research found that cerebral blood flow was increased in highly creative individuals during art-making (Ch?vez-Eakle, Graff- Guerrero, Garc?a-Reyna, Vaugier, & Cruz-Fuentes, 2007). Meanwhile, different modes of thinking such as creative art-making impacted different parts of the brain (Fink, Benedek, Grabner, Staudt, & Neubauer, 2007). According to Kim (2010), improved 45 blood flow or improved blood flow to diverse areas of the brain was health promoting and preventative in nature (Kim, 2010) Gabriel et al. (2001) described the use of art therapy with adult cancer patients, tuberculosis patients, bone marrow transplant patients, and burn patients. Furthermore, in a pilot study by Gabriel et al., adult bone marrow transplant patients enrolled in an art therapy program were found to have increased positive thinking, improved conflict resolution abilities, deepened spiritual insight, and improved communication with loved ones (2001). Through art therapy, patients fell into two primary groups in which they were able to resolve difficulties in relationship, or they were able to work through concerns about death and dying (Kim, 2010). In a review of 54 studies by Moss, Donnellan, and O?Neill (2012), art was found to improve the self-esteem, confidence, and hope of patients. Moreover, the impact of art and culture on patient care was particularly noteworthy due to ability of art to ?reflect the story and experience of the participant? (Moss, Donnellan, & O?Neill, 2012, p. 3). Art provided an opportunity to assess experience, strengths and challenges in diverse populations. Kim (2010) discussed the impact of art therapy on older adults. Her research indicated that art therapy reduced negativity, improved self-esteem, improved cognition, stimulated the senses, and improved social engagement. These findings contributed to perspective of improved feelings of empowerment, decreased depression and anxiety, and improved healthy aging experienced by patients in the presence of art. Marnocha and Marnocha (2007) discussed the power of the art of narration with post-traumatic stress disorder and other chronic disease states. Relaxation and meditation 46 were found to be helpful for medical staff as well as patients. Writing exercises and reflection improved expression surrounding difficult life circumstances. Environmental benefits for patients. The broad category of disciplines includes the aesthetics of the environment. Patient safety is impacted by the design of the environment. Over 150 years ago, Florence Nightingale recognized the importance of the patient care environment on patient well- being and noted that nurses were to create an environment conducive to health (Edvardsson, Sandman, & Rasmussen, 2005). Appropriate light, warmth, cleanliness, fresh air, and sound were some of the healing properties that continue to be recognized in the physical environment. Nightingale hypothesized that ensuring the best possible environment facilitated the reparative processes of the patient (Edvardsson, Sandman, & Rasmussen, 2005). A systematic review by Dijkstra, Pieterse, and Pruyn (2006) reviewed thirty studies regarding the effects of the environment in healthcare settings on the health and well-being of patients. The results summarized of a clear trend of supporting data indicating that the environment impacted patient well-being. While the impact of art on patient care deserves further exploration, there is supporting evidence to suggest that art impacts patient care in the community, healthcare environment, aging process, and overall well-being. Art and health stretches beyond the scientific study of the disease process and offers potential benefits to patients and patient communities that are outside of scientific phenomena. Arts and Health: Caregivers The first discussed focus area is related to caregiving. Providing care is an art because there is ?a synthesis of knowledge and experience of inner and out connection, 47 and of seeing patterns beyond conscious thought that transcend reduction by rational analysis? (Wright, 2006, p. 21). Providing care, like art, requires skill, experience, and intuition. Two concepts that emerged at the intersection of art and healing were intuition and uncertainty. Professional caregivers, as well as, family caregivers startled by human suffering, attempt to meet the challenge of the realities of illness and mortality. This warrants support according to the Society for the Arts in Healthcare, now the Global Alliance for Arts and Health (2012). Caregiving is demonstrated through the interpersonal relationship between the care provider and the patient, but communicating and interacting with dementia patients is particularly difficult (Hammar et al., 2011). While patients with dementia may have difficulty recognizing people or places, many patients are still able to display negative and resistant behavior and emotions as their brains attempt to navigate their confusing world. Support groups affiliated with local hospitals, religious organizations, and the Alzheimer?s Association provides necessary ongoing professional and peer support while encouraging empathy and humanism (Alzheimer?s Association, 2013). The study by Hammar, Emami, G?tell, & Engstr?m (2011) found that resistance behavior and the display of negative emotions was common in dementia patients; however, when music played during care giving interactions with dementia patients, there was a decrease in this resistant behavior and display of negative emotions. Moreover, positive emotions increased. This was impactful on caregivers attempting to perform care as patients with dementia became less resistant. The study suggested that the caregivers simply sang and encouraged the patient to sing along. This ultimately indicated that 48 benefits of informal music therapy with dementia patients stretched across cultures and geographical regions (Hammar et al., 2011). Palo-Bengtsson and Ekman (1999) explored creative dance and movement activities. They found that there was a dichotomy between nurse education and the application of what they learned in school. When caregivers in a nursing decided to incorporate dance into the nursing home activities, patients with dementia laughed and displayed positive feelings. Neither of these studies utilized formal music therapy; there was no special training other than their professional medical education. The practitioners utilized professional nursing strategies and arts-based interventions after having made a nursing assessment (Palo-Bengtsson & Ekman, 1999). The medical practitioners in these studies simply incorporated the arts into care giving for demented patients. By singing and dancing with these patients, the caregivers were able to connect with their patients beyond the cognitive impairments. The arts led to a more positive experience for the patients, as well as, the caregivers which promoted empathy and humanism. In visual art, there is a transference between the artist and the canvas, but unlike the product of the visual arts, transference exists between the arts and nursing also, but, unlike the product of visual art, the product of the transference of care vanishes, without tangible evidence. The care giving process may be more comparable to performance art because the process of the performance is active and inspiring, but when it stops, it is no longer tangible. It becomes a memory (Wright, 2006). The debate surrounding the art of nursing partially exists because of a lack of tangible evidence; however, performance art leaves nothing either. 49 Nursing and art are not always considered congruent. According to Bishop and Scudder (1997), the discussion of nursing as an art or a science reveals that there are various positions based on the particular definitions of art or science. According to these authors, the purpose of art is to create beauty, and the purpose of nursing is to foster healing and wellness, but these definitions may be inadequate (Bishop & Scudder, 1997). The semantics of the art of nursing, by these definitions, opposes the actions of nursing care because there is a supposition that nursing must have an absolute or rote definition. Intuition. Meanwhile, Paniagua (2004) argued that intuition could not be explained and, therefore, could not be included in the work of a nurse or any medical professional. Nevertheless, Smith (2009) suggested that intuition was a legitimate form of knowing after evidence revealed that nurses regularly use intuition in clinical practice. Furthermore, the transference and application of something unseen such as memory, intuition, or caring related to the affective domain of healthcare provision. Uncertainty. According to Stilos, Moura, and Flint (2007), uncertainty in nursing was inevitable and, oftentimes, stress producing. Deepening the understanding of the concept brought an awareness to the decision to diffuse it or embrace it. The intersection between art and science was both abstract and concrete which allowed for the exploration of multiple concepts. With ever expanding complexities and information in health care, clinical nurses have been faced with regular uncertainties related to the provision of care. The environment, technology, competence, interpersonal skills, and ethics were each impacted by uncertainty. Wichowski (1994) identified an apparent duality faced by 50 nurses as they navigate the technical aspect of medical care and merge this driver of patient care with the affective domain related to caring for the human. Moreover, uncertainty occurred from the perspective of the nurse and from the perspective of the patient. It did not rest in personal silos. When present, it quickly spread between the clinical nurse and the patient. Contrast the negativity of uncertainty in nursing to Da Vinci who used a feeling of uncertainty as part of his drive to learn. Even the Mona Lisa had a purposely ambiguous smile. In an effort to embrace uncertainty and turn it into a quest for knowledge, Da Vinci maintained that sometimes the answer to the problem began with acknowledging that the answer was unknown (Davidson, 2010). Creative people may seem to avoid absolutes. They see both sides of an argument. Creativity comes from the unknown, from uncertainty. Developing skills to embrace uncertainty through art addresses the landscape of uncertainty in nursing. The intentional uncertainty of the Mona Lisa was not limited to the 1500?s; 21st century art has continued to sidestep explanation and embrace ambiguity. An ambiguous piece of art leaves the viewer open to possibilities for interpretation. In a quantitative study conducted by Jakesch and Leder (2009), art with a moderate level of ambiguity was found to be the most interesting, and moderate ambiguous art pieces were preferred over other types of artwork. Moderate ambiguity in art not only elicited higher aesthetic judgments, it was found to elicit the enjoyment of ambiguity as viewers attempted to understand it. Ambiguity is an important determinant of aesthetic appreciation (Jakesch & Leder, 2009). Uncertainty in many aspects is unappreciated and may be threatening; however, in the world of art, ambiguity has found a way to be appreciated and enjoyed. 51 Uncertainty drives science. The scientist and the artist are quite similar in that they are simply exploring their world to understand the complexities that exist within in it (Staricoff, 2006). Uncertainty can be viewed as revealing or terrifying. The scientific model asks the questions, then assembles and organizes the knowledge based on the evidence; science tells us why things are the way they are. Art takes this a step further and explores the experience of things (Wright, 2006). Macneill (2011) acknowledged that the utilization of art and health should be active and should challenge assumptions in an engaging way in order to promote comfort with ambiguity and be situated in the role of learning. Arts and Health: Community In a personal narrative, Barrett (2011) described his own battle with cancer and chemotherapy treatments. Once he completed his treatments, he began teaching community art courses to cancer patients and caregivers. This article revealed the inner loneliness and isolation felt by cancer patients undergoing treatment. Included in the article were patient narratives describing works of art and comments from caregivers. The article described a community arts course, in which patients were asked to describe a photograph in the context of their chemotherapy. The responses included; ?I feel stuck;? ?How did I get here again;? ?There is a feeling I must push up the mountainside, only to roll back down again? (Barrett, 2011). Utilizing music and dance with dementia patients and looking at art history with cancer patients were two ways that the arts and medicine intersected in the community health setting. Art offered an opportunity for emotional expression, social interaction, and support (Lipe et al., 2012). Moreover, outcomes associated with the incorporation of art 52 into a community adult day care included a decrease in patient stress, increase in coping, and an increase in management of self-care which reinforced the significance of art in the science of mental health (Lipe et al., 2012). Kim (2010) found that art therapy promoted well-being and a better quality of life when she researched the incorporation of art therapy in an adult day care program. It was uncovered that art therapy promoted healthy aging physiologically and emotionally. She also uncovered that engaging in creative exercises impacted dopaminergic imbalance in the brain which suggested that neurotransmitters were involved in art therapy. According to Kim, this had not been researched extensively, but the dopaminergic stimulation in the art therapy participant accounted for her findings of increased emotional experiences and increased sensitivity in the patients. The University of Florida established Shands Arts in Medicine (AIM) in 1990 to focus on providing leadership and assistance for hospital arts programs (Arts in Medicine, 2013). With program titles such as; ?Lose your Dialysis Blues? and ?Art for the Heart? patients were able to engage in the visual arts with trained artists. Meanwhile, AIM has reached out to rural communities by providing a toolkit for the development of arts programs in rural healthcare settings. Beyond the United States, an additional AIM program, AIM for Africa, has expressed a clear commitment to global health. These and other initiatives have landed art in a pivotal position to address health across communities and cultures. Ewing and Hayden-Miles (2011) discussed the impact of art within community groups. They noted that graffiti on buildings was an example of cultural practices and diversity in values and beliefs. This type of art allowed insight into the culture of the 53 community thereby impacting nursing practice. Simons and Hicks (2006) acknowledged a direct correlation between the health of a society and the amount of artistic activity within it. Arts and Health: In-Patient Settings In 2004, a survey by the Joint Commission on Accreditation of Healthcare Organizations, a national accrediting body, found that 2,000 hospitals in the United States offered arts programs (Larson, 2006). Art was found to impact in-patient healing, pain, and hope. As technology exploded, art therapy was beginning to disappear from hospitals, but in response to a need for the technical world of medicine to heighten the focus on the human, the arts have made a resurgence. Marnocha and Marnocha (2007) discussed the appropriate utilization of relaxation and imagery skills as enrichment to patient care and improved interpersonal skills. In a literature review conducted by Flood and Phillips (2007), the researchers stated that physiological and mental health benefits emerged from artistic creativity. Cohen (2006) also found that art increased empowerment, social engagement, and a positive outlook. Arts-based interventions provided a social platform for seniors that improved their quality of life (Houser, 2011). Cohen (2006) stated that the incorporation of imagination and engagement brought hope to situations that may otherwise by filled with despair and confusion. Arts and Health: Environment The intersection between art and in-patients rested beyond arts-based interventions and art therapy, the art of the in-patient environment also was found to impact care. Houser (2011) acknowledged that art in patient rooms in the intensive care 54 units provided relaxation and reduced the need for pain medication. A systematic review of thirty studies by Dijkstra, Pieterse, and Pruyn (2006) revealed that the environment impacted the well-being of patient. Evidence-based design is the process of including the best evidence in the design of the healthcare space to promote healing, comfort, and the best patient outcomes. According to Herbert and Yoder (2008), evidence based design demonstrated improvement in clinical, outcomes, customer satisfaction, and productivity within the organization. While Nightingale may have recognized the importance of the impact of the environment on patient health, environmental psychology was the specialty that emerged as a scientific discipline with a focus on the understanding and researching the relationship between humans and the environment (Moore, & Geboy, 2010). Literature supports the link of the art of the physical environment in the promotion of health and safety (Brown, & Ecoff, 2011). One of the leading experts regarding the environment and health was Roger Ulrich who was a behavioral scientist. He conducted research to determine the effects of healthcare facilities on patient outcomes and patient safety. In his landmark study, he found that patients recovered faster and utilized less pain medication when they had a view of trees as opposed to a view of a brick wall (Ulrich, 1984). This caused a speculation of the impact of environmental factors on patient well-being (Miles, 1994). Later, Ulrich explored patient reactions to modern abstract art. The idea that the environment influences health began in the days of Hippocrates, continued through Florence Nightingale, and continued into the 21st century (Edvardsson, Sandman, & Rasmussen, 2005). Evidence-based design (EBD) features 55 continue to be an essential element in patient and employee safety. Some of the dimensions of environmental design included; single rooms, lighting, acoustics, ergonomic designs, floor layouts, healing gardens, wall art, music, and unit layout (Ulrich, et al., 2008). These design features have been found to be important with regard to patient infection, patient safety data, and employee satisfaction and retention (Brown & Ecoff, 2011). According to Staricoff (2006), poor healthcare environment design was linked with increased patient blood pressure and anxiety. Meanwhile, medical errors and hospital acquired infections increased as a result of poor hospital design. EBD incorporated a multi-disciplinary team including architects, builders, engineers, artists, designers, and health care professionals in order to promote wellness by creating physical surroundings that were conducive to healing (Staricoff, 2006). Appropriate light, warmth, cleanliness, fresh air, and sound are some of the healing properties that Florence Nightingale recognized in the physical environment over 150 years ago that promoted health and healing. She hypothesized that ensuring the best possible environment facilitated the reparative processes of the patient. There are far-reaching effects of art within the hospital setting (Staricoff, 2006). Since the study by Ulrich was published, there has been a plethora of research published (Dijkstra, Pieterse, & Pruyn, 2006). The Center for Health Design offers the Evidence- based Design Accreditation and Certification (EDAC) to individuals knowledgeable in EBD (The Center for Healthcare Design, 2013). Arts and Health: Medical and Nursing Education 56 After discussing the four other focus areas, the final dimension of art and health in education is explored. The importance of healthcare education and art is recognized by the National League for Nursing (NLN) and the American Association of Colleges of Nursing (AACN). One division of the AACN is the Commission on Collegiate Nursing Education (CCNE) which is recognized as the leading national accrediting agency for baccalaureate and graduate nursing programs. The CCNE is a nongovernmental, independent accrediting agency. The CCNE outlined five main purposes. These included: nursing program accountability, evaluation towards identified missions, goals, and outcomes of nursing programs, assessment of implementation of accreditation standards, providing information to the public with regard to nursing programs, and fostering continuous improvement in nursing programs (AACN, 2013). In a controversial article by Stanley Fish, he indicated that the humanities were useless other than providing pleasure (2008). Because the humanities expose the uncertainties and vulnerabilities of humans, those that require concrete, objective questions and answers would agree with Fish. For those who will allow their vulnerabilities to be exposed, the humanities offer a rich, unique education; they provide nourishment, and they expose human purpose and goals (McClay, 2010). The debate that surrounds the humanities is no less controversial in medical and nursing education. Wachtler, Lundin, and Troein (2006) acknowledged this chasm in medical education when they found that scientific and technical education were embraced with little explanation while the humanities required validation. This posed a potential ?opposition between the medical and humanities epistemologies? (Wachtler et al., 2006, p. 9). In a controversial article, Paniagua (2004) challenged the arts in nursing by denying 57 the role of intuition and aesthetics in healthcare related to an inability to perform measurements on these concepts. Integrating the humanities into the clinical experience improved observation, communication, assessment skills, and empathy (Ferrell, Virani, Jacobs, Mallow, & Kelly, 2010; Frei, Alvarez, & Alexander, 2010). The medical humanities fulfilled a social responsibility; however, the reality was that these programs required resources and, perhaps more importantly, recognition. Furthermore, the incorporation of art broadened student understanding of patient encounters; the integration of humanities, and in particular, art, into the nursing curricula advanced the clinical and critical thinking skills of students in a profession that operated at the intersection of science and art (Frei, Alvarez, & Alexander, 2010). A review of the literature surrounding the infusion of art into medical practitioner education (which includes medical and nursing professional education) found benefits associated with the incorporation of art into medical practitioner education. Improved observational skills associated with arts based teaching permeated throughout the studies, but medical practitioner students also acquired a combination of additional advantages such as improved communication, empathy, diagnostic skills, and human understanding (Casey, 2009; Wikstr?m, 2000; Wikstr?m, 2011). History. According to Sonke, Rollins, Brandman, and Graham-Pole (2009), art in healthcare lessened human suffering and promoted health. Since the early 1900?s, a shift has occurred in the healthcare landscape. The century began with acute conditions driving the mortality of the United States population. With the advent of antibiotics, 58 medical technologies, and evidence based medicine, acute conditions, while expensive, were primarily curable (Braunstein, 2012). However, chronic conditions increased, and they now hold the top spots for mortality in this country. The advances in medical technological during the last one hundred years were profound; yet, there has been an understandable focus on cure as the primary goal with comfort or relief of suffering relinquished to afterthoughts (Sonke et al., 2009). Nevertheless, over the last fifty years, a slowly developing trend towards an integrative healthcare system to address the current need for change in the United States healthcare system has evolved (Sonke et al., 2009). Harvey (2009) addressed the need for holistic care that included the body, mind, and spirit in his three volume work in which he attempts to humanize patient interaction. Moving from a state of reactive medicine to preventative medicine to meet the current disease process challenges required innovation and creativity. Arts and art therapy are ?finding their long overdue place in modern Western healthcare? (Sonke et al., 2009). Pratt (2003) suggested that the arts have deeply impacted the paradigm shift from the reactive state of healthcare institutions to the preventative state of community-focused environments. In 1965, the National Endowment for the Arts was founded to increase accessibility to the arts; this same year there were 7,700 nonprofit arts organizations (Ivey, 2005). Thirty years later, there were over 40,000 nonprofit arts organizations (Ivey, 2005). Numerous arts in healthcare programs have emerged such as Hospital Audiences Incorporated (HAI) and Very Special Arts (VSA) which became associated with the John F. Kennedy Center for the Performing Arts (Sonke et al., 2009). In 1978, the National Endowment for the Arts established what would become the Health Arts Network at 59 Duke (HAND) in 2003 (Sonke et al., 2009). Soon after, higher education institutions across the country were establishing similar art and health programs. Next, the establishment of The Society for the Arts in Healthcare emerged in 1991 in order to define arts in healthcare and to provide organization and clarification of the discipline (Sonke et al., 2009). Since that time the Society has been renamed the Global Alliance for the Arts and Health. Based on Sonke et al. (2009), the following table suggests a timeline for the history of the arts and health. Table 5 History and Development of the Arts and Healthcare As art in healthcare was growing, the infusion of the humanities into medical education was also being recognized. In 1967, the College of Medicine at Penn State implemented the first humanities department within a United States medical school. As Arts in Healthcare Year National Endowment for the Arts (NEA) 1965 The first humanities department at a U.S. medical school- Penn State 1967 Hospital Audiences Inc. (HAI) New York 1969 American Art Therapy Association 1969 Duke University Hospital Health Arts 1976 University of Iowa 1976 Aesthetics, Inc. 1980 Arts for the Aging, 1988 1988 Shands Arts in Medicine 1990 Center for Arts in Healthcare Research and Education 1999 Center for Health Design 1993 National Center for Creative Aging, Washington D.C. 2001 Note: Adapted from Sonke, Rollins, Brandman, & Graham-Pole, (2009). The state of the arts in healthcare in the United States. 60 other schools began to mimic this department, research accumulated surrounding the arts and medical education. Benefits. The benefit of incorporating visual art into the foundations of medical practitioner education is hinged on the complementary interventions of clinical and theoretical study. In a study conducted by Shapiro et al., (2006), traditional clinical instruction was compared to visual arts based instruction. The outcomes of the study revealed that clinically based training was more effective in conveying pattern recognition while arts based instruction was more effective with comprehension of the human condition. Essentially, the traditional clinically based teaching method taught about the pathogen, and the art-based method taught about treating the human being impacted by pathogen (Shapiro et al., 2006). Bardes et al. (2001) also found an improvement in observational skills and a heightened awareness of human emotion within the art infused medical courses; it was noted that the study of the visual arts emphasized the subjective experience of existence as a stark contrast to depersonalizing patients into elaborate machines (Bardes et al., 2001). In 2002, Strickland, Gambala, and Rodenhauser described a study in which questionnaires were mailed to all United States medical schools regarding arts-related activities and the assessed outcomes. In a follow-up study, the researchers deduced that there were four distinct improvements that resulted from the employment of the arts in medical education: (a) student well-being, (b) clinical skills, (c) reflection and contemplation, and (d) teaching, particularly within community outreach (Rodenhauser et al., 2004). Halperin (2010) reiterated the importance of service by addressing the need for 61 medical education to serve the public and cultivate the public mind. The current state of public discontent with medical care calls for an infusion of human qualities in medicine. Additionally, a mixed methods study by Naghshineh et al. (2008) and quantitative studies by Kirklin et al. (2007) and Dolev et al. (2001) explored the application of fine arts concepts to improve the visual acumen of medical practitioner students. These studies found, through quantitative methods, that arts based training improved observations and increased student diagnostic capabilities. Pellico, Friedlaender, and Fennie (2009) also found an increase in observational skills after visual arts training. The arts based pedagogy was addressed within this study which acknowledged the importance of innovative curricula especially with non-traditional students. Both Naghshineh et al. (2008) and Pellico et al. (2009) discussed the significance of education through the senses. Beyond the improvement of visual acumen, communication and stress coping also improved with arts based teaching. In a study by Elder, Tobias, Lucero-Criswell, and Goldenhar (2006), visual arts education improved observation skills and communication skills, but the researchers also noted improvements in personal growth and reflection as a result of responding to art. Moreover, the study noted that exploring through reflection allowed for a seamless transference of concepts into the clinical setting (Elder et al., 2006). De la Croix et al. (2011) explored arts subjects in medical school curricula. The themes that emerged from the study centered on an increased ability to relate to and engage with people. One unique aspect of this study was the acknowledgement of psychological distress that medical practitioner students and eventually medical 62 practitioners endure. The use of visual arts training provided skills for reflection and balance ultimately providing practitioners with tools to avoid burnout. Moderating feelings of practitioner stress, anxiety, and fear decreases the need to reduce empathy in the clinical setting. De la Croix et al. (2011) revealed that the integration of arts based training impacted the practitioner beyond mere scientific transference. Positive coping mechanisms associated with reflection and human awareness were also developed. Techniques for the integration of the arts into the programs were addressed also. Pellico et al. (2009) offered instruction for the replication of this implementation noting that any facility, even those without access to a museum, could institute arts based training through the use of print images and personal computer applications. In a literature review, Wikst?m (2011) defined the role of the educator in visual arts training to support and encourage students. The article stated that instructors, rather than revealing their personal opinions, were to guide the students to use their own resources, memories, and experiences with the works of art. This was reiterated in an article by Hubard (2007) when she noted that the experience of the viewer must come prior to instructor comments. Challenges. The body of knowledge that acknowledges and supports the infusion of art into medical practitioner education is not impervious to challenges. Varying schools of thought on the implementation, the manner of curriculum incorporation, and the contributions of art in practitioner education are inherent obstacles to overcome. Even student reservation may diminish enthusiasm for the pedagogy (Kirklin, Duncan, McBride, Hunt, & Griffin, 2007). 63 Student Response. Bardes et al. (2001) found that students enrolled in a program focusing on painted portraits were enthusiastic and involved; however, Wikstr?m (2011) acknowledged the hesitancy expressed by some students who questioned the purpose of art in their studies. She suggested a pre-session interview to potentially divulge student attitudes toward the use of art in the classroom and to overcome potential barriers. De la Croix et al. (2011) also recognized that a small number of students that were unconvinced by the benefits of art inquiry. Students desiring objectivity and practicality found the theoretical component of art instruction irrelevant. However, De la Croix (2011) found that some students that were initially skeptical found the art instruction to be applicable and eventually even suggested that arts training should be mandatory. Transference. Burton, Horowitz, and Abeles (2000) discussed the transfer of information from the arts to other subjects. Cognitive capacities such as creativity, imagination, and critical thinking were found to be transferable from art to non-art subjects; however, practicing these skills in another domain required that the skill be presented in a way that transference was addressed (Burton et al., 2000). Infusing the humanities into medical practitioner education programs is inherently interdisciplinary (Halperin, 2010). However, the term interdisciplinary could potentially be misleading when referencing the science and humanities. Transference is necessary; however, reducing the role of the humanities to transplanting theory, content, 64 or methods into medical education may devalue the essence of them. Offering courses in the humanities is not sufficient; students need active, intentional learning opportunities woven into their study of medicine (Pardue, 2004). The studies reviewed for this study did not discuss the long-term benefits of arts based teaching. Naghshineh et al. (2008) noted an increase in the number of observations, but further research was necessary to determine the quantifiable benefits in clinical application of increased observational ability. According to Elder. Tobias, Lucero- Criswell, and Goldenhar (2006), when utilizing art to improve observation skills, a clinical component was necessary. Beyond increasing accurate observations, a link must be formed to understand the impact of these abilities on the practice of the delivery of medical care and the coping mechanisms of the practitioner. Quantifying. Hubard (2011) challenged the idea of increased observational skills as a result of the study of visual art. While she agreed that observational skills may be increased, she suggested that an increase in observational skills or critical thinking was inherent when practiced with inquiry. She suggested that the skills improved whether in the presence of observing art or observing non-art because it was actually observation that was being taught. Bardes, Gillers, and Herman (2001) stated that the incorporation of art in medical and nursing education must exceed the explicit purpose of developing a defined skill-set. It was suggested that art added subjectivity to the objective study of medicine thereby emphasizing the subjective experience of existence (Bardes et al., 2001). Regardless of the alternative benefits of art, developing observational skills are fundamental to high-quality assessments (Pellico, Friedlaender, & Fennie, 2009). As 65 early as the mid 1800?s, Florence Nightingale embraced the idea of utilizing observation to better the lives of humankind. Measuring an increased number of observations of medical practitioner students based on diverse pedagogy is quantifiable which adds validity to a pedagogical method that is highly qualitative. Nevertheless, measuring the impact of the humanities is a paradox because the essence of the humanities serves as a reminder of the complexities of humans that are beyond measure (McClay, 2010). Quantifying the arts may seem incongruous, but formal assessment and evaluation are essential in order to move beyond opinion and anecdotal commentary (Hamilton, Hinks, & Petticrew, 2003). Curriculum. Even though the incorporation of the arts into health education has been recognized by various governing agencies including the AACN, the incorporation of the arts into a curriculum requires commitment. Medical practitioner education curricula are full of scientific concepts necessary for passing licensing exams. The massive amount of coursework is highly content driven, and faculty members are motivated to deliver relevant information applicable to standardized medical licensure tests (Pavill, 2011). Professors may fail to integrate the arts into the classroom because while creativity and critical thinking may be enhanced, there is a lack of quantifiable recognition for the ability of the arts to promote success on state board examinations. Meanwhile, faculty members may feel uncomfortable with teaching a subject outside of their expertise (Pavill, 2011). In particular, educators with a primary background in patient care delivery may enter graduate teaching programs that tend to focus on scientific content as opposed to teaching strategies, techniques, and theories. The compulsion for adequate exam 66 preparation in combination with lack of familiarity with varied andragogical strategies may perpetuate a lack of pursuit toward the development alternative teaching strategies in healthcare education. There was a trend throughout the literature surrounding the infusion of art in professional medical education. While several studies were indicative of improved observations and development of empathy in the students (Frei, Alvarez, & Alexander, 2010; Pardue, 2005; Shapiro, Rucker, & Beck, 2006), there was also concern regarding the evaluation of the arts-based instruction surrounding improved patient care and student attitude and behavior (Perry, Maffulli, Willson, & Morrissey, 2011). The following table of studies regarding art in professional medical practitioner education were not exhaustive of the literature, but they provided clear trends of the use of art and medical education (See Table 6). 67 Table 6 Studies Regarding Art and Medical Practitioner Education (continued) Literature Purpose Major findings Bardes, C.L., Gillers, D., & Herman, AE. (2001) Described a program between med schools and museums The program helped students improve observation and empathy. Casey, B. (2009) Study to determine impact of arts-based training Improved inquiry and critical thinking. Recognized ambiguity presence. De La Croix, A., Rose, C., Wildig, E., & Willson, S. (2011) Qualitative study on arts subjects in professional medical education Students felt arts teaching was valuable. Dolev, J.C., Fiedlaender, L.K., Braverman, I.M. (2001) Experimental study on impact of observation with arts based learning Increased number of observations in art based interventions group of students. Elder, N.C., Tobias, B., Lucero-Criswell, A., Goldenhar, L. (2006) Qualitative study regarding student perception of art-based intervention. Defined a need better evaluation tools. Positive experience and led to personal development Frei, J., Alvarez, S.E., & Alexander, M.B. (2010) Examples of nursing school and museum gallery education Discussed specific learning activities related to art and nursing Kirklin, D., Duncan, J., McBride, S., Hunt, S., & Griffin, M. (2007) Experimental study on impact of observations in arts based training Improved observational skills in those trained with art. Does it transfer to patient care? 68 Literature Purpose Major Findings Loden, K.C. (1989) Review of clinical experience at a museum. Students reported improved cultural awareness and holistic care. Naghshineh et al., (2008) Formal art observation training in medical school. Improved observations of art and physical findings. Ousager, J., & Hohannessen, H. (2010) Literature of humanities in medical education Extensive review of the literature Pardue, K.T. (2005) Discussion of inclusion of art and humanities Improved ?aesthetic knowledge? and empathy (p. 337) Pavill, B., (2011) Discussion of experience in museum Expansion of holistic understanding of patient care, develop empathy Pellico, L.H., Friedlaender, L., Fennie, K. P. (2009) Observation and nursing education Increased observations by nursing students with arts intervention Perry, M, Maffulli, N., Willson, S., & Morrissey, D., (2011) Art-based interventions: A literature review Discussion of a need for further evaluation to determine impact on practitioner attitudes Rieger, K.L., & Chernomas, W.M. (2013). Concept analysis of arts- based learning Concept analysis and literature review of arts-based nursing education. Robinson, S. (2006) Introduction to arts-based health Art brought cognitive and affective change in students. Rodenhauser, P., Strickland, M.A., Gambala, C.T. (2004) Survey of art-related courses in medical schools More than 50 percent of U.S. Medical schools incorporated arts. Shapiro, J., Rucker, L., & Beck, J. (2006) Explore visual arts in medical education, observation, empathy Art observation improved pattern recognition Wikstr?m, B. (2000) Experimental study of visual art and nursing Studying works of art improved social intelligence, related art to interpersonal lives. Wikstr?m, B. (2011) Explore visual art and nursing education Visual arts increased empathy, communication, observation 69 Humanities in Health Education The AACN Essential document (AACN, 2008) called for the inclusion of a liberal education into the baccalaureate nursing curriculum. The sciences and the arts, as defined as fine arts, performing arts, and the humanities, were included in the first essential. A brief exploration of art and health revealed the importance of the inclusion of the arts. Next, a search in the literature revealed the importance for the inclusion of the humanities into baccalaureate nursing curricula. Bruderle and Valiga (1994), defined the humanities as a ?branch of knowledge that deal with what it means to be human, to live authentically, and to share with others? (p. 120). There was a debate that surrounded the infusion of the humanities into a predominately scientific discipline. First, the importance of the exposure to human interests promoted a holistic education for the baccalaureate prepared nurse. Next, the incorporation of the humanities was important independently of a holistic education in that it offered an understanding of what it meant to be human (Bruderle & Valiga, 1994; Charon, 2010). In further review, the incorporation of the humanities into the nursing curriculum heightened this debate. The well-defined scientific paradigm and the loosely defined humanitarian paradigm were at odds (McKie, 2012). Moreover, McKie expressed concern that the liberal arts education in nursing was unnecessary because of the current demands for technical and informatics-based skills within the rapidly advancing field of medicine. The business of medicine demanded that nurses be prepared with transferable skills, not those associated with immeasurable attributes. Additionally, DeBrew (2010) recognized the challenge associated with outcomes that were difficult to measure in 70 higher education. Charon (2010) expressed concern regarding the humanities in an ?outcomes-based medical education model that demands proof? (p. 936). However, Charon (2010) also indicated that more robust metrics were becoming available in order to evaluate outcomes associated with the humanities. Studies showed that integrating the humanities into the clinical experience improved observation, communication, assessment skills, and empathy (Ferrell et al., 2010; Frei, et al., 2010). The National League for Nursing accrediting Commission (NLNAC) encouraged an interdisciplinary approach to nursing education through their document NLNAC Standards and Criteria, Baccalaureate under Standard four. It revealed that curriculum and instructional processes should reflect interdisciplinary collaboration and innovation. The integration of humanities, and in particular, art, into the nursing curricula advanced students clinical and critical thinking skills in a profession that operated at the convergence of science and art (Frei et al., 2010). According to Sternberg (1999) the characteristics of successful people include academic intelligence, creative intelligence, and practical intelligence. Freeland (2009) echoed these ideas by adding that the incorporation of all three of the intelligences is necessary. In addition to the national nursing associations and accrediting agencies, the Association of American Medical Colleges (AAMC) directly addressed the need for compassion, empathy, and respect for patients among students (Rodenhauser et al., 2004). Additionally, according to Schwartz et al., in 1984, the Association of American Medical Colleges called for reform of the premedical curricula to stress the value of the humanities in addition to the sciences (2009). By 2004, 88 of 125 American medical 71 schools accredited by the AAMC in the United States required humanities courses (Schwartz et al., 2009). While steps are being taken to incorporate the humanities into medical practitioner education, debate remains about the role, definition, and method of the incorporation of the humanities (Schwartz et al., 2009). Nursing education continues the attempt to navigate the technological advancements, healthcare reform, and increasing complexity of patient care. Nurses and other medical practitioners recognize the uncertainty of healthcare, and remain diligent in the pursuit of traversing the inherent ambiguity, unpredictability, and intricacies of human beings (Paniagua, 2004). While the inclusion of the humanities was critical in nursing education, Hermann (2004) also found that the andragogical strategies for the delivery of the content was just as crucial. Moreover, after a case study research project which included twelve universities, she cautioned that many of the humanities courses were found in the electives as opposed to curricular requirements. She also interviewed faculty who felt that the humanities were effective in achieving higher levels of critical thinking, personal development, and a humanistic perspective (Hermann, 2004). In addition to faculty responses, a qualitative study by DeBrew (2010) found that the liberal education outcomes were acknowledged in the student responses within her study. Research indicated that both faculty and students felt that the humanities assisted students with the development of a holistic view of nursing care. Bruderle and Valiga (1994) discussed this history of the humanities and nursing; they suggested that liberal arts, and more specifically, the humanities, were related to professionalism. These authors challenged the traditional thinking of the purpose of the 72 humanities. While they acknowledged the importance of a humanistic understanding gained through the humanities, they also provided a list of the benefits of the humanities in nursing which included: an understanding of values, choice, decisions, and imaginations, a clarification of goals and perspectives, an awakening of self, world realities, social consciousness, and prejudice, and an appreciation of intuitive thinking, ambiguity, diversity, and culture (Bruderle & Valiga, 1994). Extending the notion, DeBrew (2010) uncovered several thematic outcomes associated with the humanities in nursing education which included: lifelong learning, teamwork, communication, literacy, ethics, responsibility, creative thinking, critical thinking, and synthesis. This reiterated the findings of Rodenhauser (2001) regarding arts related activities in United States medical schools. Anthony and Templin (1998) discussed internal and external challenges to including the humanities into nursing education. External challenges related to student concern regarding the expertise of the faculty in teaching humanity courses, and internal challenges related to the personal confidence of the faculty member in meeting the objectives of the humanities courses which were outside of the usual nursing course objectives. Hermann (2004) raised several questions concerning the infusion of the humanities. One question under consideration was: what type of instructor was trained in the humanities? There was also a concern about infusing the humanities into an already content-laden program (Hermann, 2004). Because of the nature of the humanities, Bruderle and Valiga (1994) mentioned that courses in the humanities must be in line with the mission, goals, and values of the school. 73 A review of the literature revealed several consistencies in the literature that addressed the incorporation of the humanities into diversified types of professional medical education. Outcomes remained a consistent conundrum throughout articles discussing the humanities in medical and nursing education. The duality of the paradigms was also a consistent theme. Many of the studies acknowledged that the humanities should be an integral consideration in medical education (Fried, Madar, & Donley, 2003; McKie, 2012; Wachtler, Lundin, & Troein, 2006). Finally, thematic categories also emerged from the literature surrounding the humanities in medical education. The research primarily argued in favor of interdisciplinary collaboration, called for or promoted awareness of the humanities in medical education, or described specific programs or courses in the medical humanities. These studies were not exhaustive of the literature, but they provided clear trends in the medical humanities literature (See Table 7). 74 Table 7 Studies Regarding the Humanities in Professional Practitioner Education (continued) Humanities and Medical Education Literature Challenges Addressed Discussion Category Anthony, M.L. & Templin, M.A., 1998 Internal and External barriers Liberal arts importance, improved evaluation, communication interaction with students. Argued in favor of interdisciplinary collaboration and the incorporation of the humanities into curricula. Bruderle, E.R. & Valiga, T.M., 1997 The importance of the humanities Goals and benefits of the humanities were listed. Argued in favor of the incorporation of the humanities into curricula. Charon, R., 2010 Difficulty in outcomes measurement Challenged the intent of outcomes in the humanities. Argued in favor of the incorporation of the humanities into curricula. DeBrew, J.K., 2010 Outcomes were difficult to measure Humanities perceived as effective in global perspective, critical thinking, professional growth Argued in favor of the incorporation of the humanities Evans, M., 2001 Humanities into medical curricula Assessment should not drive learning. Humanities as a window and a core for medicine. Discussion of humanities course. Fried, C., Madar, S., & Donley, C., 2003 Duality of science and humanities Acknowledged program success measurement was challenging. Discussion of humanities courses and a biomedical humanities program. Halperin, E.C., 2010 Concerned with resources to support the humanities. Humanities were an essential part of medical education. Defended programs in the humanities for training in medicine. Hermann, M.L., 2004 Faculty expertise and content laden curriculum Humanities perceived as effective Promoted awareness and need for development of humanities, Lazenby, M., 2013 Challenges the purely scientific notion of nursing Humanities and scientific knowledge led to professionalism. Challenged the nature of science over humanities. 75 Conclusion The intersection of art and health was found within the practice of the arts, the recipients of the arts, the settings of the arts, and the disciplines included in the arts. Essentially, this led to eight dimensions of art and health which included: patients, environments, caregivers, communities, healthcare settings, and professional medical education. By exploring the multiple facets of this convergence, a clear understanding of Humanities and Medical Education Literature Challenges Addressed Discussion Category Marnocha, S. & Marnocha, M., 2007 Outcomes measurements and content laden curricula. Recognized a lack of formal outcome studies. Argued in favor of the incorporation of the humanities and application during the experiential portion of nursing education. McKie, A., 2012 Need for transferable skills in market. Dual paradigms Recognized the duality of science and humanities. Argued in favor of the incorporation of the humanities Ousager, J & Johannessen, H., 2010 Outcomes were difficult to measure. Humanities perceived as effective. Informational, Inclusion of multiple additional studies. Schwartz et al., 2009 Impact and measurement of humanities Debated and measured outcomes of the impact of the humanities Called for further research on the impact of the humanities. Sullivan, E.J., 1996 Technology versus the humanities. Science and the humanities should be seen as one entity. Argued in favor of the incorporation of the humanities. Wachtler, C., Lundin, S., & Troein, M., 2006 Challenged to find equality among sciences and humanities. Discussed the differing goals of the humanities faculty and medical faculty. Awareness of primarily qualitative outcomes. Called for an equality of the humanities and sciences. Discussed humanities courses. Wear, D., 2009 Lack of predictability or uniformity in the humanities offerings Acknowledged the necessity of multiple perspectives and disciplines in medical education Discussion of medical humanities program. 76 the consequences developed. These consequences were the concepts that allowed medical professionals or any caregiver to attempt to understand the individual nature of humans and to foster the health of them (Paniagua, 2004). In essence, the literature suggested that patients were human beings that could not be reduced to purely scientific study. Furthermore, exploring the humanities in medical education promoted the exploration of the human spirit and condition. The specific precipitates the intersection between art and health were explored. The incorporation of art into health education improved communication, observation, and critical thinking (Frei, Alvarez, & Alexander, 2010; Robinson, 2006; Shapiro, Rucker, & Beck, 2006; White & Robinson, 2001). Meanwhile, patients engaged in art-based interventions and art therapy had positive physiological and psychological benefits. The application of art to patient care promoted an increase in the acceptance of ambiguity and intuition. The ability to see and manipulate space promoted the creation of a healing environment when art was applied to healthcare design. Beyond the realities of patient care, healthcare providers were faced with providing support to grieving family members. The application of art to promote the wellness of caregivers promoted empathy and the humanity of nursing. The convergence of art and health also met with the promotion of well-being in the community. For the healthcare practitioner, this promoted a connection between the self and the context of the population. Meanwhile, it built an awareness of culture and cultural considerations. The approaches to integrating art with medical practitioner education varied. There were challenges to the inclusion of the arts into professional medical education. However, a review of the research highlighting the incorporation of art (fine arts, 77 performing art, and the humanities) into health practitioner education consistently revealed outcomes conducive to improved care. The arts and in particular, visual art, for non-art majors had significant potential benefits for ensuring that practitioners were responsive to the human and social dimension of medicine (Rodenhauser et al., 2004). A synthesis of knowledge combined with an ability to see patterns beyond conscious thought ?transcend[ed] reduction by rational analysis? (Wright, 2006, p. 21). De la Croix (2011) noted that arts-based training improved medical practitioner student communication, confidence, and stamina which ultimately strengthened their practice. Meanwhile, arts based training was also shown to have the ability to develop tools to utilize reflection and incorporate balance which were essential to sustaining their practice (De la Croix, 2011). However, the quantifiable data that surround the esoteric benefits of art was limited. The humanities offered intrinsic benefits that allowed students to experience a variety of perspectives that could be used to examine and question phenomena (Wear, 2009). Because of the benefits associated with arts based instruction (fine art, performing art, and the humanities), more research was necessary to determine the most efficacious methods for the development, implementation, and evaluation of these programs. There was an acknowledgement of an essential need for research to preserve the role of the humanities in education, to overcome obstacles, and raise the level of awareness of the humanities in an increasingly complex world. The AACN identified a liberal education which included the arts (fine art, performing art, and the humanities) as an Essential element in baccalaureate education; however, they did not create specific recommendations for the application of this study. 78 Because there were no explicit regulations, nursing schools could differ in the infusion of the arts into the curriculum. An organized assessment of the inclusion of the arts into baccalaureate nursing education would reach beyond testimonial support for the presence of the arts and provide an overview of the current state towards achieving the arts Essential of nursing education (AACN, 2008). The body of knowledge that acknowledged and supported the infusion of art into medical practitioner education was not impervious to challenges. Varying schools of thought on the implementation, the manner of curriculum incorporation, evaluation of outcomes, and the contributions of art in practitioner education were consistently mentioned as inherent obstacles to overcome. In the end, the concept of art and nursing programs had historical beginnings. The intersection of art and health was identified through the four broad focus areas. The arts, according to the AACN, include the visual arts, the humanities, and the performing arts. The literature was rich with reviews and qualitative studies; however, quantitative explorations of the incorporation of the arts into medical education programs was limited to the tangible evidence indicating educational outcomes. Descriptive, quantitative studies concerning the extent of the arts within medical education was limited. A review of the history of nursing education and the current state of nursing education provided an awareness of the expanding healthcare complexities that accentuated the need for nursing education to prepare students for the challenges of the 21st century (Hermann, 2004). The multiple entry points into nursing licensure stretched the need for a cohesive, organized, approach to the infusion of the arts in baccalaureate nursing education. The intersection of art and health has been identified as an Essential in nursing education (AACN, 2008). Understanding the body of evidence that surrounds the 79 importance of the infusion of art into medical education was one step. Next, the exploration of the current state of these concepts into the nursing curriculum provides an evidence-based picture of the application of art to nursing education. An exploration of southeastern schools that are members of the American Association of Colleges of Nursing provided a glimpse into the current state of the integration of the arts into nursing education. 80 Chapter 3 Methods Introduction Sonke, Rollins, Brandman, and Graham-Pole (2009) suggested that the purpose of the arts in healthcare was to promote health and well-being and ease suffering. Further literature suggested that the inclusion of the liberal arts in nursing education improved observation, illuminated cultural awareness, fostered ethical consideration, encouraged empathy, and developed communication skills (Bardes, Gillers, & Herman, 2001; De la Croix, Rose, Wildig, & Willson, 2011; Dolev, Friedlaender, & Braverman, 2001; Elder, Tobias, Lucero-Criswell, & Goldenhar, 2006; Kirklin, Duncan, McBride, Hunt, & Griffin, 2007; Naghshineh, Hafler, Miller, Blanco, Lipsitz, Dubroff, & Katz, 2008; Pellico, Friedlaender, & Fennie, 2009; Phillips & Fragoulis, 2012; Shapiro, Rucker, & Beck, 2006; Wikstr?m, 2011). Healthcare practitioners, in an attempt to provide holistic care for humans, are challenged to negotiate a delicate balance between the science of medicine and an awareness of the human condition (Pellegrino, 1984). Purpose of the Study This study explored the curricula of AACN affiliated nursing schools in the southeastern United States to describe the amount and structure of the arts as defined as the fine arts, performing arts, and the humanities. More specifically, data from nurse educator leaders were collected to reveal the perceptions of the effectiveness in meeting the AACN Essential surrounding the arts. 81 The AACN Essentials of Baccalaureate Education for Professional Nursing Practice was referred to as The Essentials (AACN, 2008). The first Essential was a call for the inclusion of a liberal education for baccalaureate nursing students. The liberal education component was further divided into the sciences and the arts. The intent of this research was to broadly explore the arts (fine arts, performing arts and humanities) and nursing education for the purpose of identifying potential value surrounding The Essentials. This study did not explore the sciences which included the social sciences. Data from nursing curricula were reviewed to determine the extent, frequency, and variation of the arts in nursing education. While the American Association of Colleges of Nursing (AACN) identified the arts as an Essential element in baccalaureate education, specific recommendations for the application of this study were not addressed (AACN, 2008). Because there were no explicit regulations, nursing schools differed in the infusion of the arts into the curriculum. An organized assessment of the inclusion of the arts into baccalaureate nursing education reached beyond testimonial support for the presence of the arts and provided an overview of the current state towards achieving the arts Essential of nursing education (AACN, 2008). Collecting and organizing a body of empirical information surrounding the current state of art infused baccalaureate nursing education provided information for nursing schools in order to improve the incorporation of the arts in nursing education, as well as, meet The Essential guidelines outlined by the AACN (2008). Macneill (2011) cautioned that art provided more than a mere instrument toward efficacious practitioners. Chapter 2 explored the dimensions of art and health. The intrinsic value of the arts moved 82 medical practitioner education from dogmatic scientific practice and promoted education beyond vocational training. This was particularly important in nursing education because of the multiple entry points into nursing practice. In addition to the recommendations by the AACN for the inclusion of the arts, the Association of American Colleges and Universities (AACU) also urged stakeholders to infuse the mission of the liberal arts throughout content, as well as, teaching strategies (Hermann, 2004). There is evidence that recognized the impact of the infusion of the arts into nursing education; unfortunately, measuring the achievement of learning goals associated with the arts was lacking (Hermann, 2004). Research Questions The following Research Questions were used in this study: 1. What are the characteristics of arts coursework (fine arts, performing arts, and humanities) found in baccalaureate nursing curricula in the southeastern United States? 2. What are the leadership perceptions of art coursework (fine arts, performing arts, and humanities) found in their baccalaureate nursing program curricula? 3. What are the leadership perceptions of the effectiveness of arts coursework (fine arts, performing arts, and humanities) in meeting the Essential outcomes within their baccalaureate nursing program curricula? 4. To what extent is art coursework (fine arts, performing arts, and humanities) being incorporated into baccalaureate nursing curricula in the southeastern United States institutions? 83 5. What is the relationship, if any, between demographic characteristics and leadership perceptions? A review of the literature brought awareness to the history and current state of nursing education, the history of art and health, the various dimensions of art and health, and more specifically, art and professional healthcare education which included nurse and physician education. Exploring the literature that surrounded the historical and current states of nursing education revealed how transitions in the healthcare marketplace have impacted nursing education curricula. Meanwhile, the history of art and health provided the groundwork for the significance of the infusion of the arts (fine arts, performing arts, and the humanities) into nursing education. The exploration of the arts and health uncovered a multi-faceted perspective of the arts in healthcare which included the integration of the arts into healthcare practitioner education. This study explored the nursing curricula of AACN accredited nursing schools in the southeastern United States, as identified by the Carnegie Foundation, to describe the amount and structure of the arts (fine arts, performing arts, and humanities) required within their programs. This chapter explores the population, variables, instrumentation, data collection, sample, and process for the descriptive data analysis of this research project. Design Overview The study utilized two instruments to address the Research Questions. A non- experimental descriptive comparative survey design was utilized to examine the perceptions of nurse educator leaders regarding the outcomes as defined by the AACN of 84 the incorporation of the arts (fine arts, performing arts, and humanities) into baccalaureate nursing programs across the by states and Carnegie Classification. Data were collected from nursing education leadership in the Leen Nursing Program Essentials and Effectiveness Survey to uncover the perceptions of nursing educator leaders regarding the effectiveness of the arts in meeting the AACN Liberal Arts standard (Essential I) outcomes (AACN, 2008). A convenience sample was utilized based on the responses to the survey. Next, data from the course catalogs of participating schools were collected and categorized. This secondary non-experimental descriptive comparative survey, the Catalog Survey, was completed outlining southeastern nursing school curricula and Carnegie Classification descriptors. Data from the Leen Nursing Program Essentials and Effectiveness Survey and the Catalog survey were assimilated and analyzed. In addition to categorizing schools by state, utilizing the Carnegie Classification system, schools were categorized according to the 2010 Basic Classification, size, control, undergraduate program class, community engagement, historical Carnegie classification, minority serving, land grant institutions, and urban institutions. Finally, a descriptive analysis was performed with the use of Microsoft Excel? 2013 to address the Research Questions. Population The population for this research included all of the American Association of Colleges of Nursing (AACN) members in the southeastern United States nursing schools that offered a four year baccalaureate nursing education. The Carnegie Foundation recognized 12 member states in the southeast which included Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Mississippi, North Carolina, South Carolina, 85 Tennessee, Virginia and West Virginia. Florida had the most AACN member institutions while Arkansas, Mississippi, and West Virginia had the least number of AACN member schools. Table 8 Study Population by State Incorporation of the Carnegie Classification system, which was developed in 1973, provided an opportunity to explore descriptive data that included institutional missions and educational functions (Boyer, 1987; McCormick & Zhao, 2005). The Carnegie Classification has been updated six times since the inception because of the changes in institutions and the shift in the academic landscape over the last forty years (McCormick & Zhao, 2005). As a result of these changes, the institutions were classified according to a variety of categories within the classification system. The 2010 Basic Classification is the most recent update. The population for this study included 187 southeastern AACN member schools. According to the 2010 Basic Carnegie Classification, the majority of the schools Southeastern AACN States Number of AACN Nursing School Programs by State Percentage Alabama 16 8.56% Arkansas 7 3.74% Florida 28 14.97% Georgia 21 11.23% Kentucky 15 8.02% Louisiana 12 6.42% Mississippi 7 3.74% North Carolina 20 10.70% South Carolina 11 5.88% Tennessee 22 11.76% Virginia 21 11.23% West Virginia 7 3.74% Total 187 100.00% 86 (47.9 percent) within the southeastern population were considered smaller, medium, and larger master?s colleges and universities. Research universities made up 23 percent of the southeastern population. Baccalaureate colleges made up 19.25 percent of the total southeastern population (See Table 9). There were seven associate schools included in the population according to the Carnegie Classification; nevertheless, any AACN member school that offered a baccalaureate in nursing was included in the study regardless of Carnegie Classification. The population was also categorized according to other Carnegie categories such as undergraduate program classification, size, community engagement, 2000 Carnegie classification, control, minority serving, land grant institutions, and urban institutions. (See Appendix C). Table 9 Study Population by Carnegie Basic 2010 Classification 2010 Basic Classification for Population Count Percent Associate's--Public Rural-serving Medium 1 0.53% Associate's--Public Rural-serving Large 1 0.53% Associate's--Public Urban-serving Multi-campus 1 0.53% Associate's--Private For-profit 2 1.07% Associate's--Public 4-year Primarily Associate's 2 1.07% Research Universities (very high research activity) 19 10.16% Research Universities (high research activity) 14 7.49% Doctoral/Research Universities 10 5.35% Master's Colleges and Universities (larger programs) 60 32.09% Master's Colleges and Universities (medium programs) 21 11.23% Master's Colleges and Universities (smaller programs) 8 4.28% Baccalaureate Colleges--Arts & Sciences 6 3.21% Baccalaureate Colleges--Diverse Fields 25 13.37% Baccalaureate/Associate's Colleges 5 2.67% Special Focus Institutions--Medical schools and medical centers 5 2.67% Special Focus Institutions--Other health professions schools 7 3.74% Total 187 100.00% 87 Instrumentation There were two primary instruments utilized in this research. Permission was granted through the Institutional Review Board at Auburn University to collect data (See Appendix B). The surveys were created by Dr. Maureen Leen (Leen, 1990). The surveys were also tested by Leen for validity and reliability. Permission was obtained from Dr. Leen to utilize the survey instruments (See Appendix A). The electronic survey, henceforth referred to as the Leen Nursing Program Essentials and Effectiveness Survey, and the Catalog Survey were constructed after a pilot procedure was conducted by Leen (1990). Leen Nursing Program Essentials and Effectiveness Survey The Leen Nursing Program Essentials and Effectiveness Survey consisted 25 questions divided among four sections. The survey was utilized with permission from Dr. Leen and the AACN (See Appendix A). The Essentials document identified expected outcomes, and the survey utilized these projected outcomes of Essential I as outlined by the AACN (2008). The survey was emailed via a link from the introduction letter using the web-based software, Qualtrics?, to a nurse leader at each of the 187 schools which were identified as southeastern, according to the Carnegie Classification, and held an AACN membership (American Association of Colleges of Nursing, 2013). The first section included the respondent demographic data. This section described the position, longevity in position, and gender of the respondent. The second section which consisted of four questions surrounded the general program information. 88 These questions provided information regarding the number and frequency of graduates, the accreditation of the school, and distance education. The third section, identified as Part III, consisted of eight questions. The first six questions were rote, yes or no, questions regarding the arts within the liberal education program. According to the AACN, Essential I was described as ?a liberal education that includes both the sciences and the arts? (AACN, 2008). The sciences included; physical science, life sciences, mathematical science, and social sciences while the arts were defined by the AACN to include the fine arts, performing arts, and the humanities (AACN, 2008). The eight questions in this section strived to gather information surrounding the characteristics and the extent of the incorporation of the arts, as defined by the AACN, into baccalaureate nursing curricula. The respondents were asked to identify if the arts within the liberal education program have been reviewed or need to be reviewed. Next, the respondents were asked how the arts were infused into the curriculum, how writing was integrated across the curriculum, and how the arts courses were taught. The next two open-ended questions concerned the greatest the strengths and greatest weaknesses of the institution regarding the arts within the liberal education program for baccalaureate nursing students. Table 10 displayed the variables, questions, and options. 89 Table 10 Constructs and Survey Questions The final section, identified as Part IV, was a Likert survey (See Table 11). This section asked the respondents to rank the overall effectiveness of the program in preparing the learner to meet the outcomes identified by the AACN with regard to the arts (fine arts, performing arts, and the humanities). Variable / Construct Question Number Survey Question Response Curricular Review 9,10 9. The arts within the Liberal Education program have been reviewed in the last five years. 10. The arts within the Liberal Education program is in need of review. Yes or No Academic Exposure (horizontal, vertical) 11,12 11. The arts within Liberal Education program requirements are taken throughout the four college years (vertically). 12. The language and composition requirements (writing) are integrated across the curriculum. Yes or No Curricular Characteristics 13,14 13. More than 50 percent of the arts within the Liberal Education courses are interdisciplinary. 14. More than 50 percent of the arts within the Liberal Education courses are taught in small groups, seminars, and discussions (less than 30 students). Yes or No Perceived Program Effectiveness 15,16 15. In your judgment, what is the greatest strength of your institution?s arts within Liberal Education program for baccalaureate nursing students? 16. In your judgment, what is the greatest weakness in your institution?s arts within Liberal Education program for baccalaureate nursing students? Open-Ended 90 Table 11 Fourth Section of the Leen Nursing Program Essentials and Effectiveness Survey Note. This information was adopted, with permission from the AACN, from The Essential of Baccalaureate Education for Professional Nursing Practice (AACN, 2008). Catalog Survey The second instrument utilized within the study was the Catalog Survey which was originally based on the Carnegie Study Survey (Leen, 1990). The Catalog Survey helped to provide a broad picture of the incorporation of art into the baccalaureate nursing curricula. According to Leen, no other researchers have utilized either the Leen Nursing Program Essentials and Effectiveness Survey or the Catalog Survey (Personal Communication, July 19, 2013). To what extent do you feel that the arts (fine arts, performing arts, and the humanities) within the baccalaureate program prepare the graduate to: (AACN Essentials, 2008) 4-Very Effective, 3-Effective, 2-Minimally Effective, 1-Ineffective 1. Integrate theories and concepts from liberal education into nursing practice. 1 2 3 4 2. Synthesize theories and concepts from liberal education to build an understanding of the human experience. 1 2 3 4 3. Use skills of inquiry, analysis, and information literacy to address practice issues. 1 2 3 4 4. Use written, verbal, non verbal, and emerging technology methods to communicate effectively. 1 2 3 4 5. Apply knowledge of social and cultural factors to the care of diverse populations. 1 2 3 4 6. Engage in ethical reasoning and actions to provide leadership in promoting advocacy, collaboration, and social justice as a socially responsible citizen. 1 2 3 4 7. Integrate the knowledge and methods of a variety of disciplines to inform decision making. 1 2 3 4 8. Demonstrate tolerance for the ambiguity and unpredictability of the world and its effect on the healthcare system. 1 2 3 4 9. Value the ideal of lifelong learning to support excellence in nursing practice. 1 2 3 4 91 The Catalog Survey was utilized in a descriptive process of reviewing the catalogs of the baccalaureate nursing curricula of the sample institutions and completing the standard format. Data were collected and categorized. The Catalog Survey explored the number of hours required in the professional nursing courses, the number of hours required in the arts (fine arts and performing arts), the number of hours required in the humanities (literature, theology, and ethics), the combined number of semester hours of the arts and the humanities, the total number of hours required for the baccalaureate degree, the number of hours in the professional nursing curriculum, the writing curriculum, prescriptive curricula, and the distribution of the arts. The humanities did not include psychology and sociology as they were categorized in the social sciences according to the AACN (AACN, 2008) At this point, the Carnegie Classification information was included as well (See Appendix C). The Carnegie data points included; the 2010 Basic Carnegie Classification, the undergraduate program classification, size, community engagement, 2000 Carnegie Classification, control, urban institutions, land grant institutions, and minority institutions such as historically black colleges and universities, tribal colleges, Hispanic colleges, and women?s colleges (See Appendix C). For the purposes of this study, the convenience sample consisted of only the nursing schools that completed and returned the Leen Nursing Program Essentials and Effectiveness Survey; therefore, the Catalog Survey was only completed on those schools for which the Leen Nursing Program Essentials and Effectiveness Survey was returned. 92 Variables The selected variables in the study were reported from information gathered from the Leen Nursing Program Essentials and Effectiveness Survey, the Catalog Survey, and the Carnegie Classification system. The following table summarized the variables and each source of the variable. Table 12 Variables, Sources, and Related Research Questions Construct Variable Source Research Questions Curricula characteristics ? Nursing Credit hours ? Total hours for BSN ? Writing Intensive program ? Prescriptive status ? Horizontal or Vertical Infusion of the arts across the curricula ? Semester hours of arts (fine arts, performing arts, and humanities) Catalog Survey 1 Leader perceptions of curriculum Section II. Questions 9-15 Leen Nursing Program Essentials and Effectiveness Survey 2 Leader perceptions of efficacy of curriculum Section IV. Questions 1-9 Leen Nursing Program Essentials and Effectiveness Survey 3 Extent of art coursework in curricula ? Semester hours of arts (fine arts, performing arts, and humanities) ? Number of semester hours required in degree ? Number of nursing semester hours required in degree Catalog Survey 4 Relationship between demographics and leader perceptions ? Basic 2010 Carnegie Classification ? Carnegie Classification Size ? Carnegie Classification Control ? Section IV. Questions 1-9 ? NCLEX? Pass Rates Carnegie Classification data; Leen Nursing Program Essentials and Effectiveness Survey 5 93 Data Collection The Auburn University Institutional Review Board for Research Involving Human Subjects granted approval for this study with expedited status (See Appendix B). After gaining Institutional Review Board approval, an electronic survey, with an informational letter that described the voluntary and confidential nature of the study, was submitted to the 187 schools within the population (See Appendix C). Institutions were given four weeks to respond, and weekly electronic reminders were disseminated. After the survey period, there were a total of 68 responses included in the sample. Two surveys were utilized for data collection. The Catalog Survey was completed only on schools that responded to the Leen Nursing Program Essentials and Effectiveness Survey; therefore, the Leen Survey was sent to the entire population first. If the Leen Survey was completed by a nursing school, then the Catalog Survey was conducted on the nursing curriculum of the institution. Leen Nursing Program Essentials and Effectiveness Survey Data Collection The process for data collection began after IRB approval. An email invitation through Qualtrics? was electronically sent to the leadership of all southeastern AACN member schools to recruit participants. The introduction letter informed potential participants of the purpose and relevance of the study. A link to the Leen Nursing Program Essentials and Effectiveness Survey which was the first measurement tool for the study was included in the email. The Leen Nursing Program Essentials and Effectiveness Survey was created and validated by Leen (1990). Participants were presented with the initial information letter, and completion of the survey was considered consent to participate. The information 94 letter contained the key terms and concepts of the AACN Essentials document that related to the purpose of the survey (AACN, 2008). If, at any time, a participant was uncomfortable with the survey, they were instructed to simply close their browser and exit the survey. Participants were informed of individual participant confidentiality and consent procedures. According to Patton (2010), survey information can offer valuable information to guide and enhance the quality of programs. Patton suggested that because of the saturation of incoming surveys into inboxes across the country, survey response was often challenged. According to Monroe and Adams (2012), the Dillman approach, in which the surveyor attempted repeated contact with a potential respondent, increased the survey response rate. The Dillman Approach, also known as the Tailored Design Method (TDM), has been regarded as the standard for surveys conducted by mail and can be applied to the electronic mail format (Thorpe et al., 2009). In this study, the Modified Dillman Approach was utilized to maximize the response rate. Potential respondents were given research information, confidentiality notices, and a link to the questionnaire via the introduction letter to encourage participation. Furthermore, respondents were given four weekly reminders with an additional email, deadline for participation, and link to the survey. A final reminder was sent to thank the potential participants. There were 68 electronic survey responses received from the 187 population schools between September 1, 2013 and October 1, 2013. The sample size was approximately 36 percent of the population size. The returned responses determined the study sample size. 95 Catalog Survey Data Collection Once the Leen Nursing Program Essentials and Effectiveness Surveys were returned, a Catalog Survey was completed on each participating school by utilizing the public access BSN program catalog outlined in the online course catalog for each school. The researcher reviewed the BSN curricula for each school and completed each Catalog Survey. The purpose of the Catalog Survey was to determine the how the arts (fine arts, performing arts, and humanities) were being infused into the course work. The online catalogs were reviewed to determine what courses were required other than non-nursing professional courses and when, during the four year curriculum, the non-nursing professional courses were required. The Catalog Survey was originally designed and validated by Leen (1990) and patterned after the Carnegie study in 1985. In August of 2013, ten catalogs were reviewed. During this process, the survey tool was modified for clarity for the purposes of efficiency and analysis. Once the Leen Nursing Program Essentials and Effectiveness Surveys began to be returned, a Catalog Survey was completed on each participating school. Identifiable information about the individual participant from the institution was removed; however, the Leen Nursing Program Essentials and Effectiveness Survey and the Catalog Survey were paired based on the identified institution. 96 Carnegie Classification An additional step in the data collection process was the categorization of the respondent institutions according to the Carnegie Classification system. The respondents were categorized according to the Basic classification, undergraduate program classification, size, community engagement, control, 2000 Carnegie Classification, land grant institutions, and urban institutions, and minority institutions which included; Historically Black Colleges and Universities, Tribal Colleges, Women?s Colleges, and Hispanic Colleges. Sample The convenience sample for this study emerged from the voluntary responses to the Leen Nursing Program Essentials and Effectiveness Survey. Once an institution responded to the survey, the institution became a part of the sample. Essentially, the sample for this study included the southeastern nursing schools that offered four year baccalaureate nursing education and members of the American Association of Colleges of Nursing that responded to the Leen Nursing Program Essentials and Effectiveness Survey. There were 68 respondents to the Leen Nursing Program Essentials and Effectiveness Survey (See Table 13). 97 Table 13 Population and Respondents by State Florida and Tennessee accounted for the highest portion of schools in the population; whereas, Tennessee and Virginia accounted for the highest portion of schools in the sample distribution. A convenience sample was used because the study was trying to detect a relationship between different phenomena. The focus of the study was to explore the present state of the incorporation of the arts and look at the factors that could influence it. One criticism surrounding convenience sampling was that the sample may not represent the population. A sampling error was the error between the sample statistic and the population parameter (Gravetter & Wallnau, 2011). However, according to Reichardt and Gollob (1999), the most common samples were samples of convenience. Southeastern & AACN States Nursing School Programs by State Study Population (Surveys Sent) Percentage of Population by State in Population Nursing School Programs by State Study Sample (Surveys Returned) Percentage of Population by State in Sample Alabama 16 8.56% 7 10.29% Arkansas 7 3.74% 3 4.41% Florida 28 14.97% 6 8.82% Georgia 21 11.23% 8 11.76% Kentucky 15 8.02% 4 5.88% Louisiana 12 6.42% 3 4.41% Mississippi 7 3.74% 1 1.47% North Carolina 20 10.70% 6 8.82% South Carolina 11 5.88% 5 7.35% Tennessee 22 11.76% 11 16.18% Virginia 21 11.23% 10 14.71% West Virginia 7 3.74% 4 5.88% Total 187 100.00% 68 100.00% 98 Additionally, Nieswiadomy (1998) added that convenience sampling was the most utilized sampling method in nursing research studies. Once the Leen Nursing Program Essentials and Effectiveness Surveys were returned, institutions were categorized according to the Carnegie Classification. The Carnegie Classification groups higher education institutions according to their missions, functions, and offerings (Boyer, 1987). Within the sample, Larger programs of Master?s Colleges and Universities was the largest category in the 2010 Basic Classification within the sample. These institutions accounted for 33.8 percent of the total sample (See Table 14). Classifying the sample institutions according to a variety of categories provided further demographic data and addressed the updates to the Carnegie Classification (See Appendix C). 99 Table 14 Stratification of Population and Sample by 2010 Carnegie Classification Data Analysis Once the data were collected through Qualtrics?, all closed-ended questionnaire responses were coded. Meanwhile, the respondent demographic data were reviewed to understand the characteristics of the respondents. Next, the Leen Nursing Program 2010 Basic Classification Category Population Surveys Sent Percentage Surveys Sent Sample Surveys Returned Percentage Surveys Returned Associate's--Public Rural-serving Medium 1 0.53% 0 0.00% Associate's--Public Rural-serving Large 1 0.53% 1 1.47% Associate's--Public Urban- serving Multi-campus 1 0.53% 0 0.00% Associate's--Private For-profit 2 1.07% 0 0.00% Associate's--Public 4-year Primarily Associate's 2 1.07% 1 1.47% Research Universities (very high research activity) 19 10.16% 7 10.29% Research Universities (high research activity) 14 7.49% 6 8.82% Doctoral/Research Universities 10 5.35% 5 7.35% Master's Colleges and Universities (larger programs) 60 32.09% 23 33.82% Master's Colleges and Universities (medium programs) 21 11.23% 7 10.29% Master's Colleges and Universities (smaller programs) 8 4.28% 2 2.94% Baccalaureate Colleges--Arts & Sciences 6 3.21% 3 4.41% Baccalaureate Colleges--Diverse Fields 25 13.37% 8 11.76% Baccalaureate/Associate's Colleges 5 2.67% 2 2.94% Special Focus Institutions-- Medical schools and medical centers 5 2.67% 1 1.47% Special Focus Institutions--Other health professions schools 7 3.74% 2 2.94% Total 187 100.00% 68 100.00% 100 Essentials and Effectiveness Survey results were paired with the Catalog Survey results for each institution. Additional demographic information surrounding the Carnegie Classification was also recorded for each institution included in the sample. Data were compiled and entered into Microsoft? Excel 2013. Descriptive summaries, including frequency distributions, were performed to explore the sample demographics, reveal curricula patterns, and examine the relationship between demographics, the arts in the curricula, and the leadership perceptions. Program curricula information was compared with the data gathered from the Leen Nursing Program Essentials and Effectiveness Survey. With the 2008 edition of The Essentials, Leen expressed that they became broader and less prescriptive; so, an exploration of the current state was necessary (Personal Communication, July 19, 2013). By comparing the perceived effectiveness ratings collected through the Leen Nursing Program Essentials and Effectiveness Survey to the curricula of the institutions, trends related to the incorporation of the arts into nursing curricula were identifiable. This heightened the understanding of how southeastern AACN members are currently meeting the AACN Essential related to the arts. Again, descriptive research was utilized to uncover an association between the variables within the sample. This did not imply a causal relationship as there was no manipulation of an independent variable. Summary Chapter 3 described the population, sample of the study and the procedures used to address the purpose and Research Questions of the study. The instruments and methods were also discussed. The design of instruments in addition to the reliability and validity tested by Leen (1990) were also discussed. The use of the Leen Nursing Program 101 Essentials and Effectiveness Survey, in addition to, the Catalog Survey addressed the Research Questions by uncovering the characteristics surrounding the infusion of the arts (fine arts, performing arts, and humanities) into the baccalaureate nursing curriculum, the perceived effectiveness by nursing leadership of the infusion of the arts into the curricula, and the extent of the arts in the nursing curricula. The population consisted of 187 southeastern AACN member schools. Southeastern schools were identified according to the Carnegie Foundation Classification while the sample was determined by those schools that responded to the emailed Leen Nursing Program Essentials and Effectiveness Survey. The sample consisted of 68 schools. The data surrounding the sample institutions were collected, categorized, and analyzed through descriptive analysis in Microsoft? Excel 2013. 102 Chapter 4 Results Introduction This study explored the curricula of AACN affiliated nursing schools in the southeastern United States to describe the amount and structure of the arts as defined as the fine arts, performing arts, and the humanities. More specifically, data from nurse educator leaders was collected to reveal the perception of the effectiveness in meeting the AACN Essential surrounding the arts. The intent of the research was to broadly explore the arts and baccalaureate nursing education to identify potential value surrounding the AACN Essentials. Additionally, data from nursing curricula were reviewed to determine the extent, frequency, and variation of the arts in nursing education. In further exploration, a review of the literature to capture the current state of art and health was conducted to increase an awareness and understanding of this intersection. Purpose of the Study The purpose of the study was to explore the nursing curricula of AACN affiliated nursing schools in the southeastern United States and to describe the amount and structure of the arts, as defined as, the fine arts, performing arts, and the humanities, within their programs. Additionally, data were collected from nurse educator leadership to uncover their perception of the effectiveness in meeting the AACN liberal arts standard outcomes related to the arts. 103 Studies have been conducted on medical school adaptation of the incorporation of the visual arts, performing arts, and the humanities; however, no study exists to determine the extent of the incorporation of the arts (fine arts, performing arts, and the humanities) into curricula of the American Association of Colleges of Nursing (AACN) affiliated programs in the southeast (Leen, 1990). Two surveys were used to address the goals of this research which included identifying the current state of AACN nursing school curricula and the perceptions of the nurse educator leaders regarding arts integration. A survey of nursing education leadership explored their perceptions with regard to the intended outcomes of the arts infusion within nursing programs. An additional survey revealed the curricula for individual programs within the sample. The intention of the research was to broadly explore the intersection of the arts and nursing education for the purpose of identifying potential value surrounding The Essentials (AACN, 2008). Moreover, a review of the literature explored art and health and captured the current state of the incorporation of art into nursing and medical education. Finally, a compilation of the survey results was utilized to create a descriptive picture of the infusion of the arts into baccalaureate nursing programs across the southeast. Research Questions The following Research Questions were used in this study: 1. What are the characteristics of arts coursework (fine arts, performing arts, and humanities) found in baccalaureate nursing curricula in the southeastern United States? 2. What are the leadership perceptions of art coursework (fine arts, performing arts, and humanities) found in their baccalaureate nursing program curricula? 104 3. What are the leadership perceptions of the effectiveness of arts coursework (fine arts, performing arts, and humanities) in meeting the Essential outcomes within their baccalaureate nursing program curricula? 4. To what extent is art coursework (fine arts, performing arts, and humanities) being incorporated into baccalaureate nursing curricula in the southeastern United States institutions? 5. What is the relationship, if any, between demographic characteristics and leadership perceptions (essentials and effectiveness)? A review of the literature in Chapter 2 brought awareness to the history and current state of nursing education, the history of art and health, the various dimensions of art and health, and more specifically, art and professional medical education which included nursing and physician education. Sonke, Rollins, Brandman, and Graham-Pole (2009) suggested that the purpose of the arts in healthcare was to promote health and well-being and ease suffering. Further literature suggested that the inclusion of the liberal arts in nursing education improved observation, illuminated cultural awareness, fostered ethical consideration, encouraged empathy, and developed communication skills (Bardes, Gillers, & Herman, 2001; De la Croix, Rose, Wildig & Willson, 2011; Dolev, Friedlaender, & Braverman, 2001; Elder, Tobias, Lucero-Criswell, & Goldenhar, 2006; Kirklin, Duncan, McBride, Hunt, & Griffin, 2007; Naghshineh, Hafler, Miller, Blanco, Lipsitz, Dubroff, & Katz, 2008; Pellico, Friedlaender, & Fennie, 2009; Phillips & Fragoulis, 2012; Shapiro, Rucker, & Beck, 2006; Wikstr?m, 2011). Medical practitioners, in an attempt to provide holistic care for humans, are challenged to 105 negotiate a delicate balance between the science of medicine and an awareness of the human condition (Pellegrino, 1984). Exploring the literature that surrounded the historical and current states of nursing education revealed how transitions in the healthcare marketplace have impacted nursing education curricula. The American Association of Colleges of Nursing (AACN) identified the arts as an Essential element in baccalaureate education; however, specific recommendations for the application of this study were not included (2008). Because there were no explicit regulations, nursing schools differed in the infusion of the arts into the curriculum. An organized assessment of the inclusion of the arts into baccalaureate nursing education reached beyond testimonial support for the presence of the arts and provided an overview of the current state towards achieving the arts Essential of nursing education (AACN, 2008). Collecting and organizing a body of empirical information surrounding the current state of art infused baccalaureate nursing education provided information for nursing schools regarding the incorporation of the arts in nursing education thus promoting the incorporation of The Essential guidelines outlined by the AACN (AACN, 2008). In addition to the recommendations by the AACN, the Association of American Colleges and Universities (AACU) also urged stakeholders to infuse the mission of the liberal arts throughout the education of healthcare providers (Hermann, 2004). While literature recognized the impact of the infusion of the arts into nursing education, measuring the achievement of learning goals associated with the arts was lacking (2004). Chapter 3 reviewed the population, sample, variables, instrumentation, data collection procedures, and the process for analyzing the descriptive measures that were 106 used to explore the arts (fine arts, performing arts, and humanities) in nursing education. Chapter 4 explores the results of the descriptive measures. After 186 surveys were electronically mailed, this study explored a convenience sample of 68 schools. Utilizing two descriptive comparable surveys, the data was analyzed in an effort to explore the Research Questions. Of the 68 schools, Tennessee had the highest number of respondent schools with eleven. Mississippi had the lowest number of respondent schools with one. Nevertheless, every state identified by the Carnegie Classification as southeastern had at least one respondent school (See Table 15). Table 15 Respondent Schools by State Two surveys were utilized for data collection. The Catalog Survey was completed only on schools that responded to the Leen Nursing Program Essentials and Effectiveness Survey; therefore, the Leen Survey was sent to the entire population first. If the Leen Survey was completed by a nursing school, then the Catalog Survey was conducted on the nursing curriculum of the institution. State Count Alabama 7 Arkansas 3 Florida 6 Georgia 8 Kentucky 4 Louisiana 3 Mississippi 1 North Carolina 6 South Carolina 5 Tennessee 11 Virginia 10 West Virginia 4 Total Number of Responses 68 107 The Catalog Survey was used to answer Research Questions one and four surrounding the curricula characteristics and the extent of the arts coursework. The Leen Nursing Program Essentials and Effectiveness Survey was primarily used to answer Research Questions two, three, and five which surrounded the nurse educator leader perceptions. The Carnegie Classification data was also used in Research Question Five. Characteristics of Arts Coursework The first Research Question of the study was: What are the characteristics of arts coursework (fine arts, performing arts, and humanities) found in baccalaureate nursing curricula in the southeastern United States? To determine the characteristics of the arts (fine arts, performing arts, and the humanities) coursework, the Catalog Survey explored the number of semester credit hours of all of the 68 schools with regard to the following: Overall baccalaureate semester credit hour requirements, nursing credit hours, elective credit hours, fine arts and performing arts credit hours, and the humanities credit hours. Next, the catalogs of all 68 schools were explored to determine their prescriptive status. The final characteristic explored considered if the arts were incorporated in all of the 68 schools vertically or horizontally. In order to determine the leadership perception, this question was also asked in the Leen Nursing Program Essentials and Effectiveness Survey. Additionally, the Catalog Survey explored the question utilizing the curricula maps. Semester Credit Hours The average total number of credit hours for a baccalaureate degree in nursing across the southeastern United States was 123. The average number of professional nursing credit hours for the southeastern United States was 63.95 which is approximately 108 51.99 percent of the total number of semester credit hours required for an AACN recognized baccalaureate nursing degree. The average number of elective semester credit hours was 3.8. The average number of fine arts and performing arts semester credit hours required in the baccalaureate degree was 2.45 while there was an average of 12.2 semester credit hours required in the humanities. For the purposes of this study, the humanities included; courses in literature, English composition, theology, philosophy, ethics, and foreign languages. While the social sciences included sociology and psychology. The average total number of fine arts, performing arts, and humanities semester credit hours across the southeastern AACN schools was 14.99 which was 12.19 percent of the average total number of semester hours (See Table 16). Table 16 Description of Semester Credit Hour Findings The average number of fine arts and performing arts semester credit hours across the southeastern AACN schools was 2.45. The average number of humanities semester credit hours, which included English, literature, composition, theology, philosophy, ethics, and foreign languages, was 12.2. The average total number of fine Average total number of credit hours 123 Average number of professional nursing credit hours 63.95 Percent of professional nursing credit hours to total number of semester credit hours 51.99 % Average number of elective semester credit hours 3.8 Average number of fine arts and performing arts semester credit hours 2.45 Average number of humanities semester credit hours 12.2 Average of the total number of fine arts, performing arts, and humanities 14.99 Percent of fine arts, performing arts, and humanities to total number of semester credit hours 12.19 % 109 arts, performing arts, and humanities semester credit hours across the southeastern AACN schools was 14.99 which accounted for approximately 12.19 percent of the average total semester hour requirements for the AACN southeastern schools. Respondents in Arkansas had the highest average required number of semester credit hours for a baccalaureate nursing degree (BSN). Respondent schools in Florida had the lowest average required number of semester credit hours for a BSN. Respondents in Mississippi and Kentucky had the highest required number of semester credit hours in professional nursing courses. West Virginia and Louisiana respondent schools had the lowest required number of semester credit hours in professional nursing courses. Respondent schools in West Virginia also had the lowest number of professional nursing courses to total baccalaureate hours. 110 Table 17 Average Semester Credit Hours by State The National Council Licensure Examination (NCLEX?) is the examination for nursing licensure. The pass rates of this exam are publically reported by institution, by the state board of nursing, or the institutional website. This purpose of this study is to illustrate a descriptive picture of the incorporation of the arts. Nevertheless, the NCLEX? pass rates were reported for each of the respondent schools within this study and averaged by state. Florida had the highest average NCLEX? pass rate. Alabama had the lowest NCLEX? pass rate (See Table 18). State Average of Total Hours Required for BSN (Total Hours Required) Average of Nursing Credit Hours (Hours of Credit in Nursing Courses) Percent of Nursing Semester Hours to BSN Hour Requirement Average Total Number of Fine Arts, Performing Arts, and Humanities in Semester Hours Percent of Total Number of Fine Arts, Performing Arts, and Humanities to BSN Hour Requirement Alabama 123.57 61.71 49.94% 16.57 13.41% Arkansas 125.67 64.67 51.46% 16.67 13.26% Florida 119.17 63.83 53.57% 9.00 7.55% Georgia 122.50 61.63 50.31% 19.13 15.61% Kentucky 121.25 67.75 55.88% 10.00 8.25% Louisiana 120.33 60.33 50.14% 16.00 13.30% Mississippi 124.00 69.00 55.65% 9.00 7.26% North Carolina 123.67 66.00 53.37% 14.17 11.46% South Carolina 124.40 64.80 52.09% 16.80 13.50% Tennessee 124.00 67.45 54.40% 16.73 13.49% Virginia 123.40 62.05 50.28% 14.85 12.03% West Virginia 123.75 60.75 49.09% 12.00 9.70% Total 123.00 63.95 51.99% 14.99 12.19% 111 Table 18 Average Semester Credit Hours for BSN and NCLEX? Pass Rates Prescriptive Status Respondent schools included in the catalog survey were categorized according to their prescriptive status. Schools that were primarily prescriptive and had one or less choices in the baccalaureate nursing curricula were considered highly prescriptive. Schools that offered two to three class choices were considered moderately prescriptive. Schools that offered greater than three class choices were considered non-prescriptive. If a school did not require an elective, they could still be considered moderately prescriptive because they offered choices among courses. Row Labels Average of Total hours required for BSN (total hours required) Average of Nursing Credit hours (hours of credit in nursing courses) Average of NCLEX? Pass rates 2011-2012 AL 123.57 61.71 81.93 AR 125.67 64.67 92.80 FL 119.17 63.83 95.48 GA 122.50 61.63 93.10 KY 121.25 67.75 94.75 LA 120.33 60.33 93.76 MS 124.00 69.00 82.60 NC 123.67 66.00 85.83 SC 124.40 64.80 93.30 TN 124.00 67.45 91.91 VA 123.40 62.05 91.85 WV 123.75 60.75 84.83 Total 123.00 63.95 90.55 112 Table 19 Prescriptive Status by State The majority of respondent schools were non-prescriptive. Because different numbers of schools responded in each state, a percentage was calculated based on the responses by state (See next table). Kentucky, Louisiana, and Mississippi had the highest percentages of prescriptive respondents. Arkansas, Florida, Georgia, North Carolina, Tennessee, Virginia, and West Virginia had at least 50 percent non-prescriptive respondent institutions (See Table 20). Row Labels Prescriptive Moderately Prescriptive Non-Prescriptive Total Alabama 2 4 1 7 Arkansas 0 1 2 3 Florida 2 0 4 6 Georgia 1 1 6 8 Kentucky 2 1 1 4 Louisiana 2 0 1 3 Mississippi 1 0 0 1 North Carolina 0 3 3 6 South Carolina 2 3 0 5 Tennessee 1 4 6 11 Virginia 4 1 5 10 West Virginia 0 2 2 4 Total 17 20 31 68.00 113 Table 20 Prescriptive Status by State in Percentage of Respondent Schools. Arts Integration The southeastern AACN nursing curricula were reviewed in the Catalog Survey to determine the extent of the infusion of the arts across the four year baccalaureate nursing degree. Because the bulk of the professional nursing content fell into the last two years of the degree for most respondents, a review of the school catalogs revealed the number of schools that incorporated courses dedicated to the fine arts, performing arts, and the humanities across the entire four years (horizontal) or only in the first two years of the curriculum (vertical). Across the 68 schools, a review of the school catalogs revealed that 72.06 percent of schools included the arts just in the first two years (vertically) while 27.94 percent of the surveyed schools included the arts across all four years (horizontally). State Prescriptive Moderately Prescriptive Non-Prescriptive Alabama 28.57% 57.14% 14.29% Arkansas 0.00% 33.33% 66.67% Florida 33.33% 0.00% 66.67% Georgia 12.50% 12.50% 75.00% Kentucky 50.00% 25.00% 25.00% Louisiana 66.67% 0.00% 33.33% Mississippi 100.00% 0.00% 0.00% North Carolina 0.00% 50.00% 50.00% South Carolina 40.00% 60.00% 0.00% Tennessee 9.09% 36.36% 54.55% Virginia 40.00% 10.00% 50.00% West Virginia 0.00% 50.00% 50.00% Total 25.00% 29.41% 45.59% 114 Table 21 Horizontal and Vertical Arts Integration Leadership Perceptions of Art Coursework The second Research Question was: What are the leadership perceptions of art coursework (fine arts, performing arts, and humanities) found in their baccalaureate nursing program curricula? This question was answered utilizing the results of the Leen Nursing Program Essentials and Effectiveness Survey. Questions nine through fourteen asked the respondents (yes or no) questions regarding the review of the arts within the liberal education program, the need for review of the arts, the integration of the arts, the writing requirements, and the setting in which the arts were taught. Demographics of Respondents There were 65 responses to the questions by the nursing leaders regarding their title and time, in years, in their current role. The average length of time in their current State Horizontal Integration Percent of Programs by State Vertical Integration Percent of Programs by State Total Alabama 0 0.00% 7 100.00% 7 Arkansas 1 33.33% 2 66.67% 3 Florida 1 16.67% 5 83.33% 6 Georgia 2 25.00% 6 75.00% 8 Kentucky 2 50.00% 2 50.00% 4 Louisiana 3 100.00% 0 0.00% 3 Mississippi 0 0.00% 1 100.00% 1 North Carolina 1 16.67% 5 83.33% 6 South Carolina 1 20.00% 4 80.00% 5 Tennessee 4 36.36% 7 63.64% 11 Virginia 2 20.00% 8 80.00% 10 West Virginia 2 50.00% 2 50.00% 4 Total 19 27.94% 49 72.06% 68 115 position was 4.30 years. Of 66 respondents to the questions regarding gender and race, 65 were female and one was male. The largest group of respondents were deans, 17, and department chairs, 12. There were three black respondents and 63 white respondents. Notably, the AACN made a commitment to ?increase diversity among nursing students, faculty, and the workforce? (See Table 22; AACN, 2013). Table 22 Title of Position of Respondents and Average Time in Position After the demographics of the respondents were reviewed, the leadership perceptions of art coursework were explored by asking questions with regard to the frequency of curricular review, horizontal integration of the arts across all four years of the curriculum, and the environmental setting in which the arts were taught. The letter that accompanied the survey respectfully requested that only nurse educator leaders with knowledge of the curriculum respond to the survey. Title Average of: What is your length of time in your present position? Count of: What is your title and position in the school of nursing? Assistant Dean 1.00 2 Assistant Director 0.16 1 Assistant Professor 4.50 4 Associate Dean 7.42 6 Associate Professor 3.00 1 Department Chair 2.87 12 Dean 4.57 17 Department Head 12.25 2 Director 3.00 1 Interim Dean 1.81 4 Interim Director 0.08 1 Professor 6.25 4 Program Director 3.54 10 Average 3.88 116 Curricular review First, the leadership perceptions of the arts (fine arts, performing arts, and the humanities) were explored by asking about the frequency of curricular review. The majority of schools have reviewed the liberal education program requirements within the last five years; 16.92 percent of the southeastern AACN schools expressed that their program with regard to the liberal arts was in need of review. The Essentials document did not outline a timeframe for the review of a curriculum or a review plan (AACN, 2008). The Essentials were intended to provide a framework for the curriculum. Table 23 Count of the Arts Review Integration of the arts Next, in order to explore the leadership perceptions, respondents were asked about the integration of the arts across all four years of the BSN curriculum. The leadership perceptions indicated that 40 percent of the surveyed schools thought that the State Count of The arts within the liberal education program requirements have been reviewed in the last five years Count of The arts within the liberal education program requirements are in need of review. Yes No Total Yes No Total Alabama 5 1 6 1 5 6 Arkansas 3 0 3 0 3 3 Florida 6 0 6 0 6 6 Georgia 8 0 8 0 8 8 Kentucky 4 0 4 0 4 4 Louisiana 3 0 3 0 3 3 Mississippi 1 0 1 1 0 1 North Carolina 6 0 6 0 6 6 South Carolina 4 1 5 1 4 5 Tennessee 9 2 11 7 4 11 Virginia 8 0 8 0 8 8 West Virginia 3 1 4 1 3 4 Total 60 (92.31%) 5 65 11 (16.92%) 54 65 117 arts were infused across the curriculum during all four years, and 60 percent did not think that the arts were infused across the curriculum. Nevertheless, 84.13 percent of the nurse educator leaders acknowledged that language, composition, and writing were integrated across the curriculum (See Table 24). Table 24 Leadership Perception of Arts Integration This question regarding the arts across the curriculum was also explored in the Catalog Survey. There was a discrepancy between the respondent answers and the results of the Catalog survey. After reviewing the curricula found in the catalog of each school in the study, the Catalog Survey results revealed the 72.06 percent of schools had a vertical integration of the arts and were not incorporating arts across all four years of the Count of The arts within the liberal education program requirements are taken throughout the four college years Count of The language and composition requirements (writing) are integrated across the curriculum. State Yes No Respondents Yes No Respondents Alabama 1 5 6 5 0 5 Arkansas 2 1 3 3 0 3 Florida 1 5 6 4 2 6 Georgia 4 4 8 7 1 8 Kentucky 3 1 4 3 1 4 Louisiana 3 0 3 3 0 3 Mississippi 0 1 1 1 0 1 North Carolina 2 4 6 4 2 6 South Carolina 1 4 5 4 1 5 Tennessee 4 7 11 9 1 10 Virginia 2 6 8 6 2 8 West Virginia 3 1 4 4 0 4 Total 26 39 65 53 10 63 Total Percentages 40.00% 60.00% 84.13% 15.87% 118 curriculum. Meanwhile, 27.94 percent did incorporate the arts horizontally across all four years of the curriculum according to their own curricular map (See Table 25). Table 25 Findings of Leadership Perception of Arts Integration The nurse educator leadership respondents in Florida, Louisiana, Mississippi, South Carolina, and Tennessee had the same percentage of vertical arts integration as the Catalog Survey showed. Overall, the nurse leader perception of the horizontal integration of the arts was 40 percent while the Catalog Survey revealed that actual integration of the arts was 27.94 percent. Leen Survey of Nursing Leaders Perceived Horizontal Integration of the Arts Catalog Survey of Curricula Horizontal Integration of the Arts According to the School Catalog State Yes Respondents Percentage Yes Respondents Percentage Alabama 1 6 16.67% 0 7 0.00% Arkansas 2 3 66.67% 1 3 33.33% Florida 1 6 16.67% 1 6 16.67% Georgia 4 8 50.00% 2 8 25.00% Kentucky 3 4 75.00% 2 4 50.00% Louisiana 3 3 100.00% 3 3 100.00% Mississippi 0 1 0.00% 0 1 0.00% North Carolina 2 6 33.33% 1 6 16.67% South Carolina 1 5 20.00% 1 5 20.00% Tennessee 4 11 36.36% 4 11 36.36% Virginia 2 8 25.00% 2 10 20.00% West Virginia 3 4 75.00% 2 4 50.00% Total 26 65 40.00% 19 68 27.94% 119 Arts Integration Setting Next, the nurse educator leaders were asked about the setting in which the arts courses were taught. The leaders were asked if more than 50 percent of the arts within the liberal education requirement courses were taught in small groups, seminars, and discussions with less than 30 students. Of the 64 respondents across the AACN southeastern nursing schools, 56.25 percent stated that the arts classes in their institution were taught in small groups with less than 30 students; however, 43.75 percent of respondents revealed that the arts courses were not taught in small groups. Table 26 Nurse Educator Leader Perceptions of Arts Integration Setting Response to More than 50 percent of the arts within the liberal education requirement courses are taught in small groups, seminars, and discussion. (less than 30 students) State Yes: Count Yes: Percent by State No: Count No: Percent by State Total Alabama 3 60.00% 2 40.00% 5 Arkansas 1 33.33% 2 66.67% 3 Florida 3 50.00% 3 50.00% 6 Georgia 4 50.00% 4 50.00% 8 Kentucky 3 75.00% 1 25.00% 4 Louisiana 0 0.00% 3 100.00% 3 Mississippi 1 100.00% 0 0.00% 1 North Carolina 4 66.67% 2 33.33% 6 South Carolina 3 60.00% 2 40.00% 5 Tennessee 8 72.73% 3 27.27% 11 Virginia 4 50.00% 4 50.00% 8 West Virginia 2 50.00% 2 50.00% 4 Total 36 56.25% 28 43.75% 64 120 Leadership Perceptions of Effectiveness of the Arts Integration The third Research Question was: What are the leadership perceptions of the effectiveness of arts coursework (fine arts, performing arts, and humanities) in meeting the Essential outcomes within their baccalaureate nursing program curricula? After permission was granted from the AACN, the Essential I outcomes as defined by the AACN were put into a Likert scale with one being the least effective and four being very effective (See Table 27). The nursing leaders were asked to rank the overall effectiveness of their program in meeting the recommendations outlined by The Essentials. Table 27 Likert questions from the Leen Survey Note. The outcomes as outlined by The Essentials are being utilized with permission from the AACN (See Appendix A). To what extent do you feel that the arts (fine arts, performing arts, and the humanities) within the baccalaureate program prepare the graduate to: (AACN, 2008) http://www.aacn.nche.edu/education-resources/baccessentials08.pdf 1. Integrate theories and concepts from liberal education into nursing practice. 1 2 3 4 2. Synthesize theories and concepts from liberal education to build an understanding of the human experience. 1 2 3 4 3. Use skills of inquiry, analysis, and information literacy to address practice issues. 1 2 3 4 4. Use written, verbal, non verbal, and emerging technology methods to communicate effectively. 1 2 3 4 5. Apply knowledge of social and cultural factors to the care of diverse populations. 1 2 3 4 6. Engage in ethical reasoning and actions to provide leadership in promoting advocacy, collaboration, and social justice as a socially responsible citizen. 1 2 3 4 7. Integrate the knowledge and methods of a variety of disciplines to inform decision making. 1 2 3 4 8. Demonstrate tolerance for the ambiguity and unpredictability of the world and its effect on the healthcare system. 1 2 3 4 9. Value the ideal of lifelong learning to support excellence in nursing practice. 1 2 3 4 121 There were 62 responses to these nine questions. An average score was determined for each state to determine the overall effectiveness ranking according to the Essentials outcomes. The highest ranked Likert statement across the southeastern states was the response to number nine which discussed the value of lifelong learning in nursing practice. The lowest ranked Likert statement was number eight which discussed the uncertainty and unpredictability in healthcare. The highest ranking AACN southeastern state in overall effectiveness according to the nurse leader perceptions was Florida. The lowest ranking AACN southeastern state in overall effectiveness according to the nurse leader perceptions was Mississippi. However, there was only one respondent for Mississippi (See Table 28). 122 Table 28 Responses from the Likert Questions in the Leen Survey by State. State Average of 1. Integrate theories and concepts from liberal education into nursing practice Average of 2. Synthesize theories and concepts from liberal education to build an understanding of the human experience. Average of 3. Use skills of inquiry, analysis, and information literacy to address practice issues Average of 4. Use written, verbal, non- verbal, and emerging technology methods to communicate effectively. Average of 5. Apply knowledge of social and cultural factors to the care of diverse populations. Average of 6. Engage in ethical reasoning and actions to provide leadership in promoting advocacy, collaboration, and social justice as a socially responsible citizen. Average of 7. Integrate the knowledge and methods of a variety of disciplines to inform decision making. Average of 8. Demonstrate tolerance for the ambiguity and unpredictability of the world and its effect on the healthcare system. Average of 9. Value the ideal of lifelong learning to support excellence in nursing practice. Average Alabama 3.20 3.60 3.60 3.60 3.40 3.60 3.00 3.00 3.60 3.40 Arkansas 3.00 2.67 3.33 4.00 3.67 3.00 3.33 3.00 3.67 3.30 Florida 3.33 3.33 3.67 3.50 3.67 3.83 3.33 3.33 3.83 3.54 Georgia 3.38 3.25 3.38 3.38 3.63 3.38 3.00 3.13 3.25 3.31 Kentucky 3.50 3.25 3.25 3.50 3.75 3.75 3.00 3.25 3.50 3.42 Louisiana 3.67 3.67 3.67 3.67 3.33 3.33 3.00 2.67 3.33 3.37 Mississippi 2.00 3.00 3.00 4.00 3.00 2.00 3.00 2.00 2.00 2.67 North Carolina 3.67 3.67 3.67 3.17 3.50 3.50 3.50 3.00 3.50 3.46 South Carolina 3.40 3.40 2.80 3.40 3.60 3.00 3.00 2.80 3.60 3.22 Tennessee 3.36 3.55 3.18 3.27 3.36 3.18 3.09 2.73 3.73 3.27 Virginia 3.29 3.29 3.14 3.29 3.43 3.43 3.14 2.86 3.29 3.24 West Virginia 2.67 3.33 3.33 3.00 2.67 3.33 2.67 2.67 3.33 3.00 Total 3.32 3.39 3.34 3.40 3.47 3.37 3.11 2.94 3.50 3.32 123 In addition to the Likert survey portion of the questionnaire, respondents were also asked open-ended questions regarding the arts integration of their program. Respondents were asked what they felt was the greatest strength and greatest weakness within the arts integration of their program. The most mentioned greatest strength of the arts within the liberal education program for the baccalaureate nursing student was the quality of the pre-nursing curriculum. Next, the nurse educator leaders felt that the faculty were highly qualified. Student engagement was also considered a strength of the program, but it was only mentioned by one school. The greatest weakness of the arts within the liberal education program mentioned in the free text portion of the survey was either cited as ?unknown? or ?the number of credit hours.? Twelve respondent schools stated that there was not enough time in the curriculum for the arts. High numbers of students per class or section and the flexibility of the arts courses were also mentioned as weaknesses. The following table summarizes all of the response. Table 29 Summary of Responses to Open-ended Survey Question Regarding Greatest Strength In your judgment, what is the greatest strength of your institutions' arts within the liberal education program for BSN students? Excellent pre-nursing courses 15 Qualified faculty 12 Diversity in course offerings 8 Small class sizes 7 Quality of fine arts and humanities 6 Unable to answer or not applicable 5 Inter-professional 4 Current with education and global trends. 4 Jesuit pedagogy 1 Growth and Development 1 Student Engagement 1 124 Table 30 Summary of Responses to Open-ended Survey Question Regarding Greatest Weakness Extent of Art Coursework The fourth Research Question was: To what extent is art coursework (fine arts, performing arts, and humanities) being incorporated into baccalaureate nursing curricula in the southeastern United States institutions? All of the curricula from the institutions that responded to the Leen Nursing Programs Essentials and Effectiveness Survey were explored. Of the 68 southeastern schools, the average number semester credit hours of fine arts and performing arts was 2.45. The humanities were defined by the AACN to include English, literature, composition, theology, philosophy, and foreign languages (AACN, 2008). The average number of semester credit hours of the humanities across the southeastern AACN respondent schools was 12.2. The average total number of arts and humanities in semester credit hours was 14.99. By state, Kentucky had the highest In your judgment, what is the greatest weakness in your institution's arts within the liberal education program for BSN students? None or unknown 12 Number of credit hours; not enough time in curriculum 12 High number of students per class 4 Access or flexibility of courses 4 Need more sections of students; capacity 4 Lack of writing across the curriculum 3 Student population 3 Not enough interdisciplinary 3 Science 2 Beyond the control of the nursing program 2 Faculty: lack of collaboration, adjunct 2 Unsure that the arts are essential; assessment of outcomes 2 These courses are not integrated throughout the 4 years. 1 scheduling 1 Fine Arts 1 Humanities 1 Global emphasis 1 125 average of semester credit hours in the fine arts. Tennessee and Alabama had the highest humanities average in semester credit hours. Overall, Georgia has the highest average of the combined fine arts, performing arts, and humanities semester credit hours. The averages were taken directly from the school counts; so, the average number of fine arts, performing arts, and humanities were derived from raw scores. Georgia also had the highest percentage of fine arts, performing arts, and humanities to the required baccalaureate semester credit hours. Mississippi and Florida has the lowest percentages of fine arts, performing arts, and humanities with the required baccalaureate semester credit hours (See Table 31). 126 Table 31 Description of the Extent of Arts Course Semester Credit Hours State Average of Total hours required for BSN (total hours required) Average of Nursing Credit hours (hours of credit in nursing professional) Percent of Nursing Semester Hours to BSN Hour Requirement Average of Fine arts and performing arts in semester hours Average of number of humanities (English, literature, composition, theology, philosophy, foreign language) Average of Total number of Fine Arts, Performing Arts, and Humanities in Semester hours Percent of Total Number of Fine Arts, Performing Arts, and Humanities to Total BSN Hour Requirement Alabama 123.57 61.71 49.94% 2.14 14.43 16.57 13.41% Arkansas 125.67 64.67 51.46% 3.00 13.67 16.67 13.26% Florida 119.17 63.83 53.57% 1.50 7.00 9.00 7.55% Georgia 122.50 61.63 50.31% 3.38 11.14 19.13 15.61% Kentucky 121.25 67.75 55.88% 4.00 9.25 10.00 8.25% Louisiana 120.33 60.33 50.14% 3.00 13.00 16.00 13.30% Mississippi 124.00 69.00 55.65% 0.00 9.00 9.00 7.26% North Carolina 123.67 66.00 53.37% 1.00 13.17 14.17 11.46% South Carolina 124.40 64.80 52.09% 3.00 13.80 16.80 13.50% Tennessee 124.00 67.45 54.40% 2.50 14.45 16.73 13.49% Virginia 123.40 62.05 50.28% 2.74 12.11 14.85 12.03% West Virginia 123.75 60.75 49.09% 1.50 10.50 12.00 9.70% Total 123.00 63.95 51.99% 2.45 12.20 14.99 12.19% 127 Relationship between Demographics and Perceptions The fifth Research Question was: What is the relationship, if any, between demographic characteristics and leadership perceptions? In order to further explore the demographic characteristics of the convenience sample the Basic 2010 Carnegie Classification was determined for each school within the sample, as well as, the Carnegie Classification Size, and the Carnegie Classification Control. Carnegie Basic 2010 Classification and Semester Hours Schools were classified according to the Carnegie Basic 2010 Classification, the average number of fine arts, performing arts, and the humanities were explored according to the classification. The Baccalaureate Colleges- Arts and Sciences had the highest average of fine arts, performing arts, and humanities. The Baccalaureate Colleges- Diverse Fields had the second highest average number of humanities requirement for the baccalaureate degree nurse (See Table 32). 128 Table 32 Carnegie Basic Classification and Number of Arts Courses. Carnegie Classification Size and Semester Hours Next, schools were classified according to the Carnegie Classification Size. The highest number of respondents were Large four-year primarily non-residential Carnegie Basic 2010 Classification Number of Respondent Schools Average of Fine arts and performing arts in semester hours Average of number of humanities Average of Total number of Arts and Humanities in semester hours Associate's--Public Rural- serving Large 1 0.00 6.00 6.00 Associate's--Public 4-year Primarily Associate's 1 0.00 6.00 6.00 Research Universities (very high research activity) 7 2.14 11.14 13.29 Research Universities (high research activity) 6 2.50 11.00 13.50 Doctoral/Research Universities 5 1.80 13.40 15.80 Master's Colleges and Universities (larger programs) 23 2.80 11.66 13.89 Master's Colleges and Universities (medium programs) 7 2.29 12.71 15.00 Master's Colleges and Universities (smaller programs) 2 3.00 12.00 15.00 Baccalaureate Colleges--Arts & Sciences 3 5.00 16.50 32.00 Baccalaureate Colleges-- Diverse Fields 8 2.63 15.38 18.00 Baccalaureate/Associate's Colleges 2 0.00 13.50 13.50 Special Focus Institutions-- Medical schools and medical centers 1 3.00 12.00 15.00 Special Focus Institutions-- Other health professions schools 2 0.00 9.00 9.00 Totals 68 2.45 12.20 14.99 129 universities. The highest average of total number of arts and humanities semester hours in the respondents was the very Small four-year, primarily residential institutions. These institutions averaged 36 semester hours which was double the southeastern average in the fine arts, performing arts, and humanities within the baccalaureate nursing degree. This Carnegie Classification size also had the highest average of required humanities semester credit hours. The highest average of fine arts and performing arts semester credit hours was the Very small four-year, primarily nonresidential institutions. The lowest average of all categories fine arts, performing arts, and humanities semester credit hours occurred in the Large two-year institutions and Special focus institutions. 130 Table 33 Carnegie Classification Size and Number of Arts Courses. Carnegie Classification Control and Semester Hours Once the respondent schools were categorized according to the Carnegie Classification Control, there were 43 public institutions, 22 private not-for-profit Carnegie Classification Size Respondents Average of Fine arts and performing arts in semester hours Average of number of humanities Average of Total number of Arts and Humanities in semester hours Very small four- year, primarily residential 2 6.00 12.00 36.00 Small four-year, highly residential 8 2.25 15.75 18.00 Small four-year, primarily residential 7 3.14 14.57 17.71 Very small four- year, primarily nonresidential 2 3.38 15.56 17.25 Medium four-year, highly residential 4 1.50 15.25 16.75 Small four-year, primarily nonresidential 1 3.00 12.00 15.00 Medium four-year, primarily nonresidential 8 3.00 11.25 14.63 Medium four-year, primarily residential 8 3.50 12.13 14.38 Large four-year, primarily residential 11 2.45 9.82 12.27 Large four-year, primarily nonresidential 13 1.38 10.92 12.08 Special focus institution 3 1.00 10.00 11.00 Large two-year 1 0.00 6.00 6.00 Total 68 2.45 12.20 14.99 131 institutions, and three private for-profit institutions. The highest average of fine arts, performing arts, and humanities semester course hour requirements were the private not- for-profit institutions (See Table 34). Table 34 Carnegie Control Classification and Number of Arts Courses Carnegie Basic 2010 Classification and Likert Questions After the respondent schools were categorized according to the Basic 2010 Carnegie Classification, the average of the Likert Effectiveness questions were explored with regard to the respondent classification. The Associate?s-public Rural-Serving Large institutions ranked the highest in perceived effectiveness. However, this category consisted of one school. The Baccalaureate/ Associate?s Colleges and the Baccalaureate Colleges of Arts and Sciences had the second and third highest average Likert scores respectively. The Master?s Colleges and Universities (Medium programs) and the Special Focus Institutions- Medical schools and medical centers scored the lowest on the Likert scores regarding perceived effectiveness of the arts program in nursing education respectfully (See Table 35). Control Count of control Average of Fine arts and performing arts in semester hours Average of number of humanities in semester hours Average of Total number of Arts and Humanities in semester hours Private for-profit 3 1.13 9.38 10.50 Private not-for-profit 22 2.62 14.62 18.64 Public 43 2.47 11.21 13.44 Total 68 2.45 12.20 14.99 132 Table 35 Carnegie Classification and Likert Scores Again, there were 62 responses to the nine Likert questions. An average score was determined for each Carnegie Basic 2010 Classification represented within the study to determine the overall effectiveness ranking according to the Essentials I outcomes as outlined in The Essentials (AACN, 2008). Next, each Likert question was explored (See Table 35). Basic 2010 Carnegie Classification Count Average of Likert Effectiveness Questions Associate's--Public Rural-serving Large 1 3.89 Baccalaureate/Associate's Colleges 2 3.67 Baccalaureate Colleges--Arts & Sciences 3 3.50 Special Focus Institutions--Other health professions schools 2 3.44 Doctoral/Research Universities 5 3.42 Research Universities (high research activity) 6 3.42 Master's Colleges and Universities (smaller programs) 2 3.39 Master's Colleges and Universities (larger programs) 23 3.36 Associate's--Public 4-year Primarily Associate's 1 3.33 Baccalaureate Colleges--Diverse Fields 8 3.32 Research Universities (very high research activity) 7 3.20 Master's Colleges and Universities (medium programs) 7 2.91 Special Focus Institutions--Medical schools and medical centers 1 2.33 Total of Schools 68 3.32 133 Table 36 Carnegie Basic 2010 Classification and Each Likert Question Score (continued) Carnegie Basic 2010 Classification Average of 1. Integrate theories and concepts from liberal education ? Average of 2. Synthesize theories and concepts from liberal education to build? Average of 3. Use skills of inquiry, analysis, and information literacy? Average of 4. Use written, verbal, non-verbal, and emerging technology ? Average of 5. Apply knowledge of social and cultural factors? Average of 6. Engage in ethical reasoning and actions? Average of 7. Integrate the knowledge and methods of a variety of disciplines ? Average of 8. Demonstrat e tolerance for the ambiguity and unpredictab ility of the world? Average of 9. Value the ideal of lifelong learning? Average of Average Associate's--Public Rural-serving Large 4.00 4.00 4.00 4.00 4.00 4.00 3.00 4.00 4.00 3.89 Associate's--Public 4-year Primarily Associate's 3.00 3.00 4.00 3.00 3.00 4.00 3.00 3.00 4.00 3.33 Research Universities (very high research activity) 3.20 3.20 3.20 3.20 3.40 3.20 3.20 3.00 3.20 3.20 Research Universities (high research activity) 3.50 3.50 3.50 3.75 3.50 3.50 3.00 3.00 3.50 3.42 Doctoral/Research Universities 3.60 3.60 3.20 3.20 3.60 3.60 3.20 3.00 3.80 3.42 Master's Colleges and Universities (larger programs) 3.43 3.39 3.35 3.39 3.52 3.39 3.04 3.09 3.61 3.36 Master's Colleges and Universities (medium programs) 2.67 3.00 3.17 3.33 3.17 2.83 3.00 2.17 2.83 2.91 134 Carnegie Basic 2010 Classification Average of 1. Integrate theories and concepts from liberal education ? Average of 2. Synthesiz e theories and concepts from liberal education to build? Average of 3. Use skills of inquiry, analysis, and informatio n literacy? Average of 4. Use written, verbal, non-verbal, and emerging technology ? Average of 5. Apply knowledge of social and cultural factors? Average of 6. Engage in ethical reasoning and actions? Average of 7. Integrate the knowledge and methods of a variety of disciplines ? Average of 8. Demonstr ate tolerance for the ambiguity and unpredicta bility of the world? Average of 9. Value the ideal of lifelong learning? Average of Average Master's Colleges and Universities (smaller programs) 3.00 3.50 4.00 3.50 3.00 3.50 3.50 3.00 3.50 3.39 Baccalaureate Colleges--Arts & Sciences 3.50 3.50 3.50 4.00 4.00 4.00 3.00 3.00 3.00 3.50 Baccalaureate Colleges--Diverse Fields 3.38 3.63 3.25 3.25 3.50 3.25 3.13 2.88 3.63 3.32 Baccalaureate/Associ ate's Colleges 3.00 3.00 3.50 4.00 4.00 4.00 4.00 3.50 4.00 3.67 Special Focus Institutions--Medical schools and medical centers 2.00 3.00 2.00 3.00 2.00 3.00 2.00 2.00 2.00 2.33 Spec/Health: Special Focus Institutions-- Other health professions schools 4.00 3.50 3.50 3.50 3.50 3.00 3.50 2.50 4.00 3.44 Total 3.32 3.39 3.34 3.40 3.47 3.37 3.11 2.94 3.50 3.32 135 The nurse educator leader perceptions regarding the liberal education requirements being taught in small groups was explored through the Carnegie Basic 2010 Classification. The percent of respondent schools that taught the arts in small classes averaged 56.25 percent. The Baccalaureate/Associate?s College, Master?s Colleges and University - medium size, and the Doctoral/Research University had the highest percentages of respondents that cited small classes for the arts courses. The Primarily Associate schools had the lowest percentages of respondents that acknowledged the arts were being taught in small classes. This study also explored the Basic 2010 Classification with relation to an interdisciplinary approach to the integration of the arts. The respondents from the Primarily Associate schools, Baccalaureate Colleges- Arts and Sciences, the Baccalaureate/ Associate Colleges, and the Special Focus Institution-Health professions schools all cited an interdisciplinary approach to the arts. The respondents in these classifications were all 100 percent interdisciplinary (See Table 37). 136 Table 37 Carnegie Classification with Small classes and Interdisciplinary Integration Carnegie Basic 2010 Classification Count of More than 50 percent of the arts within the liberal education requirement courses are taught in smaller classes Count of More than 50 percent of the arts within the liberal education requirement courses are interdisciplinary Yes Total Percent with small classes Yes Total Percent of Interdisciplinary Arts Associate's--Public Rural- serving Large 0 1 0.00% 1 1 100.00% Associate's--Public 4-year Primarily Associate's 0 1 0.00% 1 1 100.00% Research Universities (very high research activity) 2 5 40.00% 3 5 60.00% Research Universities (high research activity) 1 6 16.67% 4 6 66.67% Doctoral/Research Universities 4 5 80.00% 3 5 60.00% Master's Colleges and Universities (larger programs) 13 23 56.52% 15 23 65.22% Master's Colleges and Universities (medium programs) 5 6 83.33% 5 6 83.33% Master's Colleges and Universities (smaller programs) 1 2 50.00% 1 2 50.00% Baccalaureate Colleges-- Arts & Sciences 1 2 50.00% 2 2 100.00% Baccalaureate Colleges-- Diverse Fields 6 8 75.00% 5 8 62.50% Baccalaureate/Associate's Colleges 2 2 100.00% 2 2 100.00% Special Focus Institutions--Medical schools and medical centers 0 1 0.00% 0 1 0.00% Special Focus Institutions--Other health professions schools 1 2 50.00% 2 2 100.00% Total 36 64 56.25% 44 64 68.75% 137 Summary In summary, this study explored the curricula of AACN affiliated nursing schools in the southeastern United States to describe the amount and structure of the arts in baccalaureate nursing programs. The arts were defined by the AACN as the fine arts, which included painting and sculpture, performing arts, which included dance and music, and the humanities, which included literature and theology (AACN, 2008). The Essentials of Baccalaureate Education for Professional Nursing Practice, commonly referred to as The Essentials, was published by the AACN to provide ?the curricular elements and framework for building the baccalaureate nursing curriculum for the 21st century? (AACN, 2008, p. 3). The outline that the AACN provided did not specify specific practice for incorporating the arts; therefore, the current state of the arts in the baccalaureate nursing programs (BSN programs) across the southeast were descriptively explored to expose patterns with respect to the integration of the arts. Two surveys were utilized. Data from the Leen Nursing Program Essentials and Effectiveness Survey and the Catalog Survey were collected and reviewed to create a descriptive picture of the integration of the arts in BSN programs across the southeast. The Leen Nursing Program Essentials and Effectiveness Survey was utilized to capture the perceptions of the nurse educator leaders. This survey was primarily used to answer Research Questions two, three and five. There were 68 respondents, but not all of the respondents answered every question within the survey. The respondents were asked about the arts (fine arts, performing arts, and humanities) integration within their programs. The majority of the respondents were deans of their nursing school, and the average length of time in the leadership position for the respondents was 3.91 years. 138 Large four-year, primarily nonresidential universities were the most frequent respondents. Over 92 percent of the respondent schools stated that the arts within the program requirement have been reviewed in the last five years while 16.92 percent of schools said that their programs were in need of review. The majority of respondents stated the more than 50 percent of the arts were taught in small groups. The respondents were given nine Likert questions related to the expected outcomes. The nurse educator leaders gave the highest ranking to the outcome that discussed lifelong learning; they gave the lowest ranking to the outcome that discussed student tolerance for ambiguity. The nurse educator leaders were also asked about the greatest strengths and greatest weaknesses of the arts integration. The majority of leaders stated that the quality of pre-nursing courses were the greatest strength. The greatest weakness acknowledged by the majority of leaders was the limited time (or credit hours) within the BSN curriculum to include courses dedicated to the arts (fine arts, performing art, and humanities). One respondent acknowledged an uncertainty of the necessity of the arts. Once the surveys were returned, a Catalog Survey was completed on each respondent school. The Catalog Survey was used to answer Research Questions one and four which addressed the curricula characteristics and the extent of the arts coursework. By state, Tennessee had the greatest number of respondents (11) while Mississippi had the fewest number of nurse educator leader respondents (1). The Catalog Survey was only completed on the respondent schools; therefore, the number of completed Catalog Surveys was the greatest in Tennessee and the least in Mississippi. While the number of respondent schools were not equivalent, every southeastern state was represented within the survey. 139 The Catalog Survey explored the average number of semester credit hours and explored them in relation to the number of professional nursing semester credit hours, the fine and performing arts semester credit hours, the humanities semester credit hours, and the combination of arts and humanities semester credit hours. The fine arts, performing arts, and humanities credit hours accounted for a little over 12 percent of the average total semester hour requirements. The majority of the schools were non-prescriptive which was defined as allowing more than three class choices within the curriculum. The Leen Nursing Program Essentials and Effectiveness Survey and the Catalog survey addressed the integration of the arts with respect to a vertical or horizontal approach. The responses to the Leen Nursing Program Essentials and Effectiveness Survey indicated that 40 percent of the respondents felt that the arts were horizontally integrated across the curriculum. Meanwhile, the Catalog survey revealed that 27.94 percent of the respondent school curricula were integrating the arts horizontally while 72.06 percent of schools included the arts (fine arts, performing arts, and humanities) in only the first two years. A comparison of the results from the Catalog Survey and the Leen Nursing Program Essentials and Effectiveness Survey exposed a discrepancy between the perception of arts integration by nursing leaders and the actual integration of the arts according to the curricula map. Finally, in an effort to address the fifth research question. The convenience sample of respondents was categorized according to the Basic 2010 Carnegie Classification, the Carnegie Classification Size, and the Carnegie Classification Control. The Baccalaureate Colleges ? Arts and Sciences had the highest average of fine arts, performing arts, and humanities. The Baccalaureate Colleges- Diverse Fields had the 140 second highest average required number of arts semester credit hours. The highest average required number of arts semester credit hours were found at the Very small four- year, primarily residential institutions. After exploring the Carnegie Control Classification, it was determined that the Private not-for-profit schools among these respondents had the highest average of semester credit hours devoted to the arts. By categorizing schools according to the Carnegie Classification, the required semester credit hours in the arts could be compared with the demographics of the institutions. Leadership perceptions of the integration of the arts were also explored by Carnegie Classification. The Baccalaureate/Associate colleges had the highest percentage of respondents with respect to small class sizes. One hundred percent of the respondents with the Associate schools, Baccalaureate Colleges- Arts and Sciences, Baccalaureate/Associate colleges, and special focus institutions reported interdisciplinary integration of the arts. The overall findings of the study suggested that the nurse educator leaders have reviewed the arts within the curricula within the last five years; however, the majority reported a vertical integration of the arts. Nevertheless, writing across the curriculum was acknowledged in the majority of schools. The Likert scores revealed that the majority of respondents believe that the arts program within their curriculum meets the suggested outcomes as set forth by the AACN; yet, the majority of respondent schools devoted less than 13 percent of the required semester hours to the arts (fine arts, performing arts, and humanities). The open-ended questions revealed that many of the respondents were concerned about the number of hours required for the BSN which prevented the inclusion of the arts, but over 45 percent of schools were non-prescriptive indicating that three or 141 more classes involved student choice. One comment made by one of the respondents expressed concern surrounding the necessity of the arts. In the end, the findings indicated that the integration of the arts was not considered a priority in the baccalaureate nursing program curricula by the majority of respondent schools across the southeast. 142 Chapter 5 Conclusion, Implications, Recommendations Introduction This study explored the curricula of AACN affiliated nursing schools in the southeastern United States to describe the amount and structure of the arts in baccalaureate nursing programs. The arts were defined by the AACN as the fine arts, which included painting and sculpture, performing arts, which included dance and music, and the humanities, which included literature and theology (AACN, 2008). Two approaches to data collection were completed to broadly explore the integration of the arts (fine arts, performing arts, and humanities) in nursing education for the purpose of identifying potential value surrounding the first AACN Essential regarding the arts. Purpose of the Study The purpose of the study was to explore the nursing curricula of AACN accredited nursing schools in the southeastern United States to holistically illustrate the amount and structure of the arts, as defined as, the fine arts, performing arts, and the humanities, within the baccalaureate nursing programs and to explore the perception of the arts and arts outcomes by nurse educator leaders in baccalaureate programs in the southeast. The Essentials of Baccalaureate Education for Professional Nursing Practice, commonly referred to as The Essentials, was published by the AACN to provide ?the curricular elements and framework for building the baccalaureate nursing curriculum for the 21st century? (AACN, 2008, p. 3). The outline that the AACN provided did not 143 dictate specific practice for incorporating the arts; therefore, the current state of the arts in the baccalaureate nursing programs (BSN programs) across the southeast were descriptively explored to determine if there were patterns with respect to the integration of the arts. Data from the Leen Nursing Program Essentials and Effectiveness Survey and the Catalog Survey were collected and analyzed. Ultimately, a descriptive picture of the integration of the arts in BSN programs across the southeast was developed. The data collected were descriptively analyzed in an attempt to observe trends or patterns across states and Carnegie Classifications and to identify potential value surrounding The Essentials (AACN, 2009). Studies have been conducted on medical school adaptation of the incorporation of the visual arts, performing arts, and the humanities; however, no study existed to determine the extent of the incorporation of the arts (fine arts, performing arts, and the humanities) into curricula of the American Association of Colleges of Nursing (AACN) member programs in the southeast (Leen, 1990). Research Questions The following Research Questions were used in this study: 1. What are the characteristics of arts coursework (fine arts, performing arts, and humanities) found in baccalaureate nursing curricula in the southeastern United States? 2. What are the leadership perceptions of art coursework (fine arts, performing arts, and humanities) found in their baccalaureate nursing program curricula? 144 3. What are the leadership perceptions of the effectiveness of arts coursework (fine arts, performing arts, and humanities) in meeting the Essential outcomes within their baccalaureate nursing program curricula? 4. To what extent is art coursework (fine arts, performing arts, and humanities) being incorporated into baccalaureate nursing curricula in the southeastern United States institutions? 5. What is the relationship, if any, between demographic characteristics and leadership perceptions (essentials and effectiveness)? Findings The characteristics of arts coursework found in baccalaureate nursing curricula in the southeastern United States were explored. The population for this study included all 187 AACN affiliated nursing schools in the southeast. There were a total of 68 responses to the Leen Nursing Program Essentials and Effectiveness Survey which determined the sample. The sample was 36 percent of the population. The average total number of arts semester credit hours across the southeastern respondents was 14.99. This was 12.19 percent of the average of the total semester hours. Meanwhile, the professional nursing courses accounted for approximately 51.99 percent of the total semester credit hours. Upon further investigation, the average number of semester credit hours devoted to the fine arts and performing arts was approximately one- fifth of the average number of semester credit hours found in the humanities. The integration of the arts was revealed to be primarily vertical. This indicated that the arts and humanities were included in the first two years, but they were absent in the last two years of the BSN curricula. The outcomes identified by the AACN Essentials 145 document were ranked by nurse educators; however, the bulk of the arts integration occurred prior to the last two years of the BSN program sometimes referred to as the professional nursing program. The leadership perceptions of arts coursework were explored through the Leen Nursing Program Essentials and Effectiveness Survey. The overall rankings by the nurse educator leaders regarding the perceptions of arts incorporation found that the majority of arts classes were taught in small groups. While the arts were not horizontally integrated, an overwhelming majority of nurse educator leaders did think that the composition requirements were integrated across all four years of their curriculum. The majority of respondents acknowledged that the arts programs have been reviewed in the last five years. The leadership perceptions of the effectiveness of arts coursework indicated that the outcomes framed by the AACN Essentials document were being met. The lowest ranking Likert survey question was related to tolerance for ambiguity. Beyond the Likert questions, the participants listed the greatest strength and greatest weakness of their program. Several comments related to the strengths of the program suggested that the pre-nursing curriculum was excellent and diverse. The greatest weakness identified by nurse educator leaders was either unknown or related to the required number of credit hours within the curriculum. A central theme uncovered within these comments was a perceived lack of specificity within the arts. This led to a perception of reduced significance which was compounded by a decreased prevalence of evidence-based practice and high level research within the discipline. While leaders may have inherently recognized the benefits of art, without a raised level 146 of importance through outcomes, they were unwilling to diverge from the traditional nature of nursing education based on promoting clinical aptitude. The extent of the arts within the BSN curriculum was proportionately small. In particular, the fine arts and performing arts averaged less than three semester hours within the average BSN curricula. There were seven states (Mississippi, North Carolina, Florida, West Virginia, and Alabama) that had an average of less than three credit hours of fine or performing arts within the curricula. There were three states (Florida, Mississippi, and Kentucky) that had an average of less than twelve credit hours of the arts (fine arts, performing arts, and the humanities) within their BSN programs. In addition to the exploration of the arts integration by state, the relationship between demographics and perceptions of the arts was explored utilizing the Carnegie Classification system. The average of arts semester hours in Baccalaureate Colleges- Arts and Sciences were almost twice that of the next category which was Baccalaureate Colleges- Diverse Fields and five times that of the associate schools. The Special Focus Institutions- other health professions schools ranked only slightly above the associate institutions indicating an average of nine semester credit hours in the arts and humanities. The Very small four-years, primarily residential colleges averaged six times the number of arts credit hours than those of the Large associate institutions and more than three times that of the Special focus institutions. Conclusions From these findings, four primary conclusions emerged. Because the Likert questions with the Leen Nursing Program Essentials and Effectiveness survey were ranked so highly by the respondents, there was a weak relationship between the perceived 147 efficacies in meeting the AACN outcomes related to the arts and the actual integration of the arts according to the Catalog Survey. Next, many of the nurse educator leader respondents indicated that the arts within their programs had been reviewed in the last five years and were not in need of further review. Nevertheless, the tangle of changing demographics of the population, informatics, cultural trends, and healthcare reform heightened the need for careful examination of the curricula and potentiated a shift in nursing education. Additionally, care for the 21st century diverse and chronically ill population is impacted by other global, social, and economic variables that significantly impact healthcare delivery. The information and technological advances have shifted nursing education from memorization and rote learning to a focus on access and critical thinking. No longer can students be expected to memorize the plethora of information that is available with the touch of a key. The call for innovative andragogy to address this informational and societal shift is essential as BSN students face mounting pressures related to outcomes measures. A looming nursing shortage, a demographic shift, nursing informatics, and healthcare reform have created a perfect storm that may dehumanize the care of human beings (Dellasega, Milone-Nuzzo, Curci, Ballard, & Kirch, 2007). Finally, the majority of the respondents recognized a vertical integration of the arts. Yet, the outcomes of the arts were acknowledged based on nurse educator leaders in the last two years of the professional degree. While these leaders recognized the importance of the outcomes, the arts were primarily vertically integrated across the curricula. One confidential survey respondent stated, ?Students tend to not remember how to write when they get to the upper division.? According to Staricoff (2006), nursing 148 practice should be inherently interdisciplinary. This indicated that in order to advance truly effective cooperation, the integration of the arts should occur across the baccalaureate nursing education. Infusing the arts into nursing preparation would encourage the application and extension of the underlying principles of the arts to be carried into the general nursing practice. Implications Any number of concepts could be extrapolated from the results of this study; however, there were three principal implications of this study. First, this study revealed an overall widening theory-practice gap. Next, this research uncovered siloed curricula. Lastly, a lack of specificity was suggested in the arts integration of baccalaureate nursing education. These three broad implications led to specific as well as general recommendations. These implications are ripe with repeated historical debate; however, the changing landscape of healthcare has led to a call for reform in healthcare and nursing education (Dileo & Bradt, 2009). Overall, nurse educators should consider the utilization of innovative strategies to address the changing demographics, heightened informatics, and advancing technology. Theory-Practice Gap The nurse educator leaders recognized the benefits associated with a more comprehensive nursing curriculum that included the arts; however, they did not want to omit the traditional training. The small number of hours of arts courses compared to the average number of total credit hours (12.19 percent) was evidence of a perceived inferiority of the arts as an andragogical approach to meeting BSN outcomes. The 149 concepts related to outcomes and costs were more acceptable than humanism and holistic patient care when forced to make decisions about curricula. The theory-practice gap, as defined by Henderson (2002), referred to the theoretical knowledge that was predicated on humanism and holism juxtaposed against the reality of the demands of the practice of nursing. Healthcare employers that have seized opportunities for cost containment and quantitative outcome measures have heightened this gap in their push for utilitarian nursing care at the expense of humanistic care. Academicians, in response to the plethora of nursing responsibilities have related to access, informatics, and technology, are faced with preparing nurses to provide safe, competent, and excellent care in a complex adaptive healthcare system (Braunstein, 2013). The changing demographics of the population call for an increased comprehension of cultural, economic, and social variables (Allen & Ogilvie, 2004). Addressing the needs of this diverse and chronically ill population accentuate the need for holistic care. Billings (2007) suggests that education is not about filling the minds of students with facts; rather, education is teaching students ?how to acquire, analyze, process and use information? (Billings, 2007, p. 16). The theory-practice gap exists in multiple professions, but challenging nursing students to reach beyond the mechanics of nursing empowers students to close the gap. Educators are called to recognize this need and challenge nursing students to higher order thinking. Compartmentalization The theory-practice gap has also led to a compartmentalization in the academy. This was reflected in the 60 percent majority of respondents that vertically integrated the arts. According to Henderson (2002), holistic care needed to be digested with consistent 150 application; however, in the practice setting, insecure nursing students were task-oriented as they searched for opportunities to master the technical, concrete skills of nursing. Meanwhile, well-meaning instructors placed the major emphases on objective and measurable factors within the disciplines of science, informatics, and practical clinical application in order to ensure competence (Lafferty, 1997). One reason for this was related to the basic function of nursing education which was to prepare a competent and safe nurses capable of meeting professional standards (Lafferty, 1997). The siloed technical mastery and humanistic rhetoric seemed to be instigated by nurse educators unknowingly. In 2001, the Institute of Medicine called for changes to the way healthcare professionals were being educated. Again, in 2008, the Institute of Medicine (IOM) and the Robert Wood Johnson Foundation called for a transformation in the nursing profession and education; the IOM acknowledged the three domains of nursing as: Knowledge, skills, and affect (Fleeger & Connelly, 2012). The IOM was not alone; the American Nurses Association also proposed that nursing needed to expand the curricula to include diverse pedagogy and an integration of the arts (ANA, 1995). This call was a direct response to the need for increased safety, competency, and humanism in medical education. To silo the arts or sciences, in practice or in nursing education, was to exclude a discipline that identified the humanity in human beings. Gablik (1998) contended that to consider the creative process superfluous was ethnocentric. Other cultures, particularly in eastern civilizations, recognized art as an accepted and vital part of life (1998). In contrast, the logistics of teaching the technological aspects of nursing was more suitable for quantitative pre-determined outcome measures, and therefore, more appealing to 151 United States nurse educators. Nevertheless, Billings (2007) identified nursing programs around the world attempting to improve creativity and critical thinking through the arts. Specificity This study revealed a lack of a standardized practice, definitions, and language related to the arts, health, and nursing education. According to Meyer (2012), there was a lack of specificity related to arts and health; even the terminology was highly varied. Terms such as; art-based interventions, creative arts therapies, art and health, art in medicine, healing arts, health and healing arts were difficult to discern. Without clearly defined borders, these broad ideas ultimately resulted in a lack of respect. Furthermore, the lack of specificity increased the difficulty for clinical research replication, and the advent of new pedagogical practices that integrated the arts (Meyer, 2012). Dileo and Bradt (2009) echoed this within the facets of the arts in healthcare practices. Without standard definitions, outcomes were even more difficult to measure in nursing education which may result in a lack of creditability for art as a form of learning. Staricoff (2006) suggests that high level quantitative research, capable of measuring the effects of the arts integration, would reveal the fundamental role of the arts and provide increasing validity. Concrete and specific ideas situated in evidence-based practice may be the only way to legitimize the arts in nursing education for those that are hyper- focused on outcomes and technical mastery. Schwartz et al. (2009) suggests that the humanities courses need specific and measurable goals in order to evaluate if the goals are met; this would provide evidence of the impact of the humanities and further legitimize the place of the humanities in healthcare practitioner education. Recommendations for Further Research 152 The implications of the study were related to the theory-practice gap, compartmentalization, and specificity. There was a plethora of data to explore. Once the implications were noted, there were seven recommendations following the data analysis in this study. There were five specific recommendations related to the integration and two comprehensive recommendation that emerged from the findings of the study. Recommendations 1. This study explored the integration of the arts in the southeastern AACN affiliated schools. As the study evolved, the idea of an additional descriptive study in other geographical regions throughout the United States emerged as a way to capture a national perspective of the integration of the arts in nursing education. The population, based on demographics, across the regions of the United States may vary in their appreciation of the arts and in their approach to healthcare, andragogy, and healthcare education. Moreover, Dileo and Bradt (2009) suggested that the identification of specific demographic, biological, and social variables were needed to distinguish potential confounding variables in the arts integration. 2. Beyond a nationalistic front, a qualitative or quantitative study comparing eastern and western medicine and the integration of arts would reach beyond the barriers found in western culture and medicine and may be of value. As access to global solutions explodes, trends to recognize global awareness and embrace diverse solutions are emerging. The Catalog Survey process revealed that there was emphasis on globalization throughout many of the respondent schools curricula. This indicates a trend in the need for an understanding of global healthcare needs, solutions, accesses, and structures. 153 3. A qualitative study surveying nurse educator leader responses to questions surrounding the arts integration would provide an opportunity to further explore faculty perceptions. The open-ended questions from the Leen Nursing Program Essentials and Effectiveness Survey provided an interesting peek into the specific perceptions of nurse educator leadership. A qualitative study may provide an opportunity to consider the arts and improve the position of the arts. The brief comments made in this study indicated a need for further study as over half of the respondent answers thematically challenged the legitimacy of the inclusion of the arts into baccalaureate nursing education. Without buy- in from nurse educator leaders, the infusion of the arts into nursing education would be a significant challenge. 4. Beyond specific entire courses integrating the arts, a further study may reveal that the arts were integrated throughout the curricula within specific coursework or learning activities. The Essentials addressed the need for the arts within the liberal arts; however, these were guides to curricular elements that were not necessarily intended to be individual courses (AACN, 2008). A study by Rodenhauser, Strickland, and Gambala (2004) discussed specific arts-related activities across medical schools in the United States. This study explored specific courses, specific curricular elements, and learning activities. Based on the findings from this study, a similar study within nursing schools may be warranted. For example, Billings (2007) compared the simulation process, utilized to reenact patient cases in most nursing curricula, to the performing arts. Simulation, as a form of drama, was set to attempt to meet the technical, as well as, the social and cultural challenges of care. 154 5. This study suggested that further quantitative studies that measure the outcomes of professional nursing practice were needed to document the impact of the arts. Expanding the literature surrounding the complementary relationship between the arts and the techno-scientific knowledge were necessary to reduce the siloed approach to the integration of the arts (Casey, 2009). According to Dileo and Bradt (2009), while the evidence was mounting, there was a need for higher evidence of outcomes in the arts and healthcare. Lower levels of evidence help to raise awareness; however, randomized controlled trials (RCT) and controlled trials (CT) surrounding the inclusion of art and health were warranted to determine the inherent efficacy, safety, and cost-effectiveness of this relationship (Dileo & Bradt, 2009). Comprehensive Recommendations Once the implications were noted, there were five recommendations related for future research in baccalaureate nursing education and the arts. However, there were two overarching and comprehensive recommendations that emerged from this study that were based on the overall findings. First, there must be a recognition and response to the complex adaptive system of healthcare. Secondly, there is a call for the advancement of art and health as a discipline. The Institute of Medicine charged for a shift in healthcare quality in 2001 and again in 2008, but this shift necessitated a broadening to address the changing informational and technological landscapes inherent in the healthcare arena (Dellasega, Milone-Nuzzo, Curci, Ballard, & Darrell, 2007). Nurses have to be educated in new ways to meet the demands of the turbulent healthcare system (Fleeger & Connelly 2012). Because the literature raised awareness of the expectation of nurses to meet the 155 healthcare challenges of the 21st century, the education of those nurses must be directive. Billings (2007) suggested that higher order thinking through acquiring, analyzing, synthesizing, and processing information was crucial as opposed to rote memorization and the exclusive application of motor skills. This was reiterated by Rieger and Chernomas (2013) with a call for the nursing curricula to shift from a teacher-centered and content-focused design to an environment that focused on the process of learning and engagement. The final recommendation addresses the need for the advancement of the arts and health as a discipline. Dileo and Bradt (2009) suggest that there is a need for specific decisions based on the discipline of the arts in healthcare, a specification of the arts in healthcare as a discipline, and growth in the research surrounding this discipline. A discipline is an ?organized body of knowledge consisting of theory, practice and research? (Bruscia, 1998). Currently, medical humanities programs exist in the United States, nevertheless, advancing a specific discipline of art and health would heighten awareness, encourage research, and promote the humanistic element of care (Dileo & Bradt, 2009). The discipline would not eliminate the need for an interdisciplinary approach. Those challenges would continue to exist. Nevertheless, with a call for the arts in healthcare to become a discipline, it would become defined and standardized which could create a specific field ultimately creating a concrete footing on which to expand and strengthen the move towards the integration of the arts and health. This would provide distinct recognition of the impact of the affective domain on health in qualitative as well as quantitative derived healthcare outcomes. 156 Summary This research explored the integration of the arts in baccalaureate nursing education. In the end, three principal implications of the study were exposed and discussed which included the theory-practice gap, the siloed curriculum, and a lack of specificity. These three broad implications led to specific, as well as, general recommendations for further research which surrounded embracing a pedagogical shift in education and a call for advancing art and health as a discipline. While there were challenges, art and science were not mutually exclusive. Evidence revealed that nursing care was a blend of the science and art of medicine. In the end, the employment of creative and innovative pedagogical strategies by nurse educators was necessary to address the changing demographics, heightened informatics, and advancing technologies that have forever shifted the care of human beings. 157 References Adams, M. H., & Valiga, T. M. (2009). Excellence: Everyone?s Responsibility. In M. Adams & T. Valiga (Eds.), Achieving Excellence in Nursing Education. New York: National League for Nursing. Adams, M. H. (2012). Accreditation of nursing programs. In D. Billings & J. Halstead (Eds.), Teaching in Nursing: A Guide for Faculty (4 ed.). St. Louis: Elsevier. Allen, M., & Ogilvie, L. (2004). Internationalization of higher education: Potentials and pitfalls for nursing education. International Nursing Review, 51(2), 73-80. Alzheimer's Association: About us. (2013, October 6). Retrieved from http://www.alz.org/about_us_about_us_.asp American Association of Colleges of Nursing (AACN). (2008). The Essentials of Baccalaureate Education for Professional Nursing Practice. Washington D.C. http://www.aacn.nche.edu/education/pdf/baccessentials09.pdf American Association of Colleges of Nursing (AACN). (2013). Strategic Plan. http://www.aacn.nche.edu/about-aacn/strategic-plan American Nurses Association (ANA). (1995). Nursing?s social policy statement. Washington, D.C. Anthony, M., & Templin, M. (1998). Nursing faculty teaching in the general education sequence: The value of liberal arts as a component of professional nursing practice. The Journal of Nursing Education, 37(7), 321-323. 158 Arts in medicine. (2013, October 4). Retrieved from http://artsinmedicine.ufhealth.org/about/ Bardes, C., Gillers, D., & Herman, A. (2001). Learning to look: Developing clinical observational skills at an art museum. Medical Education, 35(12), 1157-1161. Barrett, T. (2011). Experiencing art with the ill, the elderly, and their caregivers. Teaching Artist Journal, 9(2), 90-100. Benner, P. (1996). A response by P. Benner and K. Cash, "Benner and expertise in nursing: A critique" International Journal of Nursing Studies, 33(6), 669-674. Bentley, Regina Watts. "Examination of Success Rates of Traditional Nursing Students and Accelerated Nursing Students in a Four-Year Nursing Program." Order No. 3135981 Auburn University, 2004. Ann Arbor: ProQuest. Web. 6 Oct. 2013. Billings, L. (2007). Development of an arts-based curriculum for the Texas Tech University Health Sciences Center School of Nursing. (Doctoral dissertation, Texas Tech University) Retrieved from http://repositories.tdl.org/ttu- ir/bitstream/handle/2346/9758/Billings_Lynda_Diss.pdf?sequence=1 Brenner, S. (2003). In Dana Gioia (Chair). Arts in healthcare symposium. In J. Palmer, K/ Leniart (Eds.), Report on the Arts in Healthcare Symposium (pp. 1-20). Retrieved from http://arts.gov/sites/default/files/AIHReport.pdf Bishop, A., & Scudder, J. R. (1997). Nursing as a practice rather than an art or a science. Nursing Outlook, 45(2), 82-85. Bleakley, A. & Marshall, R. (2013). Can the science of communication inform the art of the medical humanities?. Medical Education, 47, 126-133. 159 Boland, D. L., & Finke, L. M. (2009). Curriculum designs. In D. Billings & J. Halstead (Eds.), Teaching in Nursing (3rd ed.). St. Louis: Elsevier. Boyer, E. (1990). Scholarship Reconsidered: Priorities of the Professoriate. Princeton, NJ: The Carnegie Foundation for the Advancement of Teaching. NY: Basic Books. Boyer, E.L. (1987). College: The Undergraduate Experience in America. New York: Harper and Row. Braunstein, M. L. (2013). Health Informatics in the Cloud. New York: Springer Publishing Company. Brown, C.E., & Ecoff, L. (2011). A systematic approach to the inclusion of evidence in healthcare design. Health environments research and design journal, 4(2), 7-16. Brown, R., Feller, L., & Benedict, L. (2010). Reframing nursing education: The Quality and Safety Education for Nurses Initiative. Teaching & Learning in Nursing, 5(3), 115-118. Bruderle, E., & Valiga, T. (1994). Integrating the arts and humanities into nursing education. NLN Publications, 14(2611), 117-144. Bruderle, E., & Valiga, T. (1997). Integrating the arts and humanities into nursing education. In P. Chinn, P. Chinn (Eds.) Art and Aesthetics in Nursing (pp. 117- 144). National League for Nursing Center for Human Caring. Bruscia, K.E. (1998). Defining Music Therapy. (2nd ed.) Galsum: Barcelona. Burton, J. M., Horowitz, R., & Abeles, H. (2000). Learning in and through the arts: The question of transfer. Studies in Art Education, 41(3), 228-257. 160 Capra, F., (2007). The Science of Leonardo: Inside the Mind of the Great Genius of the Renaissance. New York: Doubleday. Carey, J. (2002). Brain Facts: A Primer on the Brain and Nervous system. Washington, DC: The Society for Neuroscience Carnegie Foundation for the Advancement of Teaching. (2010). A Classification of Institutions of Higher Education. Casey, B. (2009) Arts-based inquiry in nursing education. Contemporary Nurse, 32(1-2), 69-82. Charon, R. (2010). Calculating the contributions of humanities to medical practice: Motives, methods, and metrics. Academic Medicine, 85(6), 935-937. Ch?vez-Eakle, R. A., Graff-Guerrero, A., Garc?a-Reyna, J. C., Vaugier, V., & Cruz- Fuentes, C. (2007). Cerebral blood flow associated with creative performance: A comparative study. NeuroImage, 38, 519-528. Chenot, T. M., & Daniel, L. G. (2010). Frameworks for Patient Safety in the Nursing Curriculum. Journal of Nursing Education, 49(10), 559-568. Cohen, G. (2005). The mature mind: The positive power of the aging brain. New York, Cohen, G. D. (2006). Research on creativity and aging: The positive impact of the arts on health and illness. Generations, 30(1), 7-15. Commission on Collegiate Nursing Education. (2013). Mission, Values, & History. Creech, J. D., & Lord, J. M. (2007). Clearing paths to college degrees: Transfer policies in SREB states. Challenge to Lead, Retrieved from www.sreb.org Davidson, S.J. (2010). Complex responsive processes: A new lens for leadership in twenty-first century health care. Nursing Forum, 45(2), 108-117. 161 Davis-Martin, S. (1990). Research on the differences between baccalaureate and associate degree nurses. NLN Publications, 15(2339), 109-145. De la Croix, A., Rose, C., Wildig, E., & Willson, S. (2011). Arts-based learning in medical education: The students' perspective. Medical Education, 45(11), 1090- 1100. Dellasega, C., Milone-Nuzzo, P., Curci, K.M., Ballards, J.O., & Darrell, G.K. (2007). The humanities interface of nursing and medicine. Journal of Professional Nursing, 23(3), 174-179. DeBrew, J. (2010). Perceptions of liberal education of two types of nursing graduates: The essentials of baccalaureate education for professional nursing practice. JGE: The Journal of General Education, 59(1), 42-62. DeBrew, J., & Rankin, C. (2009). A liberal education: Making the essentials practical. Nurse Educator, 34(3), 103-104. Dijkstra, K., Pieterse, M., & Pruyn, A. (2006). Physical environmental stimuli that turn healthcare facilities into healing environments through psychologically mediated effects: Systematic review. Journal of Advanced Nursing, 56(2), 166-181. Dileo, C., & Bradt, J. (2009). On creating the discipline, profession, and evidence in the field of arts and healthcare. Arts and Health, 1(2), 168-182. Dolev, J., Friedlaender, L., & Braverman, I. (2001). Use of fine art to enhance visual diagnostic skills. JAMA: The Journal of the American Medical Association, 286(9), 1020-1021. 162 Edvardsson, J.D., Sandman, P., & Rasmussen, B.H. (2005). Sensing an atmosphere of ease: A tentative theory of supportive care settings. Scandinavian Journal of Caring Science, 19, 344-353. Elder, N.C., Tobias, B., Lucero-Criswell, A., & Goldenhar, L. (2006). The art of observation: Impact of a family medicine and art museum partnership on student education. Family Medicine, 38(6), 393-398. Erickson, J. (2012). 200 years of nursing--a chief nurse's reflections on practice, theory, policy, education, and research. The Journal of Nursing Administration, 42(1), 9-11. Evans, M. (2002). Reflections on the humanities in medical education. Medical Education, 36, 508-513. Ewing, B., & Hayden-Miles, M. (2011). Narrative pedagogy and art interpretation. Journal of Nursing Education, 50(4), 211-215. Ferrell, B., Virani, R., Jacobs, H., Mallow, P., & Kelly, K. (2010). Arts and humanities in palliative nursing education. Journal of Pain and Symptom Management, 31(5), 941-945. Fink, A., Benedek, M., Grabner, R.H., Staudt, B., Neubauer, A.C. (2007). Creativity meets neuroscience: Experimental tasks for the neuroscientific study of creative thinking. Methods, 42(1), 68-76. Finke, L. M. (2012). Teaching in nursing: The faculty role. In D. Billings & J. Halstead (Eds.), Teaching in Nursing: A Guide for Faculty (4 ed.). St. Louis: Elsevier. 163 Fish, S. (2008, January 6). New York Times Opinionator. [Web log message]. Retrieved from http://opinionator.blogs.nytimes.com/2008/01/06/will-the-humanities-save- us/?pagewanted=print Fleeger, M.E., & Connelly, T.W. (2012). Navigating the perfect storm: Nursing and liberal education. Practice, Spring, 16-19. Flood, M., & Phillips, K. (2007). Creativity in older adults: A plethora of possibilities. Issues in Mental Health Nursing, 28(4), 389-411. Freeland, R. M. (2009). Liberal education and effective practice: The necessary revolution in undergraduate education. Liberal Education, 95(1), 6-13. Frei, J., Alvarez, S. E., & Alexander, M. B. (2010). Ways of Seeing: Using the visual arts in nursing education. Journal of Nursing Education, 49(12), 672-676. Fried, C., Madar, S., & Donley, C. (2003). The biomedical humanities program: Merging humanities and science in a premedical curriculum at Hiram College. Academic Medicine: Journal of the Association of American Medical Colleges, 78(10), 993-996. Frydman, G. (2010, March 18). EHR etiquette and the importance of eye contact in clinician-patient communication. E-patients.net. Retrieved on January 19, 2013. Gablik, S. (1998). The nature of beauty in contemporary art. New Renaissance 8(1), 1-3. http://www.ru.org/81gablik.html Gabriel, B., Bromberg, E., Vandenbovenkamp, J., Walka, P., Kornblith, A. B., & Gelb, M.J. (1998). How to Think Like Leonardo da Vinci: Seven Steps to Genius Every Day. New York: Dell. 164 George, C. (2010, February 23). Nursing forum divided on education standard. Houston Chronicle (TX). Global Alliance for Arts & Health formally Society for the Arts in Healthcare. (2013). Global Alliance for Arts and Health. Retrieved from http://www.thesah.org/template/index.cfm Goldstein, Thomas. (1980). Dawn of Modern Science: From the Arabs to Leonardo da Vinci. Boston: Houghton Mifflin. Gortner, S.R. (2000). Knowledge development in nursing: Our historical roots and future opportunities. Nursing Outlook, 48(2). 60-67 Gravetter, F. J., & Wallnau, L. B. (2011). Essentials of Statistics for the Behavioral Sciences. (7th ed.). Belmont: Wadsworth. Halperin, E. C. (2010). Preserving the humanities in medical education. Medical Teacher, 32(1), 76-79. Hamilton, C., Hinks, S., & Petticrew, M. (2003). Arts for health: Still searching for the Holy Grail. Journal of Epidemiology and Community Health, 57(6), 401-402. Hammar, L. M., Emami, A., G?tell, E., & Engstr?m, G. (2011). The impact of caregivers' singing on expressions of emotion and resistance during morning care situations in persons with dementia: An intervention in dementia care. Journal of Clinical Nursing, 20(7-8), 969-978. Harvey, R. (2009). Review of' Whole person healthcare, Volumes 1, 2, & 3. Psychotherapy: Theory, Research, Practice, Training, 46(2), 272-273. 165 Henderson, S. (2002). Factors impacting on nurses? transference of theoretical knowledge of holistic care into clinical practice. Nurse Education in Practice, 2(4), 244- 250. Hendrix, C.C. (2009). In pursuit for a more perfect union between nursing academia and practice: A reflection from a nursing faculty. The Author, 44(4). 283-285. Herbert, C., & Yoder, L. (2008). Creating the ultimate healing environment: integrating evidence-based design, IT and patient safety. Healthcare Executive, 23(5), 16. Hermann, M. L. (2004). Linking liberal and professional learning in nursing education. Liberal Education, 90(4), 42-47. Hess, J. D. (1996). Education for Entry into Practice: An Ethical Perspective. Journal of Professional Nursing, 12(5), 289-296. Houser, E. (2011). Creative engagement through the arts as health care for older people: potential and problems provoked. (Master's thesis, University of Toronto, Toronto, Toronto, Canada), Available from ProQuest. http://e-patients.net/archives/2010/03/ehr-etiquette-and-the-importance-of-eye- contact-in-clinician-patient-communication.html Hubard, O. M. (2007). Productive information: Contextual knowledge in art museum education. Art Education, 60(4), 17-23. Hubard, O. M. (2011). Rethinking critical thinking and its role in art museum education. Journal of Aesthetic Education, 45(3), 15-21. Ivey, B. (2005). America Needs a New System for Supporting the Arts. Chronicle of Higher Education, 51(22), B6. 166 Jakesch, M., & Leder, H. (2009). Finding meaning in art: Preferred levels of ambiguity in art appreciation. Quarterly Journal of Experimental Psychology, 62(11), 2105- 2112. Johnson, W.T. (2010). Shaping better physicians?: The role of the visual arts in medical education. (Doctoral dissertation, Georgetown University) Kaufman, K. (2008). Executive Summary from the Nursing Data Review, Academic Year 2005-2006, Baccalaureate, Associate Degree, and Diploma Programs. Nursing Education Perspectives, 29(3), 182-184. Kearney-Nunnery, R. & Aucoin, J.W. (2012). Informatics and documenting outcomes. In R. Kearney-Nunnery (Ed.), Advancing your Career: Concepts of Professional Nursing. Philadelphia: F.A. Davis Company. Kearney-Nunnery, R. (2012). Your professional identity. In R. Kearney-Nunnery (Ed.), Advancing your Career: Concepts of Professional Nursing. Philadelphia: F.A. Davis Company. Kim, S. K. (2010). Health aging and art therapy. (Doctoral dissertation), Available from ProQuest. Kirklin, D., Duncan, J., McBride, S., Hunt, S., & Griffin, M. (2007). A cluster design controlled trial of arts-based observational skills training in primary care. Medical Education, 41(4), 395-401. Kulisevsky, J., Pagonabarraga, J., & Martinez-Corral, M. (2009). Changes in artistic style and behavior in Parkinson's disease: Dopamine and creativity. Journal of Neurology, 256(5), 816-819. 167 Lafferty, P. M. (1997). Balancing the Curriculum: Promoting Aesthetic Knowledge in Nursing. Nurse Education Today, 17(4), 281-86. Larson, C. (2006). The fine art of healing the sick: Embracing the benefits of writing, music, and art. U.S. News & World Report, 140(21), 54-56. Lazenby, M. (2013). On the humanities of nursing. Nursing Outlook, 61(1), E9-E14. Leen, M. G. (1990). A survey of liberal education requirements of baccalaureate nursing programs: A descriptive study. (Doctoral dissertation). Retrieved from ProQuest Dissertations. Leighton, K. L. (2007). Learning needs in the traditional clinical environment and the simulated clinical environment: A survey of undergraduate nursing students. (Doctoral dissertation) Retrieved from Dissertation Abstracts International Section A. Lipe, A. W., Ward, K. C., Watson, A. T., Manley, K., Keen, R., Kelly, J., & Clemmer, J. (2012). The effects of an arts intervention program in a community mental health setting: A collaborative approach. Arts in Psychotherapy, 39(1), 25-30. Loden, K.C. (1989). Clinical experience at the museum of art. Nurse Educator, 13(3), 25- 26. Luzzatto, P. (2001). Art therapy with adult bone marrow transplant patients in isolation: A pilot study. Psycho-Oncology, 10(2), 114-123. Macneill, P. U. (2011). The arts and medicine: A challenging relationship. Medical Humanities, 37, 85-90. 168 Mailloux, C. (2011). Using the essentials of baccalaureate education for professional nursing practice (2008) as a framework for curriculum revision. Journal of Professional Nursing, 27(6), 385-389. Marnocha, S. & Marnocha, M. (2007). Windows open: Humanities teaching during undergraduate clinical experiences. The Journal of Nursing Education, 46(11), 518-521. McClay, W. M. (2010). The burden and beauty of the humanities. Arts Education Policy Review, 111(1), 33-35. McCormick, A.C. & Zhao, C.M. (2005). Rethinking and reframing the Carnegie Classification. Change, September/October, 51-57. McKie, A. (2012). Using the arts and humanities to promote a liberal nursing education: Strengths and weaknesses. Nurse Education Today, 32(7), 803-810. Melnyk, B.M. & Fineout-Overholt, E. (2011). Evidence-based Practice in Nursing and Healthcare: A Guide of Best Practice. 2nd Ed. Philadelphia: Williams, & Wilkins. Meyer, A.A. (2012). Perceived benefits of art-based interventions and nursing implications: A systematic review. Scholars Honors Program. Paper 18. Miles, M. (1994). Art in hospitals: Does it work? A survey of evaluation of arts projects in the NHS. Journal of the Royal Society of Medicine, 87(3), 161-163. Miller, C. (2010). Improving and enhancing performance in the affective domain of nursing students: Insights from the literature for clinical educators. Contemporary Nurse: A Journal for the Australian Nursing Profession, 35(1), 2-17. 169 Monroe, M.C. & Adams, D.C. (2012). Increasing response rates to web-based surveys. Journal of Extension, 50(6). Moore, K.D., & Geboy, L. (2010). The question of evidence: current worldviews in environmental design research and practice. Cambridge Journals, 14(2), 105- 114. Morris, A. H., & Faulk, D. R. (2012). Transformative Learning in Nursing. New York: Springer. Moss, H., Donnellan, C., & O'Neill, D. (2012). A Review of Qualitative Methodologies Used to Explore Patient Perceptions of Arts and Healthcare. Medical Humanities, 38(2), 106-109. Naghshineh, S., Hafler, J. P., Miller, A. R., Blanco, M. A., Lipsitz, S. R., Dubroff, R. P., & Katz,J. T. (2008). Formal art observation training improves medical students? visual diagnostic skills. JGIM: Journal of General Internal Medicine, 23(7), 991-997. National League for Nursing Accrediting Commission (NLNAC). (2008). NLNAC standards and criteria: Baccalaureate. http://www.acenursing.net/manuals/sc2008_baccalaureate.pdf Nieswiadomy, R. M. (1998). Foundations of nursing research (3rd ed). Stanford: Appleton & Lange. Ousager, J, & Johannessen, H. (2010). Humanities in undergraduate medical education: A literature review. Humanities in Medical Education, 85(5), 988-998. 170 Palo-Bengtsson, L., & Ekman, S. (2002). Emotional response to social dancing and walks in persons with dementia. American Journal of Alzheimer's Disease & Other Dementias, 17(3), 149-153. Paniagua, H. (2004). Can the underlying principles of art be applied to nursing?. British Journal of Nursing, 13(4), 220-223. Pardue, K.T. (2005). Blending aesthetics and empirics: Teaching health assessment in an art gallery. Journal of Nursing Education, 44(7), 334-336. Patton, C. (2010). Survey Savvy. University Business, 13(9), 38-44. Pavill, B. (2011). Fostering creativity in nursing students. Holistic Nursing Practice, 25(1), 23. Peet, R. (1995). The Nightingale Model of Nursing. Edinburg: Campion Press. Pellegrino, E. (1984). The humanities in medical education: Entering the post-evangelical era. Theoretical Medicine: An International Journal for the Philosophy and Methodology of Medical Research and Practice, 5253-5266. Pellico, L., Friedlaender, L., & Fennie, K. (2009). Looking is not seeing: Using art to improve observational skills. The Journal of Nursing Education, 48(11), 648- 653. Perry, M., Maffulli, N., Willson, S., & Morrissey, D. (2011). The effectiveness of arts- based intervention in medical education: A literature review. Medical Education, 45, 141-148. Phillips, N. & Fragoulis, I. (2012). The use of art in the teaching practice for developing communication skills in adults. International Education Studies, 5(2), 132-137. Porter-O'Grady, T. (2003). Nurses as Knowledge Workers. Creative Nursing, 9(2), 6. 171 Pratt, R. R. National Endowment for the Arts, (2003). The arts in healthcare movement in the United States: Concept paper. Retrieved from National Endowment for the Arts website:http://www.nea.gov/news/news03/nea_sahconceptpaper.pdf Raines, C., & Taglaireni, M. (2008). Career pathways in nursing: Entry points and academic progression. Online Journal of Issues in Nursing, 13(3), 3. Reichardt, C. S., & Gollob, H. F. (1999). Justifying the use and increasing the power of a t test for a randomized experiment with a convenience sample. Psychological Methods, 4(1), 117-128. Rieger, K.L., & Chernomas, W.M. (2013). Arts-based learning: Analysis of the concept for nursing education. International Journal of Nursing Education Scholarship, 10(1), 1-10. Robinson, S. (2007). Holistic health promotion: Putting the art into nurse education. Nurse Education in Practice, 7, 173-180. Rodenhauser, P., Strickland, M. A., & Gambala, C. T. (2004). Arts-Related activities across U.S. medical schools: A follow-up study. Teaching & Learning in Medicine, 16(3), 233-239. Schwartz, A., Abramson, J. S., Wojnowich, I., Accordino, R., Ronan, E. J., & Rifkin, M. R. (2009). Evaluating the impact of the humanities in medical education. Mount Sinai Journal of Medicine, 76(4), 372-380. Shapiro, J., Rucker, L., & Beck, J. (2006). Training the clinical eye and mind: Using the arts to develop medical students' observational and pattern recognition skills. Medical Education, 40(3), 263-268. 172 Shephard, K. (2008).Higher education for sustainability: Seeking affective learning outcomes. International Journal of Sustainability in Higher Education, 9(1), 87- 98. Simons, H., & Hicks, J. (2006). Opening Doors: Using the creative arts in learning and teaching. Arts and Humanities in Higher Education: An International Journal of Theory, Research, and Practice, 5(1), 77-90. Smith, A. (2009). Exploring the legitimacy of intuition as a form of nursing knowledge. Nursing Standard. 23(40), 35-40. Sonke, J., Rollins, J., Brandman, R., & Graham-Pole, J. (2009). The state of the arts in healthcare in the United States. Arts & Health: International Journal for Research, Policy & Practice, 1(2), 107-135. Staricoff, R. (2006). Arts in health: The value of evaluation. Journal of the Royal Society for the Promotion of Health, 126(3), 116-120. Sternberg, R.J. (1999). The theory of successful intelligence. Review of General Psychology, 3(4), 292-316. Stewart, R.F., Kroth, P.J, Schuyler, M., & Bailey, R. (2010). Do electronic health records affect the patient-psychiatrist relationship? A before and after study of psychiatric outpatients. BMC Psychiatry, 10(3), 1-9. Stilos, K., Moura, S., & Flint, F. (2007). Building comfort with ambiguity in nursing practice. Clinical Journal of Oncology Nursing, 11(2), 259 ? 263. Stork, David G. (2004). Optics and Realism in Renaissance Art. Scientific American. 77- 82. http://www.ithaca.edu/barr/Student/IISP21001/docs/stork_SA.pdf 173 Strickland, M., Gambala, C., & Rodenhauser, P. (2002). Medical education and the arts: a survey of U.S. medical schools. Teaching and Learning In Medicine, 14(4), 264-267. Sullivan, E.J. (1996). Are the humanities still relevant in nursing today?. Journal of Professional Nursing, 12(5), 267. The Center for Health Design. (2013). Retrieved from https://www.healthdesign.org/chd/about Thorpe, C. C., Ryan, B. B., McLean, S. L., Burt, A. A., Stewart, M. M., Brown, J. B., & ... Harris, S. S. (2009). How to obtain excellent response rates when surveying physicians. Family Practice, 26(1), 65-68. Ulrich, R. (1984). View through a window may influence recovery from surgery. Science, 224, 420-421. Ulrich, R.S., Zimring, C., Zhu, X., Dubose, J., Seo, H., Choi, Y., Quan, X., & Joseph, A. (2008). Evidence-Based Design Resources for Healthcare Executives [white paper]. Retrieved from http://www.healthdesign.org/~hcleader/HCLeader_5_LitReviewWP.pdf Valiga, T., & Bruderle, B. (1997). Using the Arts and Humanities to Teach Nursing. New York: Springer. Varnell, G. (2010). Nursing Education. In J. Zerweih & J.C. Claborn (Eds.), Nursing Today: Transitions and Trends. St. Louis: Elsevier. Wachtler, C., Lundin, S., Troein, M. (2006). Humanities for medical students? A qualitative study of medical humanities curriculum in a medical school program. BMC Medical Education, 6(16), 1-10. 174 Wear, D. (2009). The medical humanities: Toward a renewed praxis. Journal of Medical Humanities 30, 209-220. White, D. A., & Robinson, R. (2001). Critical thinking and artistic creation. Journal of Aesthetic Education, 35(2), 77-85. Wichowski, H. (1994). Professional uncertainty: Nurses in the technologically intense arena. Journal of Advanced Nursing, 19(6), 1162-1167. Wikstr?m, B. (2000). Nursing education at an art gallery. Journal of Nursing Scholarship, 32(1), 197-199. Wikstr?m, B. (2011). Works of art as a pedagogical tool: An alternative approach to education. Creative Nursing, 17(4), 187. Wilsher, M. (2005). Against explanation. Art Monthly, 286, 7-9. Wright, S. (2006). Finest of the fine arts. Nursing Standard, 21(4), 20-22. Zerwekh, J., & Claborn, J. (2003). Nursing today: Transition and trends. St. Louis, Missouri: Elsevier Science Saunders. Zuger, A. (1999, July 13). Are Doctors Losing Touch With Hands-On Medicine?. New York Times, 1-2. 175 APPENDICES 176 Appendix A Permissions 177 Permission letter to Dr. Leen Dr. Maureen Gallagher Leen Professor Madonna University School of Nursing Diponio Building Room 121 Livonia, Michigan 48150 Dr. Leen; By way of introduction, my name is Heather Hardin. I am a doctoral student at Auburn University in Auburn, Alabama in Adult Education under the direction of Dr. Maria Witte. I have been a nurse for seventeen years. While I am in school full-time, I also serve on the faculty of Auburn University Montgomery School of Nursing as an adjunct instructor. I am writing to you with regard to your dissertation, "A survey of liberal education requirements of baccalaureate nursing programs: A descriptive study." It has been a great privilege to read and study your dissertation, and I am interested in conducting a follow-up study on nursing schools in the southeastern United States. However, I would like to acknowledge your work in this area of our discipline. I am asking for your permission to reproduce and use your survey instruments in my research study. I would like to use and print your "Mailed survey" and "Catalogue Survey" under the following conditions: ? I will use this survey only for my research. I will not sell or use it with any compensated activities. ? I will send my research study and a copy of any articles that make use of this survey data promptly to your attention. If this is acceptable and you grant permission for this use under the above conditions, please indicate by signing one copy of this letter and returning it to me through postal mail or email: Heather Hardin 1407 Oak Bowery Road Opelika, Alabama 36801 HHardin@AUM.edu or in response to this email. Again, I sincerely appreciate your consideration of this proposal. Your contribution to the study of nursing education has deeply influenced the direction of my doctoral studies, and I hope to further contribute to this important issue. Best Regards, Heather Hardin, MSN, RN 178 Leen Permission Email 179 AACN Permission notice from William O?Connor the Director of Publications with the American Association of Colleges of Nursing. 180 Appendix B Institutional Review Board Documents and Approval Form 181 182 183 8/28/13 Approval, Exempt Protocol #13-295 EX 1308 Approval, Exempt Protocol #13-295 EX 1308 IRB Administration [irbadmin@auburn.edu] Sent: Wednesday, August 28, 2013 3:39 PM To: Heather Hardin Cc: Maria Witte; Sheri Downer Attachments:Investigators Responsibil~1.docx (16 KB ) Please note: Use IRBadmin@auburn.edu for questions and information; use IRBsubmit@auburn.edu for protocol/forms submissions. Dear Ms. Hardin, Your protocol entitled "The Integration of the Arts into Baccalaureate Nursing Education (working title) " has been approved by the IRB as "Exempt" under federal regulation 45 CFR 46.101(b)(2 ). (*** If you change the title, please send an updated online information letter.) Official notice: This e-mail serves as official notice that your protocol has been approved. A formal approval letter will not be sent unless you notify us that you need one. By accepting this approval, you also accept your responsibilities associated with this approval. Details of your responsibilities are attached. Please print and retain. Information Letter: Your letter(s) will soon be forwarded to you. However you still need to add the following IRB approval information to your information letter: "The Auburn University Institutional Review Board has approved this document for use from August 22, 2013 to August 21, 2016. Protocol #13-295 EX 1308" You must use the updated document to consent participants. Once you have made the update you may begin your study. Please forward the actual electronic letter with a live link so that we may print a final copy for our files. Expiration ? Approval for three year period: ***Note that the new policy for Exempt approvals is a three year approval. Therefore, your protocol will expire on August 21, 2016. Put that date on your calendar now. About three weeks before that time you will need to submit a renewal request. When you have completed all research activities, have no plans to collect additional data and have destroyed all identifiable information as approved by the IRB, please notify this office via e-mail. A final report is no longer required. If you have any questions, please let us know. 184 Best wishes for success with your research! IRB Administrator Office of Research Compliance 115 Ramsay Hall (basement) Auburn University, AL 36849 (334) 844-5966 IRBadmin@auburn.edu (for general queries) 185 (NOTE: DO NOT AGREE TO PARTICIPATE UNLESS IRB APPROVAL INFORMATION WITH CURRENT DATES HAS BEEN ADDED TO THIS DOCUMENT.) INFORMATION LETTER for a Research Study entitled ?Integration of the Arts into Baccalaureate Nursing Education? You are invited to participate in a research study to gain information about the AACN baccalaureate nursing programs in the southeast. The study is an exploration of the baccalaureate nursing curricula, as well as, nurse educator perspectives related to the American Association of Colleges of Nursing Essential I: Liberal Education for Baccalaureate Generalist Nursing Practice, outcomes. The study is being conducted by Heather Hardin, MSN, RN, under the direction of Dr. Maria Witte, EdD, in the Auburn University Department of Education. You were selected as a possible participant because you are considered a nursing education leader with in the southeast and are age 19 or older. What will be involved if you participate? Your participation is completely voluntary. If you decide to participate in this research study, you will be asked to complete a brief survey. Your total time commitment will be approximately ten to fifteen minutes. Are there any risks or discomforts? The risks associated with participating in this study are minimal. To minimize these risks, we will maintain confidentiality of all responses. You will not be asked for your name. Are there any benefits to yourself or others? If you participate in this study, you can expect to be asked about the Liberal Arts portion of baccalaureate nursing education. Benefits to others may include an increase in the understanding of how to incorporate the liberal arts into baccalaureate nursing education. There is no compensation offered for your ten to fifteen minutes of time. 186 There are no costs with the exception of ten to fifteen minutes of your time. If you change your mind about participating, you can withdraw at any time by closing your browser window. If you choose to withdraw, your data can be withdrawn as long as it is identifiable. Once you?ve submitted anonymous data, it cannot be withdrawn since it will be unidentifiable. Your decision about whether or not to participate or to stop participating will not jeopardize your future relations with Auburn University, the Department of Adult Education. Any data obtained in connection with this study will remain confidential. We will protect your privacy and the data you provide by using a number identifier. Information collected through your participation will be used in a dissertation for partial fulfillment of a doctoral degree in Adult Education If you have questions about this study, please contact the doctoral student, Heather Hardin at hzh0021@tigermail.auburn.edu or the chair of the committee, Dr. Maria Witte at MMWitte@auburn.edu . If you have questions about your rights as a research participant, you may contact the Auburn University Office of Human Subjects Research or the Institutional Review Board by phone (334) 844- 5966 or e-mail at hsubjec@auburn.edu or IRBChair@auburn.edu. HAVING READ THE INFORMATION ABOVE, YOU MUST DECIDE IF YOU WANT TO PARTICIPATE IN THIS RESEARCH PROJECT. IF YOU DECIDE TO PARTICIPATE, PLEASE CLICK ON THE LINK BELOW. YOU MAY PRINT A COPY OF THIS LETTER TO KEEP. Heather Hardin, MSN, RN July 9, 2013 Investigator Date Maria Witte, EdD July 9, 2013 Co-Investigator Date The Auburn University Institutional Review Board has approved this document for use from August 22, 2013 to August 21, 2016. Protocol #13-295 EX 1308 LINK TO SURVEY 187 Appendix C Examination of the Population 188 Table 38 Control of Institution within the Population Control of Institution Count of public and private southeastern AACN school population Public 104 Private not-for-profit 67 Private for-profit 16 Total 187 Table 39 2000 Carnegie Classifications of Population 2000 Carnegie Classification Count within southeastern AACN school population Not classified, not in classification universe 8 Doctoral/Research Universities? Extensive 25 Doctoral/Research Universities? Intensive 11 Master's Colleges and Universities I 76 Master's Colleges and Universities II 11 Baccalaureate Colleges?Liberal Arts 6 Baccalaureate Colleges?General 22 Baccalaureate/Associate's Colleges 2 Associate's Colleges 16 Specialized Institutions?Medical schools and medical centers 5 Specialized Institutions?Other separate health profession schools 3 Specialized Institutions?Schools of engineering and technology 1 Specialized Institutions?Teachers colleges 1 Total 187 189 Table 40 Count of Undergraduate Program Classification Undergraduate Program Classification Count of Population Special focus institution 12 Associates 5 Associates Dominant 8 Arts & sciences focus, high graduate coexistence 1 Arts & sciences plus professions, no graduate coexistence 2 Arts & sciences plus professions, some graduate coexistence 3 Arts & sciences plus professions, high graduate coexistence 4 Balanced arts & sciences/professions, no graduate coexistence 7 Balanced arts & sciences/professions, some graduate coexistence 39 Balanced arts & sciences/professions, high graduate coexistence 16 Professions plus arts & sciences, no graduate coexistence 6 Professions plus arts & sciences, some graduate coexistence 59 Professions plus arts & sciences, high graduate coexistence 12 Professions focus, no graduate coexistence 4 Professions focus, some graduate coexistence 6 Professions focus, high graduate coexistence 3 Total 187 190 Appendix D Leen Nursing Program Essentials and Effectiveness Survey and the Catalog Survey 191 Leen Nursing Program Essentials and Effectiveness Survey Part I Respondent Demographic Data Please complete the following information: 1. Title and position in the school of nursing. 2. Length of time in your present position 3. What is your gender? Part II General Information 1. How often do nursing students graduate with a BSN from your institution? 2. Please enter the average number of baccalaureate graduates per BSN graduating class? 3. Are you accredited by the CCNE? 4. Does your institution offer distance learning for BSN students? According to the AACN (2008), there are nine Essentials that guide the expected outcomes of BSN graduates. Essential one states that a liberal education is necessary. Furthermore, liberal education is further defined to include the sciences (physical, life, mathematical, and social sciences) and the arts (fine arts, performing arts, and the humanities). Part III The Arts within the Liberal Education Program 1. The arts within the Liberal Education program has been reviewed in the last five years. Yes or No 2. The arts within the Liberal Education program is in need of review. Yes or No 3. The arts within Liberal Education program requirements are taken throughout the four college years (vertically). Yes or No 4. The language and composition requirements (writing) are integrated across the curriculum. Yes or No 5. More than 50 percent of the arts within the Liberal Education courses are interdisciplinary. Yes or No 6. More than 50 percent of the arts within the Liberal Education courses are taught in small groups, seminars, and discussions (less than 30 students). Yes or No 7. In your judgment, what is the greatest strength of your institution?s arts within Liberal Education program for baccalaureate nursing students? 8. In your judgment, what is the greatest weakness in your institution?s arts within Liberal Education program for baccalaureate nursing students? 192 Part IV Arts Education in Baccalaureate Nursing Programs Finally, rank the overall effectiveness of your program in meeting the recommendations outlined by The Essentials of Baccalaureate Education for Professional Nursing Practice (2008) published by the American Association of Colleges of Nursing for the education of the professional nurse using the following key: 4 Very Effective Outcomes ensured by successful completion of the required Liberal Education coursework (90-100 percent of the time) 3 Effective Outcomes ensured most of the time by completion of the required Liberal Education coursework (50-89 percent of the time) 2 Minimally Effective Outcomes partially achieved by completion of the required Liberal Education coursework. (10-49 percent of the time) 1 Ineffective Outcomes not ensured through completion of the required Liberal Education coursework (Less than 10 percent of the time) To what extent do you feel that the arts (fine arts, performing arts, and the humanities) within the baccalaureate program prepare the graduate to: (AACN Essentials, 2008) http://www.aacn.nche.edu/education-resources/baccessentials08.pdf 1. Integrate theories and concepts from liberal education into nursing practice. 1 2 3 4 2. Synthesize theories and concepts from liberal education to build an understanding of the human experience. 1 2 3 4 3. Use skills of inquiry, analysis, and information literacy to address practice issues. 1 2 3 4 4. Use written, verbal, non verbal, and emerging technology methods to communicate effectively. 1 2 3 4 5. Apply knowledge of social and cultural factors to the care of diverse populations. 1 2 3 4 6. Engage in ethical reasoning and actions to provide leadership in promoting advocacy, collaboration, and social justice as a socially responsible citizen. 1 2 3 4 7. Integrate the knowledge and methods of a variety of disciplines to inform decision making. 1 2 3 4 8. Demonstrate tolerance for the ambiguity and unpredictability of the world and its effect on the healthcare system. 1 2 3 4 9. Value the ideal of lifelong learning to support excellence in nursing practice. 1 2 3 4 193 Catalog Survey State: _______ School: _________________________________________________________ CATALOG SURVEY Review the School Catalogs from the respondents of the Leen Nursing Program Essentials and Effectiveness Survey to answer the following: (multiply quarter hours by 0.75) In semester hours, indicate the number of credit hours required within the professional nursing education In semester hours, indicate the total number of hours required for the BSN Prescribed Series of courses 1=yes, 2= yes for 1-3 class choices, 3=no > 3 class choices. NCLEX? Pass Rates 2011-2012 Indicate the number of semester hours that are elective Are the arts (fine arts, performing arts, and/or the humanities) included across the baccalaureate curriculum (across 4 years)? 1=yes, 2= no Indicate the number of semester credit hours dedicated to the arts (fine arts and performing arts) Indicate the number of semester credit hours dedicated to Writing/English composition/ Literature Indicate the number of hours dedicated to theology and philosophy Indicate the number of semester credit hours dedicated to foreign language Indicate the total number of semester credit hours dedicated to the humanities as defined by the AACN Indicate the total number of semester credit hours dedicated to the humanities and the arts (fine arts and performing arts) Indicate the number of semester credit hours dedicated to history (Western and NonWestern) and Cultural Studies (International, 3rd World, Global, anthropology), Indicate the number of semester credit hours dedicated to communication studies, law, political science Indicate the number of semester credit hours dedicated to psychology and sociology Indicate the total number of hours dedicated to the social sciences. Other required courses Other required courses Comments