1 International Journal of Nursing Studies 43 (2006) The experience of nursing students in an online doctoral program in nursing: A phenomenological study Margaret Jordan Halter, Catherine Kleiner, Rosanna Formanek Hess Malone College th Street NW Canton, OH 44709, USA Received 3 September 2004; received in revised form 15 February 2005; accepted 1 March 2005 Abstract The increased sophistication of technology has led to greater use of distance learning, providing graduate nursing students with increased access to such programs, while more easily maintaining employment. Little information is available regarding the experience for those students enrolled on these programs. This information would be of value to both those who are considering online courses, and to those who are charged with developing and teaching these courses. A phenomenological approach was used in order to examine the experience of five students enrolled in an online doctoral program in nursing in the United States. Verbatim transcripts were analyzed for themes from which three main ones emerged as the essence of the experience: considering the fit, liking the fit, and making it fit. Recommendations are provided for future research pertaining to distance education, particularly in the form of graduate outcomes. r 2005 Elsevier Ltd. All rights reserved. Keywords: Distance-learning; Doctoral; Nursing; Education; Nursing shortage 1. Introduction The future of healthcare is a global concern, especially as the median age of the world s population increases due to a reduction in fertility, an increase in lifespan, and the graying of individuals born during the two decades after World War II (United Nations, 2002). At the same time, healthcare workers are aging and their numbers are declining. This imbalance may be especially severe in regards to nurses, the world s largest group of healthcare workers. A shortage of nurses is already being experienced worldwide and is endangering safe patient care and leading to a further erosion of satisfaction among nurses (Clark and Clark, 2003). According to the American Nurses Association (ANA, 2003) the shortage in the United States is being Corresponding author. address: (M.J. Halter). addressed through a variety of mechanisms including legislation to prohibit mandatory overtime (2003). One of the greatest efforts in combating the shortage is to boost enrollment in schools of nursing. This is being done through national advertising campaigns, increasing racial/ethnic diversity, and improving financial support. These efforts seem to be paying off in terms of attracting students to the profession enrollment in baccalaureate nursing programs increased by nearly 17% between 2002 and 2003 (American Association of College of Nursing (AACN), 2004). However, qualified applicants have been turned away from nursing programs due to an even more severe shortage, namely a shortage of nursing faculty. Demand that exceeds supply will likely intensify due to retirement of doctorally prepared faculty whose mean age is 53.3 years (AACN, 2003), especially since there are too few students who will be prepared to take their places /$ - see front matter r 2005 Elsevier Ltd. All rights reserved. doi: /j.ijnurstu
2 100 M.J. Halter et al. / International Journal of Nursing Studies 43 (2006) Increased numbers of doctorally prepared nurses are needed due to a demand for faculty, administrators, researchers, and theorists who possess a nursing doctorate, a demand that exceeds the supply. Particularly critical is a need for educators at the college and university level with doctoral preparation. According to the AACN (1999) fewer than half of the nursing faculty employed by colleges and universities has earned this degree, a number inconsistent with other disciplines in the academic setting where the doctorate is typically a standard entry-level requirement. Furthermore, 40% of doctorally prepared nursing faculty have degrees in other fields. Despite the need for increased numbers of doctorally prepared nurses, doctoral programs are offered at only 88 United States nursing schools, with about 3500 students enrolled in Only 419 doctoral candidates graduated during that academic period, down 10% from the prior year (AACN, 2004). What factors contribute to this faculty shortage? One factor is a financial disincentive, the tuition and loan burden is not offset by eventual increased compensation. New nurses (diploma, associate degree, and baccalaureate degree) can make $55,000 a year, and nurse practitioners (masters degree) make an average of $69,000 a year (Tumolo and Rollet, 2003; AACN, 2004). Doctorally prepared nurse faculty make an average of $59,999 as an instructor and $66,000 as an assistant professor. Doctorally prepared faculty members close the gap only after years of service $77,000 as associate professor and $95,000 as a full professor and even then could command a higher salary outside of academia (AACN, 2004). Despite these wage disparities, nurses are attracted to pursue an academic career. However, when nurses make the decision to pursue a doctorate, they tend to be older than students in other disciplines, typically have established careers, have financial and family responsibilities, and unlike most other doctoral students, the majority of them work full-time and study part time (Anderson, 2000). In the United States there are only 88 doctoral programs in nursing (AACN, 2004); finding one that is within commuting distance, not to mention consistent with the student s research interests, may be impossible. To address the barrier of proximity, nursing programs are offering distance learning options and they are becoming a common method of acquiring a nursing education. This change has raised questions and has been the impetus for a myriad of studies examining topics such as the quality of distance education (Leasure et al., 2000), online teaching methods (Ryan et al., 1999), and design and delivery issues (Halstead and Coudret, 2000). Few studies have examined what it is like to be a student in a distance learning nursing program. In one study, graduate students identified inaccessibility to faculty, problems with technology, and a sense of isolation as being drawbacks to this method (Ali et al., 2004). In another study, students were asked what the best things were and what could be improved about web-based courses. Undergraduate and graduate nursing students identified convenience and skilled faculty facilitation as pros, and expressed concern about the altered nature of connectedness/interaction with faculty and peers through this medium as cons (Seiler and Billings, 2004). A further understanding of distance learning from the students perspective may be valuable to those who are considering such an education for themselves, and also to administrators and faculty charged with developing these programs. The purpose of this study was to explore the experience of doctoral nursing students who are being educated in an online program. 2. Methodology A phenomenological research method was chosen for this study in order to explore the participants lived experience. The goal in phenomenological research is to discover meaning by integrating the experience of those researched, the researcher, and the reader of the research into a whole (Van Manen, 1990). The researcher identifies themes that capture the essence of the experience based on the words and expression used by those interviewed. Phenomenological nursing research may investigate such feelings as hope and happiness, or concepts such as developing friendships Setting All participants in this study were enrolled on an online nursing doctoral (Ph.D.) program at a private university in the Eastern United States that began offering a distance learning option in 1997 it was the first completely online doctoral program in nursing (Milstead and Nelson, 1998). At the time of the study, the program had about 45 students enrolled. The curriculum was comprised of a theory and a research sequence, cognates, an elective, and a health policy course. All core courses were offered online in a combination of synchronous and asynchronous modes. After completion of coursework, students focus on the dissertation. Faculty communicated with students via online chats, , mail, telephone, and fax. At the completion of the first and second years for initial cohorts (and prior to beginning the program for later cohorts) students were required to attend a residency week of meetings, classes, and social events, and time was provided for students to meet individually with the faculty. Students met with members of their own cohort and had the opportunity to meet students in other cohorts.
3 M.J. Halter et al. / International Journal of Nursing Studies 43 (2006) Participants A sample of five female doctoral nursing students was recruited through an request for participants from students enrolled in the same doctoral program. Those who participated were students in various stages of the program, from second semester to the dissertation phase. Students ages ranged from 39 53, and they were living in United States and two other countries. One researcher who was also enrolled on the program conducted all the interviews in an observer participant role (Polit et al., 2004). The researcher informed the participants of their confidentiality and potential risks, and consent was secured Procedure Approval for this study was granted by the university in which the students were enrolled. For consistency, interviews were conducted by only one of the three researchers involved in this study. Interviews were scheduled for a mutually acceptable time and took approximately 1 h. Three of the interviews were audio taped one in person, and two on the phone. Two of the interviews were recorded from an online chat format since the participants were outside the United States. The interview began with the question, What has it been like for you being enrolled in the nursing online PhD program? Further questions clarified comments. During data collection, two of the three researchers met periodically to discuss progress of the interviews and potential biases that might be entering into the process. Trustworthiness in this study was established in several ways. Because two of the researchers were also students in an online nursing doctoral program they bracketed their own opinions and facts (Speziale and Carpenter, 2003). To counteract possible bias another nurse researcher who had no experience with online education was involved in the analysis phase. To increase the depth of explanations, the interviewer asked for negative descriptions (Speziale and Carpenter, 2003). For example, when the participant described what he or she liked about the online program, the researcher also asked what was not liked. Using a team approach to increase the credibility of the study s findings, each researcher carried out an inductive analysis of the data. The three researchers then compared their findings, increasing thoroughness of thematic description (Norwood, 2000) Findings Verbatim transcripts of the interviews provided the data from which the essence of the experience emerged. Themes were constructed by highlighting words and statements that were common to the interviews and essential in their meaning. This essence is encompassed in three main themes. They are: considering the fit, liking the fit and making it fit. Several pertinent issues raised within the themes were also revealed Theme 1: Considering the fit Every student had to make some important decisions when considering a doctoral education. The online Ph.D. in nursing allowed students the opportunity to pursue a doctoral education they would not otherwise have been able to do. I didn t have to rethink what I am doing for a living to fit my academic process, one student said (Participant No. 2). Lack of proximity to programs was described as a major deterrent to enrolling at traditional schools. Long commutes were prohibitive for students who had commitments such as full-time employment and family obligations. One woman (P.No.2) stated, Where I was living, the closest program was two hours away for a Ph.D. in nursingy. But considering commuting into the city, it adds like, that extra burden of time of getting yourself in where you need to be, so that would have been a hassle. Another student (P.No.3) said, I wasn t up for another commute, and I thought, if I m going to do this (get a Ph.D.), let s see if this works. Moving closer to a program was not an option for others. One participant lived in Canada, and another in Israel, at the time of their enrollment. One woman said, I had been thinking of Ph.D. studies, but it almost seemed like an impossibility living [where I live] and being a single parent. So this seemed like an ideal opportunity. She added, I would have had to move somewhere, and it would have been a big sacrifice too big probably (P.No.4). Besides geographical considerations, some participants also mentioned the issue of learning atmosphere. The idea of interacting on a computer was not like, even a consideration. I thought it would be quite easy. I did wonder whether I d miss the interpersonal stuff (P.No.2). Another said, One of the things I worried about was having sort of the collegiality that you have in a classroom setting (P.No.3). Both were satisfied once enrolled despite initial concerns Theme 2: Liking the fit All of the people interviewed rated their online nursing Ph.D. program in generally positive terms. One said, It s been a great experience, much better than I could have anticipated. I find that it s challenging and yet very manageable (P.No.4). Another declared, My experience has been wonderful. I have loved almost every minute of it (P.No.3).
4 102 M.J. Halter et al. / International Journal of Nursing Studies 43 (2006) Appreciation of the online style of education was evident from comments about personal preferences as well as the convenience from a day-to-day perspective. One student (P.No.1) said, Being in a class online really suits my personality because I m not someone who really is kind of, um, belongs in a group or needs a group to get along y It s easier for me because it suits my personality. I can work on my own and to me it s very convenient to me to have people and resources available in that manner, online. Another student (P.No.2) was satisfied for a slightly different reason. Sometimes I think that another positive thing is that, I tend to be a little on the shy side. Like when I meet people I am less talkative than I am online y So I find that it s a little bit liberating to be online. Most students were employed or had other commitments that required being out of town during class time and were grateful to be able to participate from a remote location, even from a ski lodge. Even considering time zone differences, one student (P.No.5) focused on the comfort of being online rather than in a classroom, saying I would log on anywhere between 10:00 3:00 a.m. with a large mug of tea, sweats, and a blanket wrapped around me. Another (P.No3) discussed the pros and cons. I did feel that isolation sitting behind my computer. It was a small price to pay for having an opportunity to sit in a course on a winter night and be in my pajamas and coffee with me. The good outweighs the bad. The time saved in commuting could be applied directly to course work, jobs, and maintaining family life. A student noted that her 2-yr-old son was sick one evening during class. She was able to hold him in her lap and comfort him while she participated in class. This may seem to be interference, but it is likely that she would be more distracted if she had to travel to campus and worry during class how he was doing. The online format allowed her to manage class and family at the same time. Another student (P.No.2) expressed it this way. The ability to interact in a classroom setting and not have to factor in the time of commuting to and from, finding parking, all that kind of stuff y you kind of consider background noise in your education process. The flexibility of the program provided students with the ability to complete it in a time frame that fits their needs and financial situations. Students cited the additional benefit of taking courses either one at a time or full time, making it easier to juggle work and family. One student (P. No.2) expressed her opinion this way. We like to be kind of flexible and mobile. So it was either a decision ofysaying this is where we re going to be for the next seven years or whatever, or being able to maintain the flexibility of our lifestyle Theme 3: making it fit Several factors in the online situation required students to learn new skills and modify old ones. These included issues of online technology as well as interpersonal communication. Several sub-themes compose this category: adapting to the technology, talking online, feeling isolated, and building relationships. Adapting to the technology: Some students were very adept working on line, in what one (P.No.2) called, the technology of interacting. Others had to learn. One (P.No.3) confessed, It took some getting used to. Another (P.No4) also admitted, I was terrified of all the technology. I didn t think I d ever really get it going, but I called [so and so] and he was very helpful. Once I got the knack of the first class, the rest was a piece of cake! Talking online: It was necessary for students to adjust to communication based almost exclusively on the written word. Practical issues such as accommodating for different typing speeds, ignoring spelling errors and dealing with multiple comments on the screen simultaneously were mentioned. However, the starkness of the written word without nonverbal modifiers such as facial expression and tone of voice was often disconcerting and challenging. One student (P.No1) said, You don t have as much time to consider your responses. You can t make a lot of references to other things y you write ten words and if you write more than that, you are going to be left behind. You have to communicate very succinctly. Somebody will write a word and that word becomes of interest, and you just use the first letter of that word to abbreviate it. So we have abbreviations and the communication becomes very short, succinct, and concise. She continued. You miss their facial expressions and the tone of voice, so that you have to, tend to take people more at their word y we have a lot of little things on-line that will indicate our tone of voice, but it s not the same as talking face-to-face. On the other hand, students could not melt into the background and simply nod their heads to indicate involvement. Though active participation during class time is an expectation of traditional graduate courses, contributions in these online classes were more noticeable. Your presence is only felt when you are typing in and commenting. Your presence isn t felt online unless you are really participating. (P.No.2) Isolation: Students reported feelings of isolation, especially early in the program and after core courses were completed. The lack of informal talk, little
5 M.J. Halter et al. / International Journal of Nursing Studies 43 (2006) processing of ideas, and absence of physical presence complicated the usual socialization. This isolation also contributed to a sense of uncertainty regarding interpretation of assignments or understanding of material. It extended to informally interacting with faculty. One student (P.No.3) remarked, There isn t that opportunity to kind of stop by and say, I m feeling overwhelmed, I don t understand this assignment. It s a little more formal in that you y have to schedule a time. You almost have to have a reason for the call. Another student (P.No.5) added, I felt very isolated when doing the online classes. I looked forward to them, but often worried that I was perhaps less prepared or informed than other students because I am living in this bubble here. Although students desired more personal contact, they believed that the lack of face-to-face interaction was a reasonable price to pay for the benefit and convenience of online education. Furthermore, thriving in this atmosphere was seen as a virtue, as a symbol of independent learning. One student (P.No.2) expressed it this way. A person who needs an unusual amount of guidance (and there are always people like that at every level), I think would have a hard time not having someone who they could access face-to-face, you know, plop down in the office for an hour and get some positive strokes. In response to feelings of isolation, students developed methods of coping by identifying and utilizing a support system in their own community. I guess it s always something that s going to come up with online education and you re not going to have that person-to-person communication. You have to do what works y try to find your own sort of support system in your community. (P.No3) Developing relationships: Students were interested in how relationships developed online. This was particularly true for students from early cohorts who spent an entire year with their group before meeting face-to-face during the on-campus week. In my first courses, I honestly felt that I was playing some sort of game every week. I knew that there were real people on the other end, but I could only imagine who they were. When we met in May and I got to see the campus and the real professors, I realized that, yes, I am in a Ph.D. program and, yes, I have real classmates! (P.No.4) Students developed ideas of what individuals in their cohort would look like based on their online personalities. There was a sentiment that these preconceived notions were actually a part of the learning experience. It was amazing pictures in my head that I had of each person and what they thought about me, what I thought about them, when we met a year later was very, it was just really interesting to find out how much about someone that I could actually get online and how much I was wrong about y People perceived me as being harsher, stronger, more emphatic, very confident. (P.No.1) After meeting one another, students expressed surprise over their inability to guess the appearance of others. Most students created mental images of their peers that were invariably incorrect. This seemed to have little influence on the bond that developed during that first year in the online program, and may have actually helped. Furthermore, students may have benefited by having the pressure of the physical presence and visual prejudices removed. What s interesting is that once we all figured out who we really were, we just all sort of hit it off immediately there wasn t that uncomfortable feeling that you have when you first meet a bunch of new people y I consider them friends even though we don t really see each other. (P.No.3) The feeling of a common interest and sense of navigating uncharted waters strengthened the bonds that developed. Students described an unusually quick and intense development of rapport. I felt that our cohort bonded quite well right from the start we had the attitude that we re in this together and I ve noticed that the other cohorts seem to be the same a sense of identity. But it wasn t until we met in person that I felt a real closeness. (P.No.4) The geographical diversity within the cohorts provided an opportunity for expanded professional networking and learning. It sort of opened my experiences up on what is done on the West Coast, what is done in the Midwest. If I had gone to another program in [my city] it would have been primarily [people from my state] and I wouldn t have had that experience of meeting people across the country. (P.No.3) The development of faculty student relationships seemed satisfactory to the participants. The faculty provided support including prompt replies to or telephone contacts, connecting the student to the institution, and generally going beyond what is ordinarily expected in a professor. Students were unanimous in believing that faculty who teach online courses should be more skilled in leading a conversation and directing a group. Students described this as a balancing act of keeping the group focused, while encouraging openness from everyone in sharing opinions or thoughts. Overall, students asserted
6 104 M.J. Halter et al. / International Journal of Nursing Studies 43 (2006) that faculty members need to maintain control of the environment and actively direct the conversation. [A good facilitator would] pull everyone in who was online. If someone was quiet or not as involved with the discussion, the instructor would make a point of asking them what their thoughts were. A good facilitator kind of needs to keep things moving and keep us focused on the topic. (P.No.3) Students indicated that most teachers demonstrated a high level of skill in teaching online, essential to helping students to adjust to the format. The participants especially appreciated those teachers who had materials organized and posted well before class time. 3. Limitations This was a convenience sample consisting of only 5 of 45 potential students. Despite the fact that numbers were low, the researchers believe that the clear emergence of patterns from students who were at different points in the program and from varied backgrounds underscore the importance of these data. Two of the three researchers conducting this study were online doctoral students themselves at the time of the interview and may have introduced bias. A third researcher one who was unfamiliar with the program, the selection of the participants, and particular issues involved in online education also analyzed the data. Conducting interviews through three different methods in person, on the phone, and through an online chat format may have changed the quality or even quantity of data collected. The face-to-face interview provided for verbal and nonverbal cues, which facilitated the progression of the interview. The reverse may also be true that in-person interviews may impede the progression of the interview due to the interference from interpersonal cues. The telephone interviews were convenient and provided verbal cues for understanding meaning, however, visual cues are absent. The online interviews were convenient and provided a transcribed record of the interview. Drawbacks to online interviews may include one of the same as with online education in general, that is, the inability to capture richness and depth of meaning without visual and verbal cues. Furthermore, online interviews require more time to elicit typed responses as compared to verbal communication. 4. Discussion When asked about their experience in an online doctoral program in nursing, students indicated they were grateful to have a program available to them. One student (P.No.4) summed up her feelings this way. Iam very thankful that this opportunity is there for me. I know that this is the only way that I would ever be able to get a Ph.D. in nursing. Not all of these views were specific to being online, but were actually issues common to being doctoral students. What may have seemed to these students as unique to online education may, in fact, be typical of doctoral education. For example, the students descriptions of the qualities that make a professor adept sounded remarkably similar to descriptions of any proficient teacher students prefer faculty who provide direction, yet are not heavy-handed. The online experience undoubtedly exacerbated feelings of isolation, but these feelings, again, are common to graduate students. Particularly as students complete their coursework and move into the solitary phase of dissertation writing, feelings of isolation are a rite of passage. Students described the program as similar to a classroom setting. While acknowledging the differences between the online education and a traditional one in terms of process, they consistently identified their own role in learning as a role that should be assumed by any doctoral student. Students highlighted the fact that this program was chosen in order to learn, obtain research skills, and credentials the same reasons that students would choose a traditional doctoral program. A sense of self-direction was emphasized. For me I am pretty convinced that the education that I am getting in this program is similar to what I d be getting face-to-face. It s not the same type of experience of where we re all in the classroom every week and we love and support each other and pat each other on the back and hear about each others kids and I think that that s unfortunate y I also don t think it s essential to my education. I think that the education that I am getting is equal to what I am putting into it. I m really concentrating on what I need to learn, and developing relationships that will help me to learn, rather than developing relationships that will support me emotionally. The emphasis is on the educational program. (P.No.1) 5. Implications for nursing In examining options and trends for nursing education, it is likely that distance learning will continue in prominence and acceptability. Online education provides nurses who have established careers and families an additional opportunity to continue their formal education. The students believe that the quality of education is just as good as the education they would receive in the traditional classroom setting. A shortage of nurses prepared at all levels raises the concern that we could move too hastily to increase our
7 M.J. Halter et al. / International Journal of Nursing Studies 43 (2006) numbers through the mass production of nurses educated in a nontraditional (online) fashion. However, this seems unlikely given that the nursing profession is known for its attention to detail and thoroughness in undertaking new ventures. A greater concern may be that caution could possibly cost the profession, at least in the short term, lost potential in educating the next generation of nurses and nurse educators. 6. Recommendations Online learning departs from the traditional image of the academy with scholarly activity taking place behind ivy-covered brick walls. While online doctoral education in nursing may be viewed with skepticism, there is little research to support or refute possible concerns. Further studies are needed to examine the similarities and differences in online and traditional programs. A greater understanding of the social and psychological impact of online education is necessary. If an essential quality of communication is nonverbal, what elements of communication are impacted by distance learning? What are the psychological advantages/disadvantages of online learning? A related issue concerns the distinction between synchronous and asynchronous learning and how these two forms of distance learning influence the socialization process. This is especially important for this school because since the time that data was collected for this study, the program has changed from a synchronous to a largely asynchronous mode. In terms of outcomes for the students, longitudinal studies on the careers of graduates from traditional and distance doctoral programs would be useful. Similar studies that focus on issues such as publication quality and rate, career advancement, acquisition of leadership roles, and influence in health policy would be useful. Also, given the exposure to classmates from around the world, how professional networking is influenced would be worth examining. 7. Conclusion As educators and students struggle to understand the impact of technology on education, studies regarding online education should grow in importance. While the experience of online students is not the ultimate test of this educational trend, it is the acid test since no educational program can survive without enrollment, and enrollment is contingent upon students perceiving and accepting the value of distance education. An understanding of this experience will provide direction for program development and can ultimately bolster the waning number of faculty available to educate the next generation of nurses. References Ali, N.S., Hodson-Carlton, K., Ryan, M., Students perceptions of online learning: implications for teaching. Nurse Educator 29 (3), American Association of Colleges of Nursing, Salaries of instructional and administrative nursing faculty. Author, Washington, DC. American Association of Colleges of Nursing, Faculty shortages in baccalaureate and graduate nursing programs: scope of the problem and strategies for expanding the supply. Author, Washington, DC. American Association of Colleges of Nursing, enrollment and graduations in baccalaureate and graduate programs in nursing. Author, Washington, DC. American Nurses Association, ANA applauds introduction of mandatory overtime legislation. News release: Author. Retrieved September from nursingworld.org/pressrel/2003/pr0212.htm. Anderson, C.A., Current strengths and limitations of doctoral education in nursing: are we prepared for the future? Journal of Professional Nursing 16 (4), Clark, P.F., Clark, D.A., Challenges facing nurses associations and unions: a global perspective. International Labour Review 142 (1), Halstead, J.A., Coudret, N.A., Implementing web-based instruction in a school of nursing: implications. Journal of Professional Nursing 16, Leasure, A.R., Davis, L., Thievon, S.L., Comparison of student outcomes and preferences in a traditional vs. world wide web-based baccalaureate nursing research course. Journal of Nursing Education 39 (4), Milstead, J.A., Nelson, R., Preparation for an online asynchronous university doctoral course. Computers in Nursing 16, Norwood, S.L., Research strategies for advanced practice nurses. Prentice-Hall, Upper Saddle River, NJ. Polit, D.F., Beck, C.T., Hungler, B.P., Essentials of nursing research: methods, appraisal, and utilization, fifth ed. Lippincott, Philadelphia. Ryan, M., Hodson-Carlton, K., Ali, N.S., Evaluation of traditional classroom Teaching methods versus course delivery via the world wide web. Journal of Nursing Education 38 (6), 1 6. Seiler, K., Billings, D.M., Student experiences in webbased nursing courses: benchmarking best practices. International Journal of Nursing Education Scholarship 1(1). Retrieved December from ijnes/vol1/iss1/art20/. Speziale, H.J.S., Carpenter, D.R., Qualitative research in nursing: advancing the humanistic imperative, Third ed. Lippincott Williams and Wilkins, Baltimore. Tumolo, J., Rollet, J., National salary survey for nurse practitioners. Advance for Nurse Practitioners 12(7). Editorial/Editorial.-aspx?CC= United Nations, Report of the second world assembly on aging. Author, Madrid, Spain. Van Manen, M., Researching lived experience. State University of New York, New York.