Abstract: Leaders help groups navigate change while also staying true to founding values and identity. This article explores that dynamic in Seventh-day Adventist healthcare. This qualitative study distilled 12 original founding principles from a document analysis of Ellen G. White’s 1860s visions on health. It used feedback from Adventist historians to articulate these 12 principles. It then asked Adventist Healthcare leaders from around the world to discuss the nature and applicability of these 12 to current practice. Several principles were seen as universally practiced in all healthcare. Several principles were seen as possible with adaptation to modern practices. Others were viewed as challenging within many modern practices. These findings are discussed in light of the challenge to manage change while maintaining founding values.
Leaders are critical actors in organizational change, either as initiators or implementors (Walk, 2023). Leaders in faith-based institutions face the additional challenge of keeping their core “moral and spiritual commitments” and “integrity” during these changes (Iltis, 2003, p. 5). This creates a constant existential challenge to remain faithful to core commitments while navigating other changes to make those commitments and/or the organization viable in the future. How is this done?
This article explores this dynamic through the story of Seventh-day Adventist (Adventist) healthcare founding values and current practices. Faith-based healthcare organizations are a valuable place to study, given that they face both deeply anchored identities and radically changing contexts. They typically have a rich tradition, a long-developed story, and a settled identity with invested values and interests. However, they also operate in a volatile context with constant change from new technologies, techniques, research, innovation, and political and governmental reform. This creates an ideal space to explore ways leaders think about old commitments while facing new realities and a new future.
Adventist healthcare has experienced 150 years of change and, like many other organizations, it has faced changing contexts (Cummings & Worley, 2008). This article explores Adventist healthcare’s founding values and governing principles and seeks to understand how its leaders connect these to current practices.
Research Context, Design, and Procedures
The study sought to answer three questions: 1. What were the 19th-century governing principles of Adventist healthcare? 2. How do Adventist historians and experts understand and interpret these Adventist healthcare core commitments? 3. How do Adventist healthcare leaders and experts believe these governing principles work to define the unique Adventist healthcare identity?
This qualitative study combined document analysis and focus group techniques (Pimentel-Melendez, 2019). In stage 1, we reviewed Ellen G. White’s 1860s visions and writings because, regardless of diverse perceptions of White, she was and still is officially considered in the Adventist community to be an authoritative voice on Adventist ideas and purposes. Her first visions of healthcare institutions came before any Adventist healthcare institutions existed. We identified messages dated after the first Adventist healthcare institution existed in the same volumes. Still, we viewed this as clarifying previous messages White provided without adding new principles per se. These clarifications appear to be White’s attempts to amend already implemented misinterpretations of her first messages (White, 1872).
We then solicited Adventist historian feedback on this analysis of 19th-century Adventist healthcare governing principles. We identified experts using a snowballing technique called network or chain sampling (Bloomberg & Volpe, 2016). Three participants agreed to provide feedback; all were university scholars and doctoral holders with several academic publications on White’s studies or Adventist church history.
For the second stage, we held four different focus groups with Adventist English-speaking experienced healthcare leaders attending an Adventist healthcare international conference—the Global Healthcare Conference. A total of four different focus group sessions took place, with 26 participants from 13 countries representing the continents of North and South America, Africa, and Asia. We provided participants with the principles extracted from brief White quotes. Then, participants were asked to identify whether any governing principles listed were still valid and helpful.
In addition, we triangulated our analysis through an audit done by a PhD researcher. Finally, we held a group discussion with two Adventist medical doctors, experienced as the highest leader in an Adventist hospital, read the transcripts together, and discussed possible conclusions compared with our conclusions.
Twelve Founding Governing Principles
This study advances 12 governing principles from White’s early visions and writings. Adventist historians and experts confirmed these with slight modifications:
1. Health education and preventive medicine.
I was shown that we should provide a home for the afflicted and those who wish to learn how to take care of their bodies that they may prevent sickness. (White, 1855, p. 489)
This principle focuses institutions on teaching patients how the body functions and how to prevent sickness, often referred to as the “laws of nature” (White, 1905, p. 114) or principles of healthful living.
2. Healthcare for members of the Adventist Church.
I was shown that Sabbathkeepers should open a way for those of like precious faith to be benefited without their being under the necessity of expending their means at institutions where their faith and religious principles are endangered, and where they can find no sympathy or union in religious matters. (White, 1855, p. 490)
White envisioned Adventist healthcare institutions supporting Adventist members’ health and healing. She was concerned that sick people have weakened moral strength and that healthy individuals could not only withstand temptations from dubious ideologies but also champion faith and religious principles (White, 1855).
3. Indirect witnessing to non-believer patients.
But our peculiar faith should not be discussed with patients. Their minds should not be unnecessarily excited upon subjects wherein we differ, unless they themselves desire it. (White, 1872, p. 166)
White seems to anticipate non-Adventist patients would attend Adventist healthcare institutions. She envisioned Adventists having a positive influence on these guests. Because the best way to know about principles is to see them in practice, she envisioned hospitals to showcase the principles of the Gospel in organizational life and its employees. People tend to prejudge the Adventist faith, but seeing the principles in practice could acquaint patients with these ideas through a “silent influence” (White, 1872, p. 167).
4. Sustainable financial and administration model with attention to all social classes.
A fund should be raised to be used for the express purpose of treating such of the poor as the church where they reside shall decide are worthy to be benefited. . . . Such an institution should not in its infancy, while struggling to live, become embarrassed by a constant expenditure of means without realizing any returns. (White, 1855, p. 494)
Ellen White promoted running sustainable organizations but also being able to serve all classes (White, 1855). She reminded her readers that many healthcare institutions had closed due to financial challenges. She suggested both payment and donation processes for funding. Additionally, Ellen White emphasized that Adventist institutions should grow proportionally to obtain the profile of the committed personnel needed and expand their infrastructure.
5. Unwavering biblical principles.
They conduct it from a conscientious, religious standpoint, aiming to carry out the principles of Bible hygiene. (White, 1872, p. 165)
And should those connected with this enterprise cease to look at their work from a high religious standpoint, and descend from the exalted principles of present truth to imitate in theory and practice those at the head of institutions where the sick are treated only for the recovery of health, the special blessing of God would not rest upon our institution more than upon those where corrupt theories are taught and practiced. (White, 1855, p. 554)
At all costs, the aim was to avoid imitating business models focused on money-making enterprises, as non-faith-based hospitals operate. White warned against lowering standards to make the model more palatable for non-believers to attract paying patients. This has an essential impact on the believers since it presents a fragile conviction that produces a harmful influence instead of a positive one. White exalted biblical principles to obtain health recovery.
6. Holistic (body, mind, and soul) perspective.
Those who have suffered greatly from bodily infirmities are weak both mentally and morally. (White, 1855, p. 489)
This principle invites healthcare providers to attend to the whole being—mind, body, and spirit—and to see these as intertwined and affected by and affecting each other.
7. Physical activity as part of treatment.
The sick should be taught that it is wrong to suspend all physical labor in order to regain health. (White, 1855, p. 555)
Exercise helps “keep the power of the will awake” (White, 1855, p. 557).
According to White, rest was crucial to recovery, but so was activity. Mental health, as well as muscular development, was connected to physical exercise and was seen to have a positive impact not only on the mind and will but also on the well-being of various organ systems.
8. Preparing people to be holy before God.
It should ever be kept prominent that the great object to be attained through this channel is not only health, but perfection, and the spirit of holiness, which cannot be attained with diseased bodies and minds. (White, 1855, p. 554)
White explains that the “institution is designed of God to be one of the greatest aids in preparing a people to be perfect before God” (White, 1872, p. 166). The preparation was seen as not only connected to spiritual well-being but also to overall health—and vice versa, because a person in good health should be able to distinguish God’s voice easier.
9. Prayer combined with treatment and obedience to the laws of health
And I also saw that He designed the health reform and Health Institute to prepare the way for the prayer of faith to be fully answered. (White, 1855, p. 560)
That is the place to find relief from disease by treatment and right habits of living, and to learn how to avoid sickness. (White, 1855, p. 561).
This principle identified prayer as a healing component but in connection to medical and patient practices. This three-way dynamic speaks to the power of prayer. Ellen White envisioned Adventist healthcare, but with the conditional requirement: it must be done together with treatment and obedience to health laws. She promoted the idea of healthcare institutions having prayer meetings, not to discuss religious dogmas but to connect patients to God. The prayer session should include hospital staff.
10. God-fearing personnel.
Those who engage in this work should be consecrated to God and not make it their only object to treat the body merely to cure disease, thus working from the popular physician’s standpoint, but to be spiritual fathers, to minister to diseased minds, and point the sin-sick soul to the never-failing remedy, the Saviour who died for them. (White, 1872, p. 168)
Having the right people to promote the Adventist Healthcare model was crucial for White. The expectation is that all staff would be spiritually mature and have faith. This would not only allow hospital staff to express Gospel living (principle #3) but also model biblical principles (principle #5), prayer (principle #9), and the overall success of other principles in Adventist healthcare.
11. Therapeutic nature interaction.
I saw there should be connected with the Institute ample grounds, beautified with flowers and planted with vegetables and fruits. Here the feeble could find work, appropriate to their sex and condition, at suitable hours. These grounds should be under the care of an experienced gardener to direct all in a tasteful, orderly manner. (White, 1855, p. 562)
Treatment should include physical activity through interaction with nature since it directly impacts the patient’s mental health. When people are under the damaging effects of a disease, the negative thoughts and feelings focus on the patient’s problems. Mental health would affect both the spiritual and physical side. Nature interaction is considered the second inspired book (White, 1905), which could provide psychological rejuvenation and renewal.
12. Altruistic and trusting institutional model.
Money is not the great object with its friends and conductors. They conduct it from a conscientious, religious standpoint, aiming to carry out the principles of Bible hygiene. (White, 1872, p. 165)
White widely discusses institutional motivation in principle number 12. The institution should not be like the other “worldly” institutions in which the motivation relies on profit. White declares, “that which had been shown me as a place where the suffering sick among us could be helped was one where sacrifice, hospitality, faith, and piety should be the ruling principles” (White, 1855, p. 633).
Leaders’ Perceptions of the Principles Presented
When these 12 principles were presented to healthcare leaders, many resonated with them. Still, the principles were not equally emphasized, nor did all agree on their applicability; if any participant expressed any objection, we consider the principle as not applicable. Three of the most affirmed principles that were considered more applicable were the holistic perspective, health education, and preventive medicine; a generic reference to those principles related to spiritual and religious integration with medical practice. Most felt these were applied well in their institutions.
Two principles did not produce much discussion: indirect witnessing to non-believer patients and unwavering biblical principles. Those principles were considered as still applicable.
Seven governing principles were identified as valid and still applicable, but they led to widespread discussions about challenges in applying them to 21st-century healthcare. Those principles were: healthcare for Adventist members, sustain financial and administration model despite attention to all social classes, exercise (physical activity) as part of treatment, prayer combined with treatment and obedience to the laws of health, God-fearing personnel, therapeutic nature interaction, and altruistic and trusting institutional model.
Some participants considered two principles as not applicable because of the complexity of implementation in the 21st century. These principles were exercise (physical activity) as part of the treatment and preparing people to be holy before God.
Key Principles in the Organizational Dimensions
Strong Consensus
This study helped confirm the cultural solid adherence to the holistic perspective of body-mind-social-spirit, medical education and prevention, and spiritual and religious integration with Adventist practice. The three aspects raised in focus groups raised little discussion since they were considered as a matter of fact. Currently, those aspects are widely accepted in healthcare in general. For instance, researchers acknowledged the concept of a holistic healthcare perspective and recommended consideration of this holistic model to achieve a patient’s wholesome well-being (Chan, Ying Ho, & Chow, 2002; Clarke, 2010; Oakley, 2004). Adventist healthcare is well-identified for lifestyle and longevity. Diverse research publications on this topic, such as Adventist Health Study version 1 and 2 (Loma Linda University, n.d.), as well as the Blue Zones study, which includes Adventist communities (Buettner, 2016; Buettner & Skemp, 2016), are a clear sample of the research related to Adventist lifestyle. Similarly, researchers in the 21st century recommend integrating spirituality and healthcare (Pesut, Fowler, Taylor, Reimer-Kirkham, & Sawatzky, 2008; Zaidi, 2018).
Exercise as Part of Treatment/Therapeutic Nature
Although we listed exercise as part of treatment and therapeutic nature interaction as two separate principles, we are discussing them together due to their interconnection during the discussion. The focus group participants discussed them extensively. While some participants accepted them as a matter of fact, a couple of participants wondered about their applicability in a modern medical facility. White (1855) pointed out that “the sick should be taught that it is wrong to suspend all physical labor in order to regain health” (p. 555). This practice is currently implemented in several hospitals and recorded in diverse clinical settings in the research literature (Leggio, Fusco, Loreti, Limongelli, Bendini, Mazza, Coraci, & Padua, 2020; Zanini, Nery, Lima, Buhler, Silveira, & Stein, 2019). However, White (1855) provided a specific purpose, besides the physical benefit, to “keep the power of the will awake” (p. 557). Once again, current research supports the information provided by White years ago. For instance, a study in the field of leadership argues that willpower is a mental capability affected by energy levels derived from nutrition, rest, and “physical/mental practice” (Karp, 2014, p. 162). However, the correlation between exercise and willpower strength is not restricted to leaders but is for all people.
Related to exercise (or physical activity), White (1855) instructed the interaction of patients with nature therapeutically. She explained:
I saw there should be connected with the Institute ample grounds, beautified with flowers and planted with vegetables and fruits. Here the feeble could find work, appropriate to their sex and condition, at suitable hours. These grounds should be under the care of an experienced gardener to direct all in a tasteful, orderly manner. (p. 562)
White expanded on how patients should perform physical activity combined with nature therapeutic interactions. In the focus groups, some participants considered assigning patients to “work” in a 21st-century healthcare facility impractical and likely illegal. However, this principle has two key aspects: (a) the physical activity is not prescribed against the patient’s will since it is not a must but “could find work” and (b) the prescribed activity considers that work is “appropriate to their sex and condition, at suitable hours.”
Indeed, patients in their particular conditions could work on numerous activities to redirect their minds and thoughts away from their problems. Interaction with nature assists in taking the patients’ attention beyond their health problems and developing a sense of being useful (Huisman, Morales, van Hoof, & Kort, 2012). Global healthcare systems provide various activities, including art and music therapy, to assist inpatients (Malchiodi, 2013; National Organization for Arts in Health, 2017). However, White warned about the type of activity that people should use while sick, since not all activities are constructive. Activities that were not recommended include:
Such mental exercise as playing cards, chess, and checkers excites and wearies the brain and hinders recovery, while light and pleasant physical labor will occupy the time, improve the circulation, relieve and restore the brain and prove a decided benefit to the health. (White, 1855, p. 554)
Indeed, the ideal implementation of physical activity and nature therapeutic interaction in the traditional hospital setting may appear challenging. However, if the two principles are considered an integral part of the treatment, they can be implemented. The benefits of therapeutic nature interaction are already proven in various research journals. For example, researchers already identified the benefits of ornamental plants in a patient’s room and recorded a quicker surgical recovery (Lipscomb & Rollings, 2017; Park & Mattson, 2009a, 2009b). How much more can be obtained if the principles are implemented in full?
Preparing People to be Holy Before God
The principle of preparing people to be holy before God caused some of the most engaging discussions from participants. Some felt such a principle could pressure individuals into a relationship with God, which would be unethical. This principle generated the most diverse views, despite White identifying this principle as an Adventist hospital’s main aim. This principle was discussed in a variety of ways and with complicated explanations. Because of that, it is difficult to grasp its entire content in one sentence. Even from the stage in which Adventist historians provided feedback, we realized the challenges of presenting this complex concept in a few words. We initially used the term “perfection.” After the first stage, we changed the term to “holy,” following one Adventist historian’s suggestion. However, during the focus group discussions, we realized those terms are linked to the deep theological discussion on the impossible—or even possible for some theologians—state for sinful human beings to reach perfection alone; hence, their application requires further explanation. Intending to avoid such a polarized theological concept, we believe using “wholeness”—another word suggested by the same Adventist historian—would be more applicable.
The concept intended behind preparing people to be whole refers to a continual process. In the Christian setting, holiness and perfection seem unreachable for sinful humans. However, the statement does not say “making” people perfect (holy), but “preparing.” Going back to White’s (1872) statement, she highlighted that the “institution is designed of God to be one of the greatest aids in preparing a people to be perfect before God” (p. 166, emphasis added). She further explains the importance of such an institution in preparing people for a unique encounter:
In former numbers of Testimonies for the Church I have spoken of the importance of Seventh-day Adventists’ establishing an institution for the benefit of the sick, especially for the suffering and sick among us. I have spoken of the ability of our people, in point of means, to do this; and have urged that, in view of the importance of this branch of the great work of preparation to meet the Lord with gladness of heart, our people should feel themselves called upon, according to their ability, to put a portion of their means into such an institution. (White, 1855, p. 633, emphasis added)
There are two critical concepts after the word “preparation.” The first concept is to meet the Lord, which implies an encounter with God either for reconciling or restoring the relationship between humankind and God indi- vidually. The second phrase—gladness of heart—alludes to Jude 1:24–25:
Now to Him who is able to protect you from stumbling, and to make you stand in the presence of His glory, blameless with great joy, to the only God our Savior, through Jesus Christ our Lord, be glory, majesty, dominion, and authority before all time and now and forever. Amen. (NASB, emphasis added)
“Gladness of heart” provides the context of a redemptive grace gifted to humankind. The reaction is of great joy as a sinner acknowledges the extraordinary privilege God has given humanity. Hence the gladness of heart expression describes the extent of gratitude and appreciation since humankind can stand in God’s presence not by their merit but by an undeserved gift.
According to White’s philosophy, it can be concluded that the institution (i.e., an Adventist hospital) does not make anyone perfect in itself. Still, by teaching patients the importance of following God’s laws, it assists in strengthening the moral powers of the patient. White (1872) states “Therefore it is of the greatest importance that he [the patient] knows how to live so that his powers of body and mind may be exercised to the glory of God” (p. 162). By taking the patient to the source of healing and knowledge, directing the patient to the teachings of the human body’s Creator, and giving instruction for its well-being, the objective has been met according to White. At no point did the records suggest that the aim is to convert people to a specific religion; rather, it is to point them to God as the source. He will do the rest.
Once the person has acknowledged that God-given natural laws exist and understands their implications, the expectation is for that person to be connected to the Creator to strive for obedience in body, spirit, and mind so he or she can communicate better with God and hence prepare “for the coming of the Lord” (White, 1872, p. 161). White (1855) went further to explain that, “It should ever be kept prominent that the great object to be attained through this channel is not only health, but perfection, and the spirit of holiness, which cannot be attained with diseased bodies and minds” (p. 554).
It is impossible for man to present his body a living sacrifice, holy, and acceptable to God, while, because it is customary for the world to do so, he is indulging in habits that are lessening physical, mental, and moral vigor. (White, 1872, p. 163)
Could the understanding be that only healthy people (balanced in spirit, body, and mind) could reach perfection and meet God? What about the fervent church member diagnosed with dementia or a faithful Christian involved in a car accident and rendered paraplegic? Or what about someone who was depressed and indulged in bad eating habits that resulted in chronic diseases and then repented and asked for God’s intervention? If people with diseased bodies and minds cannot be saved, “Then who can be saved?” (Matt. 19:25, NASB). White (1872) comments on this:
But God is all-pitiful, gracious, and tender, and when light comes to show who have injured their health by sinful indulgences, and they are convinced of sin, and repent and seek pardon, He accepts the poor offering rendered to Him, and receives them. (p. 165)
Indeed, humankind can’t save itself. But God does not ignore a sincere heart. The apostle Paul said that God’s mercy does not cancel the ideal of having a mind, body, and spirit with full capacity to be presented as a living sacrifice. Therefore, according to White, the main aim of Adventist healthcare institutions is to prepare people for the second coming—that in this world of disease and weak minds and spirits, people can be strengthened to discern God’s voice and be ready for His coming. This can be achieved through the actions of Adventist hospitals in a conscious work to educate about the obedience of natural laws for every individual to be pointed to the source of health and wisdom. The rest is beyond the Adventist hospital’s scope. Hence, we realized the best way to include all the concepts together is to redefine the wording of this principle to prepare people to be whole in order to be reconciled with God.
God-Fearing Personnel
After considering the main aim of Adventist hospitals, to prepare people for the second coming, it’s almost automatic to think that in order for the model to work, it is necessary for the institution to involve people convinced of God’s role in health and Jesus’s second coming in Adventist healthcare’s mission. While some participants in the focus group immediately assumed that “God-fearing personnel” means a member of the Seventh-day Adventist Church, a few participants reacted by providing examples of a few Adventist members who won’t live up to the Adventist standards.
Indeed, membership does not mean the person lives up to the Adventist standards. However, it is easier to find an Adventist church member who believes in fundamental Adventist beliefs impacting these principles—such as the second coming of Christ, the preparation needed for Christ’s coming, and the role of Adventist hospitals—than a non-Adventist. Hence, religion should not be the only criterion since the evaluation should be of the individual. For this, Piasentin and Chapman (2006) advise having—instead of regular office-based interviews—inspirational orientations and periodic review of processes to align the best personnel with the hospital’s mission.
One of the challenges that were discussed in the focus groups was the legislation in certain countries, such as:
Discrimination based on religion . . . could include . . . not hiring an otherwise qualified applicant because he is a self-described evangelical Christian; a Jewish supervisor denying a promotion to a qualified non-Jewish employee because the supervisor wishes to give a preference based on religion to a fellow Jewish employee. (U.S. Equal Employment Opportunity Commission, 2008, para. 10)
Hence in some countries, the percentage of Adventist personnel in an Adventist hospital is considerably low. In other cases, the need for specialized professionals not part of the Adventist system makes it challenging. The disadvantage is when leaders downplay the role of the mission-committed personnel, hence accepting any worldview to be part of the workforce, even if such legal regulation is not in place. If the previous principle, with the Adventist hospital’s aim of preparing people for the second coming, is understood, this principle will become pivotal. No one can guide others without experience in where to guide them.
Prayer Combined with Treatment and Obedience to the Laws of Health
Prayer was widely mentioned in the discussions even before the principles were presented. Prayer is nowadays used as a research protocol by several authors such as Hendricks et al. (2019), Nimbalkar, Mungala, Khanna, Patil, and Nimbalkar (2019), and Cain (2016), among many others, not only when addressing patients but also as a coping strategy for health-care personnel. However, none of the focus group participants commented on obedience to the laws of health. White (1855) emphasized:
And I also saw that He [God] designed the health reform and Health Institute to prepare the way for the prayer of faith to be fully answered. Faith and good works should go hand in hand in relieving the afflicted among us, and in fitting them to glorify God here and to be saved at the coming of Christ. (p. 560)
As she states, health reform is a modification of the habits resulting from sickness, known as non-communicable diseases. Prayer has its place and moment. However, institutions should not promote prayer as a magical event in which everything returns to normal without any change on the patient’s side; it can be presented as a combination of our actions and prayer. This does not apply to some healthcare areas that are not a result of our behaviors, such as accidents.
Sustain Financial Model with Attention to All/Service for Adventists/Altruistic Model
The three principles interconnected in the discussion were the sustained financial model with attention to all, service for Adventists, and the altruistic model. The reason they often interacted is their understanding of financial implications. The sustainability of a financial model that can attend to all types of patients was widely discussed. The participants discussed this principle concerning the service of Seventh-day Adventist members and having an altruistic business model. Among the participants, several identified their institution as a “mission hospital.”
The Encyclopedia Britannica provides the following information about mission hospitals:
The spread of Western medicine (or conventional medicine) and the founding of hospitals in developing countries can be attributed in large part to the influence of the medical missionary. The establishment of mission hospitals gained momentum gradually in the second half of the 19th century. By the second half of the 20th century, however, this steady growth had already dwindled, since all but a few of the hospitals and dispensaries founded during that hundred years had been absorbed into the native health care system. The Christian missionaries had a great influence on the creation of centres [sic] of Western medicine in many developing countries and in promulgating the concept of a hospital in which health care would be centralized and organized for the benefit of the ill and injured, many of whom would not otherwise have survived. . . . Apart from its religious associations, a mission hospital functions as a general hospital in the sense that it admits all who need hospital care. (Piercey, Scarborough, & Fralick, n.d., n.p.)
Pradeep (2013) defines it as:
A Mission Hospital must be Seeking God’s Kingdom. . . . A mission hospital must seek especially to serve the poor and marginalized. . . . A Mission Hospital would seek to glorify His Name by running on the basis of principles put forward in His Word. (n.p.)
Regarding these principles, the nature of the hospital (either not-for-profit or business-minded vs. mission hospital) provided a sharp difference in the principle of sustained financial model with attention to all. From the participants’ interactions, we perceived that most mission hospital leaders were coming from hospitals located in what is widely classified as low-income countries. In contrast, not-for-profit, business-minded hospital leaders were primarily located in high-income countries. The Adventist mission hospital participants expressed their commitment to attending to all patients and not turning away any needy patient. Not-for-profit, business-minded Adventist hospital leaders clearly commented on the need for revenue margins for positive operations.
Participants connected the sustainability principle with the situation that many Adventist members (specifically in Adventist mission hospitals) expect lower prices or special concessions, which may be derived from the feeling of ownership that gives them to be a member of the institution that the church owns. Although the purpose of the study is not to define these two types of hospitals within the Adventist setting, we noted a pattern between the participants representing these two groups.
Besides, we realized that the principles under which the altruistic model was defined were losing the original sense of the principles characterized by White. The selection of words we used were confused with the sustained financial model. White (1855) declares, “That which had been shown me as a place where the suffering sick among us could be helped was one where sacrifice, hospitality, faith, and piety should be the ruling principles” (p. 633). Hence, this last principle is better rephrased as the organizational character of sacrifice, hospitality, faith, and piety.
Organizational Dimensions: Leadership, Drift, and Institutionalizing Values
Universality
Following the analysis of the sustainability principle discussed in the section above, we realized that universality is not necessarily applicable to implementing the principles discussed. Although a principle is a core, specific situations, such as national regulations and culture, might interact with the principles. We perceived that even though all principles apply to Adventist health institutions in a 21st-century setting, their implementation would be impacted by the culture and regulations of where they serve.
However, being a principle, adaptability would have a limit, regardless of culture. Cases of polygamy (culturally accepted in some regions but against the Bible’s principles) were an example presented in the God-fearing personnel principle. Selznick (1948) explains homogeneity as the need for a “unity derived from a common understanding of what the organization is meant to be” (p. 30). In a multinational faith-based institution, homogeneity and diversity should find a balance in which a breaking point is guarded concerning institutional integrity.
Uniqueness of Adventists
Another issue raised was the aspiration to be “unique.” During the discussions, participants identified several currently research-supported principles trending in healthcare practice. Are Adventist hospitals supposed to be different from others? What if non-Adventist hospitals adopt Adventist uniqueness? Are Adventists not themselves anymore? Do Adventist hospitals need to find more principles? Do Adventist hospitals need to look different to be different?
All the combined principles make Adventist systems unique, regardless of whether non-Adventist hospitals do similar or identical activities. Adventist hospitals aim to prepare people for Jesus’s second coming, and combining this objective with Adventist principles makes an Adventist institution. The key differentiator is not “how” Adventist hospitals are perceived but “why” Adventist hospitals do what they do (Sinek, 2009). Other institutions may focus on vegetarian diets or emphasize exercise and prevention, but the reasoning behind the “why” will impact the full range of the implemented Adventist principles.
Diversity in the Applicability of Governing Principles and Organizational Drift
Most participants saw these 12 principles as valuable or ideal, and many were being applied. Most of the participants seemed eager to know more about these principles and learn from others how to make them part of their organizations. Several participants also hinted that a gap between the ideal and actual practice existed and often used expressions such as “that is the ideal.” Before leaving the room, one participant who opposed implementing a couple of principles said, “All these are utopia.” This tension between ideal and reality is related to Selznick’s organization paradox of apparent incongruence between people’s beliefs and what people do in an organization. This may be a universal tension between the desired and actual, between individuals and organizations, between the formal and informal realms. It may be the nature of “divergent interest within the organization” (Selznick, 1948, p. 28).
Such tensions may be viewed in various ways: as a margin of growth motivating change or as a margin of others’ unrealistic idealism where the ideal needs to be dropped. In the smallest focus group of well-known leaders of Adventist healthcare, there was an exchange of opposite opinions between two particular leaders regarding the universality of Adventist healthcare. The difference of opinion was relevant since it was noted how personal inclinations may impact the promotion, follow-up, and implementation of founding principles. It was difficult to fully understand the subtle “emotions” or “feelings” about this gap, which was not assessed in this study.
As Harrison (2000) explains, organizational identity is interpreted or even accepted peculiarly by each individual in a unique way. Indeed, the world church is a global faith-based organization that welcomes diverse points of view, but the founding ideals of a particular ministry should be conciliated. This study did not dictate a given position but pointed out the need for discussion, definition, promotion, and guidance on the relationship between governing principles and the operation of Adventist hospitals.
Besides the role of leaders in guarding governing principles, Selznick points to a particular group of individuals in an organization: the elites (Selznick, 2011). If chosen correctly and nurtured in founding principles, this group of organizational members can guard the organizational mission. Indeed, these elite groups may play a more substantial role since top executives move around to other organizations more often than long-term elite members.
Another issue inseparable from faith-based organizations’ governing principles is the organizational drift or unofficial behaviors that contradict its founding or even revisit ideology. Indeed, Whetten (2006) stated that organizational identity should be “central, enduring, and distinctive” (p. 220). However, if an organization revises its governing principles and decides to modify its identity, it at least makes conscious decisions toward a new horizon. Change is not drifting in such circumstances, as Greer and Horst state (2014).
The challenge is the unofficial drift, not the official new direction. As Selznick (2011) pointed out, “when an enterprise is permitted to drift, making short-run, partial adaptations, the greatest danger lies in uncontrolled effects on organization character” (p. 145). Linked to the Adventist healthcare system and speaking of “greatest dangers,” White warned from the time of her first vision that the greatest danger is that managers “depart from the spirit of the present truth and simplicity which should characterize the disciples of Christ” (Douglass, 1998, loc. 10130). Sometimes, leaders follow operational opportunities to be aware of “institutional surrender made in the name of organizational survival” (Selznick, 2011, p. 145).
Several questions emerge. First, how to preserve whatever an organization has proposed itself to be? How do we face organizational drift if faith-based organizations are known for having a higher risk of drifting from their purpose? Researchers on this topic believe that for an organization to remain true to its mission, it should: (a) recognize that Christ is the difference, (b) affirm that faith sustains the organization, (c) understand that functional atheism is the path of least resistance (Greer & Horst, 2014). This faithfulness, referred to by Selznick as institutional integrity, can also be protected by “(1) selective recruiting, (2) specialized training, and (3) withdrawal from the everyday pursuits of mankind, especially from exposed competition in the marketplace” (2011, p. 122).
Greer and Horst highlighted two main actions required for an organization to keep institutional integrity: have a clear Christian mission and intentionally protect it. From the focus group responses of what makes an Adventist hospital Adventist, we could perceive the need for a sharper definition of a 21st-century Adventist healthcare mission and governing principles. The first step would promote a clear mission and governing principles to ensure the second component takes place: guarding the mission.
Conclusions
We found widespread support for many of these principles foundational to the identity of Adventist healthcare. Several founding Adventist principles and innovative practices have become widespread in most hospitals worldwide. There was a broad interpretation of what constituted good Adventist healthcare, from the resource-challenged and culturally constrained mission hospital to their massive “industrial complex” not-for-profit counterparts. There were principles that Adventist healthcare leaders perceived as difficult to apply in modern settings, even if they were sympathetic to the value of the founding governing principle. Finally, we noted some differ- ences and even resistance to a few of these principles applied to modern Adventist healthcare.
Adventist healthcare has been on a long journey, influenced by historical changes in healthcare and medicine and manifested differently in different cultural and political contexts. Adventist healthcare is diverse and multifaceted, yet this study has shown that it is still drawn from its roots and propelled forward by some early fundamental principles and ideals. The influence of these principles may have ebbed and flowed in varying degrees, but they also make up the “topics” and “jargon” that come into the way Adventist healthcare thinks about itself and tells its story. In this journey, Adventist healthcare leaders have strived to forward Adventist healthcare, in their context. It is beautiful work. It is a work worth continuing. How can this work be done even better to bring Christ’s healing ministry to more people and more places?
Application
This study’s findings have implications for Adventist hospital leaders (and even for other faith-based organizations) and healthcare researchers. These stakeholders could consider: (a) promoting attention and discussion on the Adventist healthcare governing principles in their decisions and justification principles in administrative and staff meetings, and (b) identifying and celebrating programs or activities promoting these founding governing principles.
Regarding regional and global questions, either Adventist or other faith-based healthcare leaders might consider: (a) establishing a team with international and intercultural representation to study and discuss founding governing principles and their reflection on current governing principles, or (b) funding research and publications that guide leaders in how these principles are practiced in their contexts. Eventually, they can leverage these principles within the curriculum and experiences of regional and global healthcare training forums (universities, centers, churches, among others).
Many, if not all, decisions healthcare leaders make affect the hospital’s direction. Change of direction, change in itself, is not necessarily detrimental. As a larva experiences metamorphosis and becomes a beautiful butterfly without necessarily changing its DNA, we believe Adventist healthcare institutions can change without losing themselves. Adventist hospital leaders can become more aware of these principles, distance their organizations from decisions that undermine critical commitments, and move forward by making decisions faithful to them. DNA should be consciously guarded against unofficial “mutations” that may arise from the pressures of operational activity, competition, and new technologies. This approach could be considered at least until an official revision of governing principles is deemed necessary.
The aim is to thrive on reducing the gap between the ideal and the reality, between what we are supposed to be versus what we are as an organization. The aim is to be consistent, congruent, and true to whatever an organization consciously commits. This can only be obtained when we as leaders revise organizational principles by either making unofficial changes official or by strengthening the current founding ideology to avoid organizational amnesia. Part of identity is to have a good memory of where an organization came from and where it is going (Casey, 2019). “Only take heed to thyself, and keep thy soul diligently, lest thou forget the things which thine eyes have seen, and lest they depart from thy heart” (Deut. 4:9, KJV). It is important to remember who we are and which direction we are taking the institutions we lead.
Cesiah Y. Pimentel Melendez is an associate dean for quality and mission effectiveness at the Adventist School of Medicine of East-Central Africa at the Adventist University of Central Africa. She is an alumnus and adjunct faculty member in the Leadership PhD program at Andrews University.
Duane M. Covrig, PhD, is professor of religion at Kettering College in Kettering, Ohio.
References
Bloomberg, L. D., & Volpe, M. (2016). Completing your qualitative dissertation: A road map from beginning to end (3rd ed.). Sage.
Buettner, D. (2016). El secreto de las zonas azules: Comer y vivir como la gente más saludable del mundo (A. M. Tato, Trans.). Penguin Random House.
Buettner, D., & Skemp, S. (2016). Blue zones: Lessons from the world’s longest lived. American Journal of Lifestyle Medicine, 10(5), 318-321.doi:10.1177/1559827616637066
Cain, C. D. (2016). The effects of prayer as a coping strategy for nurses. Journal of Perianesthesia Nursing, 31(4), e54. doi:10.1016/j.jopan.2019.03.013
Casey, A. (2019). Organizational identity and memory: A multidisciplinary approach. Routledge.
Chan, C., Ying Ho, P. S., & Chow, E. (2002). A body-mind-spirit model in health. Social Work in Health Care, 34(3–4), 261–282. https://doi.org/10.1300/J010v34n03_02
Clarke, J. (2010). Body and soul in mental health care. Mental Health, Religion & Culture, 13(6), 649–657. doi:10.1080/13674676.2010.488416
Cummings, T. G., & Worley, C. G. (2008). Organization development and change (9th ed.). South Western Cengage Learning.
Douglass, H. E. (1998). Messenger of the Lord: The prophetic ministry of Ellen G. White. Pacific Press.
Greer, P., & Horst, C. (2014). Mission dirft: The unspoken crisis facing leaders, charities, and churches. Bethany House.
Harrison, J. D. (2000). Multiple imaginings of institutional identity: A case study of a large psychiatric research hospital. The Journal of Applied Behavioral Science, 36(4), 425–455. doi:10.1177/0021886300364003
Hendricks, M., Steenveld, C. M., Thompson, V., Andrade, A., Kahl, G., Farlam, P., Balagadde-Kambugu, J., Hendricks, S., Rackstraw, A., Pedersen, L., Burger, D. R., Meiring, M. A., Davidson, A., & van Eyssen, A. (2019). Building a psychosocial and spiritual care service for children with cancer and their families. South African Journal of Oncology, 3(1), 1–8. doi:10.4102/sajo.v3i0.52
Huisman, E. R. C. M., Morales, E., van Hoof, J., & Kort, H. S. M. (2012). Healing environment: A review of the impact of physical environmental factors on users. Building and Environment, 58 (December), 70–80. doi:10.1016/j.buildenv .2012.06.016
Iltis, A. S. (2003). Institutional integrity in health care: Essential for organizational ethics. In A. S. Iltis (Ed.) Institutional Integrity in Health Care. Springer. https://doi.org/10.1007/978-94-017-0153-2_1
Karp, T. (2014). Leaders need to develop their willpower. Journal of Management Development, 33(3), 150–163. doi:10.1108/JMD-04-2012-0051
Leggio, M., Fusco, A., Loreti, C., Limongelli, G., Bendini, M. G., Mazza, A.,Coraci, D., & Padua, L. (2020). Effects of exercise training in heart failure with preserved ejection fraction: An updated systematic literature review. Heart Failure Reviews, 25(5), 703–711. doi:10.1007/s10741-019-09841-x
Lipscomb, M., & Rollings, K. (2017). Outside in: Influences of indoor plants on psychological well-being and memory task performance in a workplace setting. Perkins & Will Research Journal, 9(2), 33–43.
Loma Linda University. (n.d.). Adventist health study. https://adventisthealthstudy.org/ Malchiodi, C. A. (Ed.). (2013). Art therapy and health care. The Guilford Press.
National Organization for Arts in Health. (2017). Arts, health, and well-being in America.
Nimbalkar, A. S., Mungala, B. M., Khanna, A. K., Patil, K. H., & Nimbalkar, S. M. (2019). Prayers and beliefs among relatives of children admitted in pediatrics wards. Journal of Family Medicine and Primary Care, 8(3), 1123–1128. doi: 10.4103/jfmpc.jfmpc_333_18
Oakley, R. (2004). How the mind hurts and heals the body. American Psychologist, 59(1), 29–40. doi:10.1037/0003-066X.59.1.29
Park, S., & Mattson, R. H. (2009a). Ornamental indoor plants in hospital rooms enhanced health outcomes of patients recovering from surgery. The Journal of Alternative and Complementary Medicine, 15(9), 951–952. doi:10.1089/acm.2009.0075
Park, S., & Mattson, R. H. (2009b). Therapeutic influences of plants in hospital rooms on surgical recovery. American Society for Horticultural Science, 44(1), 102–105. doi:10.21273/HORTSCI.44.1.102
Piercey, W. D., Scarborough, H., & Fralick, P. C. (n.d.). Hospital. Britannica. https://www.britannica.com/science/hospital/The-modern-hospital
Pesut, B., Fowler, M., Taylor, E. J., Reimer-Kirkham, S., & Sawatzky, R. (2008). Conceptualising spirituality and religion for healthcare. Journal of Clinical Nursing, 17(21), 2803–2810. doi:10.1111/j.1365-2702.2008.02344.x
Piasentin, K. A., & Chapman, D. S. (2006). Subjective person-organization fit: Bridging the gap between conceptualization and measurement. Journal of Vocational Behavior, 69(2), 202–221. https://doi.org/10.1016/j.jvb.2006.05.001
Pimentel Melendez, C. Y. (2019). Adventist healthcare: A qualitative study of 19th century founding governing principles in 21st century Adventist hospitals [Doctoral dissertation, Andrews University]. Digital Commons. https://digitalcommons.andrews.edu/dissertations/1733
Pradeep, N. (2013). What is a mission hospital? Countertrend. http://pradeepninan.blogspot.com/2013/01/what-is-mission-hospital.html
Selznick, P. (1948). Foundations of the theory of organization. American Sociological Review, 13(1), 22–35. doi:10.2307/2086752
Selznick, P. (2011). Leadership in administration: A sociological interpretation. Quid Pro Books.
Sinek, S. (2009). Start with why: How great leaders inspire everyone to take action. Portfolio.
U. S. Equal Employment Opportunity Commission. (2008, July 22). Title VII,
29 CFR part 1605 questions and answers: Religious discrimination in the workplace. https://www.eeoc.gov/laws/guidance/questions-and-answers-religious-discrimination-workplace
Walk, M. (2023). Leaders as change executors: The impact of leader attitudes to change and change-specific support on followers. European Management Journal, 41(1), 154–163. https://doi.org/10.1016/j.emj.2022.01.002
Whetten, D. A. (2006). Albert and Whetten revisited: Strengthening the concept of organizational identity. Journal of Management Inquiry, 15(3), 219–234. doi:10.1177/1056492606291200
White, E. G. (1905). The ministry of healing. Pacific Press.
White, E. G. (1855). Testimonies for the church (Vol. 1). Pacific Press.
White, E. G. (1872). Testimonies for the church (Vol. 3). Pacific Press.
Zaidi, D. (2018). Influences of religion and spirituality in medicine. American Medical Association Journal of Ethics, 20(7), 609–612. doi:10.1001/amajethics.2018.609.
Zanini, M., Nery, R., de Lima, J. B., Buhler, R., da Silveira, A. D., & Stein, R. (2019). Effects of different rehabilitation protocols in inpatient cardiac rehabilitation after coronary artery bypass graft surgery: A randomized clinical trial. Journal of Cardiopulmonary Rehabilitation and Prevention, 39(6), 19–25. doi:10.1097/HCR.0000000000000431