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Selection of nurse’s role behaviors and identification of determinant factors in development of such… Farhang Mehr, Mahnaz 1977

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SELECTION OF NURSE'S ROLE BEHAVIORS AND IDENTIFICATION OF DETERMINANT FACTORS IN DEVELOPMENT OF SUCH ROLES B.S.N., Pahlavi University, 1974 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING THE SCHOOL OF NURSING We accept t h i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA A p r i l , 1977 (§) Mahnaz Farhang Mehr, 1977. by MAHNAZ/FARHANG MEHR i n In presenting th i s thesis in pa r t i a l fu l f i lment of the requirements for an advanced degree at the Univers i ty of B r i t i s h Columbia, I agree that the L ibrary sha l l make it f ree ly ava i l ab le for reference and study. I fur ther agree that permission for extensive copying of th is thesis for scho lar ly purposes may be granted by the Head of my Department or by his representat ives. It is understood that copying or pub l i ca t ion of th is thesis for f inanc ia l gain sha l l not be allowed without my written permission. Department of NURSING The Univers i ty of B r i t i s h Columbia 2075 Wesbrook Place Vancouver, Canada V6T 1W5 ACKNOWLEDGEMENTS I wish to express my appreciation to the U.B.C. B.S.N.'s who pa r t i c i p a t e d i n t h i s study. I would also l i k e to thank Assistant Professors Helen E l f e r t and Mary Cruise for t h e i r encouragement and assistance i n the development of t h i s study. I also wish to acknowledge my sincere appreciation and gratitude to Miss Ida N. Vyse for her constructive c r i t i -cism and suggestions i n the preparation of t h i s manuscript. I am p a r t i c u l a r l y g r a t e f u l to Miss Fl o r a M. Musgrave, whose f i n a n c i a l support, encouragement and patience over the past years have made the completion of t h i s project possible. I am indebted to her for a l l her support. i ABSTRACT The purpose of t h i s exploratory study was to determine the r o l e behavior and the determinant factors influencing the achievement of such r o l e behaviors by the B.S.N, graduates, May 1976, i n the basic program of the University of B r i t i s h Columbia School of Nursing. Questions asked were: 1. What kind of r o l e behaviors do University of B r i t i s h Columbia graduates have at the time of graduation, May 1976, and a f t e r three months employment i n the hospital? 2. What are the determinant factors that influenced achieve-ment of r o l e behaviors of these B.S.N, graduates of the University of B r i t i s h Columbia School of Nursing? Marlene Kramer's Integrative Role Behavior scale and open-ended questionnaire were used to derive the information pertinent to the research problem. Kramer's Integrative Role Behavior scale was administered twice, once at graduation time, and the other three months af t e r employment i n the h o s p i t a l . The open-ended questionnaire was administered a f t e r employment only. The study sample were 17 B.S.N.'s who were working i n the hospitals throughout B r i t i s h Columbia and answered both sets of questionnaires at the two designated times. Analysis of the data included des-c r i p t i v e analysis, frequency tables, and the use of the T. t e s t . The findings of the study showed that the University of B r i t i s h Columbia B.S.N.'s selected professional role behavior s i g n i f i c a n t l y higher at graduation time than upon employment. Besides, r o l e behaviors appeared to be immediately responsive to exposure t o t h e work system. The changes o f r o l e b e h a v i o r upon employment were a h i g h e r s e l e c t i o n o f b u r e a u c r a t i c and i n t e g r a t i v e r o l e b e h a v i o r and lower s e l e c t i o n o f p r o f e s s i o n a l r o l e b e h a v i o r . The changes i n s e l e c t i o n o f b u r e a u c r a t i c and i n t e g r a t i v e r o l e b e h a v i o r s were not s t a t i s t i c a l l y s i g n i f i c a n t , b u t t h e t r e n d o f change was as l i t e r a t u r e s u g g e s t e d . The d e t e r m i n a n t f a c t o r s i n development o f r o l e b e h a v i o r were m o s t l y t h e r e s u l t o f i d e a l n u r s i n g e d u c a t i o n and a c t u a l work as a n u r s e f o l l o w i n g employment. I n t h e e d u c a t i o n a l s e t t i n g i n s t r u c t o r s were i n s t r u m e n t a l i n s h a p i n g t h e i d e a s o f t h e n u r s e ' s r o l e among B.S.N.'s. The s t u d y showed t h a t t h e s e B.S.N.'s v a l u e d t h e i r e d u c a t i o n p o s i t i v e l y and t h e i r work s e t t i n g s ( h o s p i t a l s ) n e g a t i v e l y . The s t u d y s u g g e s t s more e x t e n s i v e r e s e a r c h on the problem. I n the meantime, t h e t h r e e groups i n v o l v e d - i . e . nu r s e e d u c a t o r s , n u r s i n g s e r v i c e a d m i n i s t r a t o r s and B.S.N.'s i n v o l v e d - s h o u l d s h a r e t h e i r f r u s t r a t i o n s and s u g g e s t i o n s f o r b e t t e r c l i e n t c a r e . 114 Pages. TABLE OF CONTENTS Page LIST OF TABLES v i i CHAPTER I INTRODUCTION TO THE STUDY 1 Introduction . . . 1 Statement of the Problem 7 Theoretical Base of the Problem 7 Significance and Implementation of the Research Problem to Nursing . . . 12 D e f i n i t i o n of Terms 14 Assumptions of the Study 15 Limitations of the Study 15 II REVIEW OF THE LITERATURE . 16 Introduction 16 Professional-Bureaucratic C o n f l i c t . . . 16 Nursing Studies Related to the Problem. . 21 Summary 33 III RESEARCH DESIGN AND DEVELOPMENT OF THE STUDY 35 Selection of the Study Group . . . . . . 35 The Subject 35 The Setting 36 I n i t i a l Contact with the Subjects . . 37 i v CHAPTER Page Instrumentation 37 Personal Data 38 Kramer's Integrative Role Behavior scale 38 Open-ended Questionnaire 39 Data Analysis 42 Summary 43 IV ANALYSIS OF THE DATA 44 Cha r a c t e r i s t i c s of the Study Population . 45 Time 45 Pos i t i o n 46 Plan for Work 47 Description of the Study Population upon graduation 50 Duration of Work . 50 Hospital Description 51 Pos i t i o n 52 C l i n i c a l F i e l d 53 Location 54 Selection of Role Behavior 55 Determinant Factors i n Developing Role Behavior 60 Background Factors 60 Educational Factors 64 v CHAPTER Page Work Setting Factors 83 Ranking 89 Summary 90 V SUMMATION, CONCLUSIONS, LIMITATIONS AND SUGGESTIONS 94 Summation 94 Conclusions 96 Implications 100 Suggestions 104 BIBLIOGRAPHY 107 APPENDIX 114 v i LIST OF TABLES Table Page 1 PERCENTAGE DISTRIBUTION OF THE STUDY POPULATION BY WORK EXPERIENCE 46 2 PERCENTAGE DISTRIBUTION OF THE STUDY POPULATION BY THE POSITION AT WORK . . . . 47 3 PERCENTAGE DISTRIBUTION OF THE STUDY POPULATION BY THE SELECTION OF THE WORK AREA 49 4 PERCENTAGE DISTRIBUTION OF THE STUDY POPULATION BY THE PLAN FOR WORK AFTER GRADUATION . 49 5 PERCENTAGE DISTRIBUTION OF THE STUDY SAMPLE BY DURATION OF WORK EXPERIENCE IN THE HOSPITAL 51 6 PERCENTAGE DISTRIBUTION OF THE STUDY SAMPLE BY THE DESCRIPTION OF THE HOSPITAL IN WHICH THEY WERE WORKING 52 7 PERCENTAGE DISTRIBUTION OF THE STUDY SAMPLE BY POSITION IN THE HOSPITAL . . . . 53 8 PERCENTAGE DISTRIBUTION OF THE STUDY SAMPLE BY THE CLINICAL FIELD IN WHICH THEY WERE WORKING 54 9 PERCENTAGE DISTRIBUTION OF THE STUDY SAMPLE BY THE LOCATION OF THE HOSPITAL IN WHICH THEY WERE WORKING 55 10 SIGNIFICANCE OF MEAN DIFFERENCES IN SCORES ON SELECTION OF ROLE BEHAVIOR AT GRADUATION TIME AND FOLLOWING EMPLOYMENT . 56 11 PERCENTAGE DISTRIBUTION OF THE STUDY SAMPLE BY COMPARISON OF ROLE BEHAVIOR SCORES FOLLOWING EMPLOYMENT WITH THOSE OF GRADUATION TIME 57 12 PERCENTAGE DISTRIBUTION OF THE SAMPLE BY THE AGE OF DECISION TO BECOME A NURSE . . . 61 v i i T a b l e Page 13 PERCENTAGE DISTRIBUTION OF THE STUDY SAMPLE BY THE MAJOR SOURCE OF INFLUENCE TO BECOME A NURSE 62 14 PERCENTAGE DISTRIBUTION OF THE WAYS THE SAMPLE ACQUIRED INFORMATION ABOUT NURSING . 63 15 PERCENTAGE DISTRIBUTION OF THE WAYS THAT THE NURSING EDUCATION PROGRAM HELPED THE STUDY SAMPLE TO DEVELOP THE IMAGE AND PERCEPTION OF NURSING . 65 16 PERCENTAGE DISTRIBUTION OF EDUCATIONAL FACTORS THAT INFLUENCED STUDY SAMPLE'S ROLE BEHAVIOR 67 17 PERCENTAGE DISTRIBUTION OF EDUCATIONAL FACTORS THAT INTRODUCED STUDY SAMPLE TO THEIR DUTIES . 69 18 PERCENTAGE DISTRIBUTION OF WEAKNESSES OF NURSING EDUCATION PROGRAMS IN INTRODUCING THE SAMPLE TO THEIR ROLE 71 19 PERCENTAGE DISTRIBUTION OF THE STRENGTHS OF NURSING EDUCATION PROGRAMS IN INTRODUCING THE SAMPLE TO THEIR ROLE . . . 72 2 0 PERCENTAGE DISTRIBUTION OF THE EFFECT OF FACULTY MEMBER'S EXPECTATION ON THE SAMPLE'S ROLE AS A NURSE 74 21 PERCENTAGE DISTRIBUTION OF HELPFUL BEHAVIOR OF INSTRUCTORS ON THE SAMPLE'S ROLE BEHAVIOR 75 22 PERCENTAGE DISTRIBUTION OF THE EFFECT OF CLASSMATES' BELIEF ABOUT NURSING ON THE SAMPLE'S ROLE 77 23 PERCENTAGE DISTRIBUTION OF THE NURSING COURSES THAT HELPED IN DEVELOPMENT OF SAMPLE'S ROLE AS A NURSE 79 24 PERCENTAGE DISTRIBUTION OF THE INFLUENCE OF CLINICAL EXPERIENCE ON THE SAMPLE'S ROLE 81 v i i i T a b l e Page 25 PERCENTAGE DISTRIBUTION OF THE STUDY SAMPLE'S RESPONSE ABOUT THEIR PREPARATION FOR WORK BY NURSING EDUCATION 83 26 THE EFFECT .OF WORKING IN THE HOSPITAL ON THE SAMPLE'S IDEAS ABOUT THE NURSE'S ROLE . 85 27 PERCENTAGE DISTRIBUTION OF FACTORS THAT FAMILIARIZED THE STUDY SAMPLE TO THEIR RESPONSIBILITIES IN THE HOSPITAL 87 28 PERCENTAGE DISTRIBUTION OF THE EFFECT OF HOSPITAL PERSONNEL ON THE SAMPLE'S IDEAS ABOUT NURSE 1S ROLE 89 29 MEAN RANKING OF THE FACTORS THAT HELPED THE STUDY SAMPLE TO DEVELOP THEIR ROLE AS A NURSE 90 i x 1 CHAPTER I INTRODUCTION TO THE STUDY I. Introduction For the past few years research has been in progress investigating the r o l e conception and adaptation of bacca-laureate nurses, (hereafter c i t e d as B.S.N.) who are s o c i a l i z e d by a professional educational system but employed by a bureaucratic work system. The baccalaureate degree i s the f i r s t professional degree i n nursing. However, the f u l l p o t e n t i a l of t h i s bacca-laureate graduate has never been r e a l i z e d . T h e review of l i t e r a t u r e during the past decade or so indicates that the B.S.N, graduate wrestles constantly with problems created by the difference between professional nursing, as she i s taught to anticipate i t , and her work experiences. During professional education B.S.N.'s are s o c i a l i z e d to a nurse's r o l e that values i n d i v i d u a l i z e d , comprehensive, d i r e c t care of patients. I t i s oriented toward knowledge, understanding and innovation, and the B.S.N.'s are taught to think of themselves 2 as professionals, autonomous i n some spheres of t h e i r work. ^Marjorie Stanton, "Three Factors of Significance to Baccalaureate Nursing Education," Faculty Curriculum Development  Part V, New York: The National League for Nursing, Department of Baccalaureate and Higher Degree Programs, 19 75, p. 3. ^Marlene Kramer, "Role Conception of Baccalaureate Nurses and Success in Hospital Nursing," Nursing Research, Vol. 19, No. 5, (September-October 1970), p. 428. 2 Therefore, they undergo a period of intense professional s o c i a l -i z a t i o n and are prepared for a professional role and the primary functions within that r o l e . ^ I t i s a process oriented r o l e , i n which "whole task" approach to care i s basic.^ When the B.S.N.'s graduate, they expect to be able to practice within a profes-s i o n a l s e t t i n g , but f i n d themselves instead, employed by a bureaucratic organization which functions and operates on the bur e a u c r a t i c a l l y structured system where many of these values are not functional.^'^ Most hospitals are arranged along the l i n e s of bureau-c r a t i c work p r i n c i p l e s . The bureaucratic system of work organi-zation i s based on the notion that e f f i c i e n c y i s augmented when a task i s subdivided, with component tasks performed by workers e s p e c i a l l y trained for each part.** To attempt the goal of 3 Marlene Kramer, "Collegiate Graduates Nurses i n Medical Center Hospital: Actual Challenge or Duel," Nursing Research, Vol. 18, No. 3, (May-June 1969), p. 197. ^Diane McGivern, "Preparation of the Nurse P r a c t i t i o n e r at the Baccalaureate Level," Current Issues i n Nursing Education, New York: The National League for Nursing, 1974, pp. 1-14. W^. Richard Scott, "Professionals i n Bureaucracies - Areas of C o n f l i c t , " P r o f e s s i o n a l i z a t i o n , eds. H. M. Vollmer and D. L. M i l l s , New Jersey: Pr e n t i c e - H a l l , Inc., 1966, pp. 265-275. ^Marlene Kramer, "Role Conception of Baccalaureate Nurses and Success i n Hospital Nursing," Nursing Research, Vol. 19, No. 5, (September-October 1970), p. 428. ^Marlene Kramer, "Collegiate Graduates Nurses i n Medical Center Hospital: Actual Challenge or Duel," Nursing Research, Vol. 18, No. 3, (May-June 1969), p. 196. ^Marlene Kramer and Constance Baker, "The Exodus: Can We Prevent I t ? , " The Journal of Nursing Administration, Vol. 1, No. 3, (May-June 1971), p. 16. 3 optimum care f o r a large group of patients within the confines and l i m i t a t i o n s imposed by budgets and demands of i t s constituent society, h o s p i t a l organization i s primarily a system concerned with maintaining an e f f i c i e n t and e f f e c t i v e operation. E f f i c i e n c y i s expected to be enhanced when a t o t a l task i s subdivided into component tasks. These tasks, i n turn, are performed by workers whose s p e c i a l t r a i n i n g or r e p e t i t i v e practices ensure l e v e l s of competence and speed, which r e s u l t i n cost reduction. Within t h i s frame of reference hospitals need w e l l - q u a l i f i e d nurses who are not only competent to give i n d i v i d u a l i z e d patient care, but also able to work, organize work and delegate part tasks to lesser educated personnel. This d i v i s i o n of labor and s p e c i a l i z a t i o n i s considered mandatory for maximal u t i l i z a t i o n of l i m i t e d resources.^ i n t h i s s i t u a t i o n the professional nurse must d e l i v e r q u a l i t y care to i n d i v i d u a l patients, but also see that complex multifaceted care i s given to larger groups of patients. The foregoing contradictions and dilemmas are summarized by Marlene Kramer: "Nursing schools and nurse-employing organizations represent two d i f f e r e n t subcultures of the nursing world. The norms, values, and behaviors expected are more d i f f e r e n t between school and work than they are between two d i f f e r e n t work settings. I t i s , therefore, quite possible for a person to be con-gruently s o c i a l i z e d into one subculture but not i n t o another. To the extent that the two subcultures propogate values, attitudes and behavior that are ^Marlene Kramer, "Role Conception of Baccalaureate Nurses and Success i n Hospital Nursing," Nursing Research, Vol. 19, No. 5, (September-October 1970), p. 430. 4 d i f f e r e n t , an i n d i v i d u a l who d e s i r e s t o move from one s u b c u l t u r e t o a n o t h e r w i l l e n c o u n t e r d i f f i c u l t y . " ^ I t f o l l o w s t h a t c o n f l i c t can be e x p e c t e d when a n u r s e , who has been e d u c a t e d a l o n g t h e p r o f e s s i o n a l l i n e s o f work o r g a n i z a t i o n , i s employed i n one w h i c h depends on d i v i s i o n o f l a b o r and s p e c i a l i z a t i o n f o r maximal u t i l i z a t i o n o f l i m i t e d r e s o u r c e s . C o r w i n found t h a t g r a d u a t i o n from a n u r s i n g s c h o o l and i n t u c t i o n i n t o employment i n a h o s p i t a l i s a p e r i o d o f g r e a t c o n f l i c t . I t i s a t t h i s t i me t h a t t h e p r o f e s s i o n a l i d e a s s t r e s s e d i n s c h o o l c o n f r o n t t h e b u r e a u c r a t i c p r i n c i p l e s t h a t o p e r a t e i n t h e h o s p i t a l . 1 1 I n such a s i t u a t i o n t h e new g r a d u a t e may t o t a l l y r e j e c t h e r s c h o o l - b r e d i d e a l i s m and p r o -f e s s i o n a l v a l u e s and become a s u p e r e f f i c i e n t b u r e a u c r a t i c t e c h n i c i a n . Other s t u d i e s show t h a t d i s i l l u s i o n m e n t , r o l e d e p r i v a t i o n , ^ j o b d i s s a t i s f a c t i o n and r o l e c o n f l i c t a l s o a r i s e c o n s t i t u t i n g t h e main r e a s o n s f o r t h e B.S.N, t o become e i t h e r a d i s s a t i s f i e d o r a c o n f o r m i s t worker o r a d r o p o u t from the p r o f e s s i o n . 1 <^Marlene Kramer, R e a l i t y Shock - Why Nurses Leave  N u r s i n g P r a c t i c e , S a i n t L o u i s : C. V. Mosby Company, 19 74, p. 39 H-Ronald G. C o r w i n , "The P r o f e s s i o n a l Employee: A Study o f C o n f l i c t i n N u r s i n g R o l e s , " The American J o u r n a l o f  S o c i o l o g y , V o l . 66, No. 6, 1961, pp. 604-615. ^ M a r l e n e Kramer, "Role C o n c e p t i o n o f B a c c a l a u r e a t e Nurses and S u c c e s s i n H o s p i t a l N u r s i n g , " N u r s i n g R e s e a r c h , V o l . 19, No. 5, (September-October 1970), p. 436. 1 ^ H a r l e n e Kramer and o t h e r s , " S e l f - A c t u a l i z a t i o n and R o l e A d a p t a t i o n of B a c c a l a u r e a t e Degree Nurses," N u r s i n g R e s e a r c h , V o l . 21, No. 2, ( M a r c h - A p r i l 1972), p. 111. 5 There seems no i n d i c a t i o n t h a t b u r e a u c r a t i c work p e r se w i l l e v e r be c o m p l e t e l y r e p l a c e d . There i s a b e l i e f t h a t t h i s p r o blem has been made c l e a r t o t h e a d m i n i s t r a t o r s i n t h e n u r s i n g s e r v i c e , b u t t h e y have n o t t r i e d t o accomodate the b a c c a l a u r e a t e g r a d u a t e s . ^ S i m i l a r l y m o t i v a t e d by a d e s i r e f o r a l e g i t i m a t e p l a c e i n the u n i v e r s i t y and by a sincere conviction o f the l o g i c and Tightness o f the whole p a t i e n t a p p r o a c h , c o l l e g i a t e e d u c a t o r s w i l l p r o b a b l y c o n t i n u e t o s o c i a l i z e t h e neophyte i n t o t h e o c c u p a t i o n o f n u r s i n g a l o n g 15 t h e p r o f e s s i o n a l work p r i n c i p l e s . From t h e above d i s c u s s i o n , i t i s a p p a r e n t t h a t t h e r o l e c o n f l i c t e x i s t s f o r n u r s e s i n a work s e t t i n g . A l t h o u g h , such a c o n f l i c t i s t h e r e a s o n f o r many n u r s e s t o l e a v e t h e n u r s i n g p r a c t i c e o r t o l o s e t h e i r p r o f e s s i o n a l ( s c h o o l ) i d e a l i s m and p e r c e i v e n u r s i n g j u s t as a j o b , not a l l B.S.N. nu r s e s g i v e up t h e f i g h t and l e a v e the h o s p i t a l . There a r e some who r e t a i n t h e i r s c h o o l - b r e d i d e a l i s m and who seem t o be a b l e t o o p e r a t i o n a l i z e s u c c e s s f u l l y and move from e d u c a t i o n 1 fi t o s e r v i c e . How i s i t t h a t some n u r s e s seem a b l e t o a d j u s t and a m e l i o r a t e t h i s r o l e c o n f l i c t , w h i l e o t h e r s do n o t ? M a r l e n e ^ M a r l e n e Kramer, " C o l l e g i a t e Graduate N u r s e s i n M e d i c a l C e n t e r H o s p i t a l : A c t u a l C h a l l e n g e o r D u e l , " N u r s i n g  R e s e a r c h , V o l . 18, No. 3, (May-June 1969), p. 196. 15 M a r l e n e Kramer, " P r o f e s s i o n a l - B u r e a u c r a t i c C o n f l i c t and I n t e g r a t i v e R o l e B e h a v i o r , " Communicating N u r s i n g Research: I s t h e Gap B e i n g B r i d g e d ? , ed. M. B a t e y , B o u l d e r , C o l o r a d o : Western I n t e r - S t a t e Commission f o r H i g h e r E d u c a t i o n , V o l . 4, 1971, p. 57. 1 6 I b i d . , p. 59. 6 17 Kramer found that the presence of integrative r o l e s t r a t e g i e s * in one's behavioral repertoire makes one less susceptible to 1 p role c o n f l i c t and possible exodus from nursing. A review of l i t e r a t u r e indicates that r o l e con-ception, i n t e g r a t i v e r o l e behavior and success i n h o s p i t a l nursing has been studied many t i m e s , 1 9 ' 2 0 ' 2 1 / 2 2 ' 2 3 ' 2 4 ' 2 5 ' 2 6 * "....the reported choices that represent a compromise between behaviors that c l e a r l y support professional values and that c l e a r l y r e f l e c t s allegiance to bureaucratic values." 1 7 I b i d . , p. 67. • ^ P a t r i c i a Benner and Marlene Kramer, "Role Conceptions and Integrative Role Behavior of Nurses i n Special Care and Regular Hospital Nursing Units," Nursing Research, Vol. 21, No. 1, (January-February 1972), p. 22. •^Marlene Kramer, "Role Conception of Baccalaureate Nurses and Success i n Hospital Nursing," Nursing Research, Vol. 19, No. 5, (September-October 1970), p. 428. 2^Marlene Kramer, "Collegiate Graduates Nurses i n Medical Center Hospital: Actual Challenge or Duel," Nursing Research, Vol. 18, No. 3, (May-June 1969), p. 197. 2 1Ronald G. Corwin, "The Professional Employee: A Study of C o n f l i c t i n Nursing Roles," The American Journal of Sociology, Vol. 66, No. 6, 1961, pp. 604-615. 2 2 Marlene Kramer, "Professional-Bureaucratic C o n f l i c t and Integrative Role Behavior," Communicating Nursing Research: Is the Gap Being Bridged?, ed. M. Batey, Boulder, Colorado: Western Inter State Commission for Higher Education, Vol. 4, 1971, p. 57. " ^ P a t r i c i a Benner and Marlene Kramer, "Role Conceptions and Integrative Role Behavior of Nurses i n Special Care and Regular Hospital Nursing Units," Nursing Research, Vol. 21, No. 1, (January-February 1972), p. 22. 2 4Marlene Kramer and others, " S e l f - A c t u a l i z a t i o n and Role Adaptation of Baccalaureate Degree Nurses," Nursing Re- search, Vol. 21, No. 2, (March-April 1972), pp. 111-123. 2^Ronald G. Corwin and others, "Professional D i s i l l u s i o n -ment," Nursing Research, Vol. 10, No. 3, (Summer 1961), pp. 141-144, 2 6Marlene Kramer, Reality Shock - Why Nurses Leave  Nursing Practice, Saint Louis: c. V. Mosby Company, 197 4. 7 No inv e s t i g a t i o n has been c a r r i e d out to determine the ro l e behavior of the B.S.N, graduates from the University of B r i t i s h Columbia School of Nursing i n Vancouver, Canada. I t was f e l t that a study on r o l e behavior of B.S.N, nurses graduated from the University of B r i t i s h Columbia School of Nursing w i l l provide more i n s i g h t for the education of future nurses at the University of B r i t i s h Columbia School of Nursing and f o r the u t i l i z a t i o n of B.S.N.'s i n the hospitals throughout B r i t i s h Columbia. II . Statement of the Problem The purpose of t h i s exploratory study was to investigate the r o l e behavior and the determinant factors influencing the achievement of such r o l e behavior by the B.S.N, graduates, May 19 76, of the basic program of the University of B r i t i s h Columbia School of Nursing. The following questions provided the focus of study: 1. What kind of ro l e behaviors do University of B r i t i s h Columbia graduates have at the time of graduation, May 197 6, and a f t e r three months employment i n the hos p i t a l situation? 2. What are the determinant factors that influenced achievement of ro l e behaviors of these B.S.N, graduates of University of B r i t i s h Columbia School of Nursing? I I I . T heoretical Base of the Problem The professional-bureaucratic c o n f l i c t i s not unique to nurses. I t has been noted, and reported to e x i s t i n many groups 8 and c o u n t r i e s o f t h e w o r l d . ^ ° ' ^ But t h e g e n e r a l p a t t e r n f o r a l l i s t h e same. The neophyte undergoes a r e l a t i v e l y e x t e n s i v e p e r i o d o f s o c i a l i z a t i o n w i t h v a l u e s i n an academic s e t t i n g w h i c h a r e c o n c e p t u a l l y s e p a r a t e d from the p o t e n t i a l e m p l o y i n g o r g a n i z a t i o n . I n t h e work s i t u a t i o n , however, he o r she i s more o r l e s s f o r c e d t o r e l i n q u i s h o l d v a l u e s and c h a r a c t e r i s t i c s . I n s t e a d she i s r e q u i r e d , o r ch o o s e s , t o p r a c t i c e i n a way c o n t r a d i c t o r y t o t h a t o f t h e p r o f e s s i o n a l work system l e a r n e d e a r l i e r . S e v e r a l i n v e s t i g a t o r s have noted t h a t t h e d i f f i c u l t i e s e n c o u n t e r e d by p r o f e s s i o n a l s employed i n b u r e a u c r a t i c o r g a n i z a t i o n s a r i s e from the systems f o r t h e o r g a n i z a t i o n o f work, r a t h e r than from t h e typ e s o f work a c t u a l l y p erformed by p e r s o n s i n bureau-c r a t i c o r g a n i z a t i o n s o r p r o f e s s i o n a l p o s i t i o n s . ^ u The b u r e a u -c r a t i c system i s o r g a n i z e d on the p r i n c i p l e s o f segmented, r o u t i n e t a s k s i . e . t h e employee p e r f o r m s o n l y a p a r t o f t h e t a s k , w h i c h t e n d s t o be r o u t i n e i n n a t u r e . T h i s t a s k d i v i s i o n o f l a b o r , on one hand, f a c e s t h e n u r s e w i t h d u t i e s w h i c h a r e m o s t l y a d m i n i s t r a t i v e r a t h e r than g i v i n g a c t u a l p a t i e n t c a r e as she e n v i s i o n e d i t . On ^'M a r l e n e Kramer, "Comparative Study o f C h a r a c t e r i s t i c s , A t t i t u d e s and O p i n i o n s o f Neophyte B r i t i s h and American N u r s e s , " I n t e r n a t i o n a l J o u r n a l o f N u r s i n g S t u d i e s , V o l . 4, (December 1967), pp. 281-294. 2^P. Brown, " B u r e a u c r a c y i n Governmental L a b o r a t o r y , " S o c i a l F o r c e s , V o l . 32 (March 1954), pp. 259-268. 2^B. G o l d s t e i n and o t h e r s , " M e d i c i n e i n I n d u s t r y : Problems o f A d m i n i s t r a t o r s and P r a c t i t i o n e r s , " J o u r n a l o f H e a l t h  and Human B e h a v i o r , V o l . 1, (Winter 1960), pp. 263-265. 3°Marlene Kramer, Some E f f e c t s o f Exposure t o Emp l o y i n g  B u r e a u c r a c i e s on t h e R o l e C o n c e p t i o n s and R o l e D e p r i v a t i o n o f  Neophyte C o l l e g i a t e N u r s e s , u n p u b l i s h e d d o c t o r a l d i s s e r t a t i o n , S t a n f o r d U n i v e r s i t y , 1966, p. 1. 9 t h e o t h e r hand, d i v i s i o n o f l a b o r l e a d s t o e x t e r n a l s u p e r v i s i o n , a h i e r a r c h i a l c o n t r o l s t r u c t u r e , and w r i t t e n r u l e s f o r maintenance of d e s i r a b l e s t a n d a r d s . 3 1 The p r o f e s s i o n a l ( s c h o o l ) system of work i n n u r s i n g i s based on t h e p r e m i s e t h a t t h e n u r s e p r o v i d e s a whole t a s k (eg. i n d i v i d u a l i z e d , comprehensive p a t i e n t c a r e ) . She e x p e c t s t h a t t h e s e i d e a s o f n u r s i n g p r a c t i c e w i l l be s h a r e d by a l l h o s p i t a l employees, and t h e w e l l b e i n g o f t h e p a t i e n t i s h e r p r i m a r y c o n c e r n . B e s i d e s , because t h e f o c u s i s on autonomy t h e e x t e r n a l c o n t r o l s a r e n o t needed. T h i s i n t u r n p r o v i d e s o p p o r t u n i t y f o r d e c i s i o n making, c r e a t i v i t y and i n n o v a t i o n f o r w h i c h t h e B.S.N, n u r s e i s p r o f e s s i o n a l l y p r e p a r e d . When a neophyte such as a B.S.N, n u r s e who has been s o c i a l i z e d i n t o an o c c u p a t i o n a l o n g one l i n e , e n c o u n t e r s t h e n e c e s s i t y o f p r a c t i c i n g h e r a r t o r s k i l l s i n o r g a n i z a t i o n s de-v e l o p e d a l o n g a n o t h e r l i n e , t h e r e s u l t i s c o n f l i c t , o r a k i n d o f 32 shock w h i c h i s i d e n t i f i e d by M a r l e n e Kramer as " r e a l i t y shock". ^ T h i s i s p a r t i c u l a r l y pronounced i n t h e case o f t h e p r o f e s s i o n a l -b u r e a u c r a t i c modes o f work o r g a n i z a t i o n because t h e two systems 33 are i n h e r e n t l y a n t i t h e t i c a l . The r e a c t i o n t o t h e s t a r t l i n g 31 M a r l e n e Kramer, " P r o f e s s i o n a l - B u r e a u c r a t i c C o n f l i c t and I n t e g r a t i v e R o l e B e h a v i o r , " Communicating N u r s i n g R e s e a r c h ;  I s t h e Gap B e i n g B r i d g e d ? , ed. M. B a t e y , B o u l d e r , C o l o r a d o : Western I n t e r S t a t e Commission f o r H i g h e r E d u c a t i o n , V o l . 4, 1971, p. 57. 3 2 M a r l e n e Kramer, R e a l i t y Shock - Why Nurses Leave  N u r s i n g P r a c t i c e , S a i n t L o u i s : C. V. Mosby Company, 1974, p. 4. 3 3 M a r l e n e Kramer, " P r o f e s s i o n a l - B u r e a u c r a t i c C o n f l i c t and I n t e g r a t i v e R o l e B e h a v i o r , " Communicating N u r s i n g R e s e a r c h :  I s t h e Gap B e i n g B r i d g e d ? , ed. M. B a t e y , B o u l d e r , C o l o r a d o : Western I n t e r S t a t e Commission f o r H i g h e r E d u c a t i o n , V o l . 4, 1971, p. 57. 10 d i s c o v e r y t h a t s c h o o l - b r e d v a l u e s c o n f l i c t w i t h w o r k - w o r l d v a l u e s and w i t h the d i s p a r i t y between e x p e c t a t i o n s and r e a l i t y a r e so s t r o n g t h a t an i n d i v i d u a l cannot p e r s e v e r e i n t h e s i t u a t i o n . I n such a s i t u a t i o n w h i l e some n u r s e s 35 3 6 e x p e r i e n c e r o l e c o n f l i c t and d i s i l l u s i o n m e n t , o t h e r s conform t o t h e norms and v a l u e s o f t h e i r e m p l o y i n g o r g a n i z a -37 t i o n s and i n c r e a s e t h e i r a l l e g i a n c e t o t h e b u r e a u c r a c y . D i s i l l u s i o n m e n t i s the r e s u l t o f near i n c o n s i s t a n c y between the n u r s e s * i n i t i a l i d e a s about r e a l i t y and t h e i r consequent 3 8 e x p e r i e n c e w i t h i t . R ole c o n f l i c t and c o n f u s i o n as Benne and B e n n i s 3 ^ d e s c r i b e i t , a r i s e when t h e r e i s a d i f f e r e n c e between p r i n c i p a l s e t s o f e x p e c t a t i o n s w h i c h d e t e r m i n e t h e c h a r a c t e r o f t h e n u r s e ' s r o l e . Such a c o n f u s i o n and c o n f l i c t l e v y a heavy t o l l on m o t i v a t i o n , j o b s a t i s f a c t i o n , and p r o -d u c t i v i t y o f t h e n u r s e . M a r l e n e Kramer, from a decade o f her own and o t h e r s t u d i e s , c o n c l u d e d t h a t t h e most common "^Mar l e n e Kramer, R e a l i t y Shock - Why N u r s e s Leave  N u r s i n g P r a c t i c e , S a i n t L o u i s : C. V. Mosby Company, 1974, p. 4, ^ M a r l e n e Kramer and o t h e r s , " S e l f - A c t u a l i z a t i o n and R o l e A d a p t a t i o n o f B a c c a l a u r e a t e Degree Nu r s e s , " N u r s i n g  R e s e a r c h , V o l . 21, No. 2, ( M a r c h - A p r i l 1973), p. 111. 3 6 M a r l e n e Kramer, " R o l e C o n c e p t i o n o f B a c c a l a u r e a t e Nurses and S u c c e s s i n H o s p i t a l N u r s i n g , " N u r s i n g R e s e a r c h , V o l . 19, No. 5, (September-October 1970), p. 430. R o n a l d G. C o r w i n , The P r o f e s s i o n a l Employee: A Study o f C o n f l i c t i n N u r s i n g R o l e s , " The American J o u r n a l  o f S o c i o l o g y , V o l . 66, No. 6, 1961, pp. 610-614. ^ ^ R o n a l d G. C o r w i n and o t h e r s , " P r o f e s s i o n a l D i s i l -l u s i o n m e n t , " HH££illH_^§££a££ll' V o l . 10, No. 3, (Summer 1961), pp. 141-144. 3^K. D. Benne and W. B e n n i s , " R o l e C o n f u s i o n and C o n f l i c t i n N u r s i n g : What i s R e a l N u r s i n g ? , " American J o u r n a l  of N u r s i n g , V o l . 59, No. 3, (March 1959), p. 380. c o n f l i c t areas which new graduates face are: 11 "1. Difference between systems of work organization (the professional being the predominant system of organization at school, the bureaucratic being the predominant system of organization at work) and the r e s u l t i n g difference between rewards and sanctions i n school and work. 2. The difference between the school world of e x p l i c i t expectations and the work of implied expectation. 3. The difference between the school cosmopolitan view and the work world's l o c a l i t e view."40 Corwin 4! was one of the f i r s t to study the d i f f e r e n t i a l presence of t h i s c o n f l i c t i n nurses i n varying status and back-grounds. Since his study i n 1960, many studies have been c a r r i e d out to investigate d i f f e r e n t aspects of t h i s conflict. 4 2'43,44,45 Recent nursing journals and l i t e r a t u r e have a wealth of a r t i c l e s dealing with d i f f e r e n t kinds of solutions for one or more aspects of t h i s c o n f l i c t . Among the most recent ones i s Marlene Kramer's "Anticipatory S o c i a l i z a t i o n Theory" which has been tested and studied extensively. This theory and r e s u l t of her studies are described i n her book "Reality Shock - Why Nurses Leave Nursing ^^Marlene Kramer, Reality Shock - Why Nurses Leave  Nursing Practice, Saint Louis: C. V. Mosby Company, 1974, p.193. 4 1Ronald G. Corwin, "The Professional Employee: A Study of C o n f l i c t i n Nursing Roles," The American Journal of Sociology, Vol. 66, No. 6, 1961, pp. 604-615. 4 2Marlene Kramer, "Role Conception of Baccalaureate Nurses and Success i n Hospital Nursing," Nursing Research, Vol. 19, No. 5, (September-October 1970), p. 428. 4 3Marlene Kramer, "Collegiate Graduate Nurses i n Medical Center Hospital: Actual Challenge or Duel," Nursing Research, Vol. 18, No. 3, (May-June 1969), p. 197. 4 4 P a t r i c i a Benner and Marlene Kramer, "Role Conceptions and Integrative Role Behaviour of Nurses i n Special Care and Regular Hospital Nursing Units," Nursing Research, Vol. 21, No. 1, (January-February 1972), p. 22. 45Ronald G. Corwin and others, "Professional D i s i l l u s i o n -ment," Nursing Research, Vol. 10, No. 3, (Summer 1961),pp. 141 -144. 12 Pr a c t i c e ? " ^ b Kramer believes that i f the neophyte nurse w i l l i n e v i t a b l y encounter discrepancies between nursing education and nursing practice, then she should be subjected to these discrep-ancies during the learning experience when she has support and guidance enabling her to prepare her defences. She describes and gives evidence that i f a nurse develops integrative r o l e be-havior i t means that some degree of growth-producing-conflict-re s o l u t i o n i n her behavior has taken place. She concludes that the presence of the inte g r a t i v e r o l e behavior in one's behavioral repertoire makes her less susceptible to professional-bureaucratic c o n f l i c t and thus a more s a t i s f i e d nurse. Proceeding from this t h e o r e t i c a l foundation, i t i s valu-able to f i n d out: 1. What kind of r o l e behavior University of B r i t i s h Columbia graduates have at the time of graduation? 2. What kind of r o l e behavior University of B r i t i s h Columbia graduates have a f t e r working i n ho s p i t a l (bureaucratic) s i t u a t i o n ( s ) ? 3. What factors influenced University of B r i t i s h Columbia graduates to develop th e i r r o l e behavior? IV. Significance and Implementation of the Research Problem to Nursing.  This i s a new research following up the studies of the l a s t decade or so, by focussing on the here and now. This study aims to extend knowledge by inve s t i g a t i n g the kind of r o l e behaviors which University of B r i t i s h Columbia graduates have,at the time of graduation, and a f t e r three months employment i n hospital Marlene Kramer, Reality Shock - Why Nurses Leave  Nursing Practice, Saint Louis! C. V. Mosby Company, 19/4, p. 13 s i t u a t i o n s . This research s t r i v e s also to produce e s p e c i a l l y useful knowledge by i d e n t i f y i n g determinant factors which helped the University of B r i t i s h Columbia graduate achieve her r o l e behavior. There seems promise of p o t e n t i a l s i g n i f i -cance for contemporary l o c a l implementation of change, i f needed, and as a frame of reference for the writer and others i n considering s i m i l a r or further research elsewhere. Findings of t h i s study w i l l reveal to what extent l o c a l education and work systems are at present helping the University of B r i t i s h Columbia graduates and new graduates face the r e a l i t y of the work se t t i n g . Nursing l i t e r a t u r e has made information a v a i l a b l e to B.S.N, educators and to B.S.N, employers i n h o s p i t a l work systems, l o c a l l y and elsewhere to the extent that many nurses experience " r e a l i t y shock." Because B.S.N.'s perceived a discrepancy between nursing education and nursing p r a c t i c e , both educators and nursing service administrators already may have modified curriculum and work organizations. This study w i l l give some indi c a t i o n as to where the University of B r i t i s h Columbia graduates stand with regard to professional, bureaucratic or in t e g r a t i v e r o l e behavior. I t w i l l be s i g n i f i c a n t to discover whether there i s a s i m i l a r i t y or a d i s p a r i t y between the role behaviors selected upon graduation and those r e s u l t i n g a f t e r three months employment. If findings indicate c o n f l i c t between "pr o f e s s i o n a l i z a t i o n " of the University of B r i t i s h Columbia grad-uates and "bureaucracy" i n h o s p i t a l organizations, then t h i s w i l l s i g n i f y a challenge to d i r e c t o r s of nursing education, to nursing service administrators and to the B.S.N.'s involved. The i d e n t i f i -14 cation of determinant factors can be of s i g n i f i c a n c e both to future planners of c u r r i c u l a , and to nursing service adminis-t r a t o r s i n the h o s p i t a l . The findings of the study w i l l be a p o t e n t i a l c o n t r i -bution to the a v a i l a b l e knowledge as to how education and service can each be oriented so that they form a united front to meet the challenge of health care delivery for the benefit of the c l i e n t . V. D e f i n i t i o n of Terms Used For the purpose of t h i s study the following terms are defined. Role: A c o l l e c t i o n of patterns of behavior which are thought to constitute a meaningful u n i t and deemed appropriate to a person occupying an informally defined position i n interpersonal r e l a t i o n , or i d e n t i f i e d with a p a r t i c u l a r value i n society. ' Role Behavior: The action component: i s the observable action or behavior of an i n d i v i d u a l functioning i n a given p o s i t i o n i n a s o c i a l system.^8 Integrative Role Behavior: The choice of a r o l e action which simultaneously permits or r e f l e c t s adherence to both professional and bureaucratic values i n methods of work organization.49 4?Ralph Linton, The C u l t u r a l Background of Personality, New York: Appleton-Century Company, 1945, p. 77. ^Marlene Kramer, "Role Conceptions of Baccalaureate Nurses and Success i n Hospital Nursing," Nursing Research, Vol.19, No. 5, (September-October 1970), p. 430. ^ P a t r i c i a Benner and Marlene Kramer, "Role Conceptions and Integrative Role Behavior of Nurses i n Special Care and Regular Hospital Nursing Units," Nursing Research, Vol. 21, No. 1, (January-February 1972), p. 25. 15 Professional Role Behavior: The choice of a r o l e action which suggests primary l o y a l t y to the nursing profession, (school-bred idealism). Bureaucratic Role Behavior: The choice of a ro l e action which suggests primary l o y a l t y to the hospital administration, (work-bred idealism). B.S.N. Nurse: A graduate of 4 or 5 year baccalaureate program functioning as a nurse. VI. Assumptions of the Study The study was based on the assumption that: 1. The h o s p i t a l system i n which the University of B r i t i s h Columbia graduates are employed i s bureaucratically structured. . 2. I t i s the University of B r i t i s h Columbia School of Nursing philosophy to prepare professional nurses. v 3. The presence of int e g r a t i v e r o l e behavior indicates that some degree of growth producing c o n f l i c t r e s olution has taken place. VII. Limitations of the Study Recognized l i m i t a t i o n s of the study were as follows: 1. The sample i s confined to the University of B r i t i s h Columbia graduates who choose to work i n ho s p i t a l s . 2. Work settings are lim i t e d to those hospitals i n which the University of B r i t i s h Columbia graduates are working. 3. The findings of t h i s study cannot be generalized beyond the University of B r i t i s h Columbia B.S.N, graduates of May 1976. 5^The University of B r i t i s h Columbia, S i x t y - f i r s t Session Calendar, Vancouver, B.C., 1975-1976, p. 53. 16 CHAPTER II REVIEW OF THE LITERATURE I. Introduction During recent years there has been considerable i n t e r e s t i n measuring the l e v e l of work s a t i s f a c t i o n , r o l e conception and success i n h o s p i t a l nursing among nurses. Findings of these studies reveal that there i s a d i s p a r i t y and c o n f l i c t between nurse functions and values propagated by the educational i n s t i -tutions, and those emphasized by employing organizations. In other words, the d i s p a r i t y stems from the f a c t that B.S.N, nurses are educated along professional l i n e s of work organization, but are employed by bureaucratically structured work systems, namely the h o s p i t a l s . The l i t e r a t u r e reviewed here f i r s t discusses the theo-r e t i c a l basis of the professional-bureaucratic c o n f l i c t as i t r e l a t e s to nursing, and then deals with the r e l a t e d studies which have been c a r r i e d out i n the l a s t decade or so. II. Professional-Bureaucratic C o n f l i c t There has been, and continues to be, a great i n t e r e s t i n the dichotomy which exists between the bureaucratic h o s p i t a l organi-zation and the professional person who functions within such an organization. B l a u 1 defines bureaucracy as a type of organization to 1 P e t e r Blau, Bureaucracy i n Modern Society, New York: Random House, 1956, pp. 28-34. 17 accomplish large scale administrative tasks by way of systematic coordination. Another usage of t h i s term refers to a b e l i e f system, namely,the bureaucratic r o l e . This i s a set of expectations about an occupational r o l e . Bureaucracy,as conceived here,is not a type of organization: i t i s a set of p r i n c i p l e s or norms which define a way of organizing the adminstrative a c t i v i t i e s . Conse-quently, persons working i n such s i t u a t i o n s may hold a d i f f e r e n t conception of these norms, and thus,of t h e i r r o l e . Bureaucratic organizations are characterized by 1) a well-defined chain of command, 2) a system of rules and procedures for dealing with work a c t i v i t i e s , 3) a d i v i s i o n of labor based on s p e c i a l i z a t i o n , 4) promotion and sel e c t i o n based on te c h n i c a l competencies, and 5) impersonality i n human r e l a t i o n . 2 The bureaucratic system emerged from the need of organizations for order and effectiveness, and from the employees' demand f o r impartial treatment. The modern h o s p i t a l may be seen to operate according to many of these p r i n c i p l e s . There i s a h i e r a r c h i a l chain of command; there are routine tasks; there i s emphasis on e f f i c i e n c y of performance and operation, and f i n a l l y there i s high r e l i a n c e on p o l i c y , r u l e s , and h i e r a r c h i a l demands. A profession can be conceptualized as an organization ^Warren Bennis, The Coming Death of Bureaucracy, Notes  and Quotes, Connecticut: General L i f e Insurance Co., 1966, p. 1. 3Nancy D. Johnson, "The Professional-Bureaucratic Con-f l i c t , " Journal of Nursing Administration, (May-June 1971), p. 32. 18 i n two ways. E t z i o n i 4 defines and describes a "professional organization" as a formal organization with the following c h a r a c t e r i s t i c s : 1) i t has the goal of producing, applying, preserving or communicating knowledge; 2) i t includes a high proportion of professionals on the s t a f f and; 3) i t has an authority over the major goal a c t i v i t i e s of the organization. Another conception of a professional organization i s that of a formally organized occupational group,committed to the development and maintenance of the c h a r a c t e r i s t i c s of a profes-sion as defined above. The professional system of work organization, taught to B.S.N.'s during t h e i r formal education, i s characterized by: 1) autonomy from organizational c o n t r o l ; 2) self-evaluation of task performance; 3) r e s p o n s i b i l i t y for the whole task; 4) colleague r e l a t i o n s h i p with others and; 5) movement from one organization to another perceived as o f f e r i n g more freedom to u t i l i z e professional be-5 havior. In the drive for p r o f e s s i o n a l i z a t i o n , nursing schools ^Amitai E t z i o n i , Modern Organizations, New Jersey: Pr e n t i c e - H a l l , Inc., 1964, pp. 77 and 81-87. 5Richard W. Scott, "Professional Employees i n a Bureau-c r a t i c Structure: S o c i a l Work," Semi Professionals and t h e i r organization, ed. Amitai E t z i o n i , New York: The Free Press, 1969, pp. 82-140. 19 today attempt to adapt B.S.N. education to the expectation of the profession and the society they serve. Therefore during the education, while students are generally busy learning a body of knowledge,and becoming f a m i l i a r with technical pro-cedures, they are also normally i n the process of learning the customs and values of a new culture. These customs and values define the expectations of one's s e l f and of others i n s p e c i f i c s i t u a t i o n s . In t h i s sense, students are learning to become someone. Consequently, t h e i r i n i t i a l r o l e con-ception i s formed i n the nui-sing school, where professional values and p r i n c i p l e s are emphasized. Theoretical d i s t i n c t i o n between bureaucratic and professional p r i n c i p l e s of work organization, as Ronald Gary Corwin^describes i t , can be examined according to the following a t t r i b u t e s : standardi-zation of task and procedure, degree of autonomy permitted, and r e l a t i o n s h i p to organizational goals of e f f i c i e n c y and service. Each of these a t t r i b u t e s may be conceptualized as a continuum on which the i d e a l type of bureaucracy i s at one end, and the i d e a l type of professionalism i s at the other end. Each of the c r i t e r i a w i l l be examined respectively. F i r s t , the tasks of a bureaucratic organization are more standardized than those of a professional organization. 6Ronald G. Corwin, Role Conception and Mobility  Aspiration: A Study in the Formation and Transformation of  Bureaucratic, Professional and Humanitarian Nursing I d e n t i t i e s , Unpublished doctoral d i s s e r t a t i o n , University of Minnesota, 1960, p. 153. 7 I b i d . , pp. 149 - 150. 20 While bureaucracy implies standard administrative routine and simple tasks, professional organizations are based on a body of knowledge and s k i l l which provides a perspective on the t o t a l i n s t i t u t i o n . Also, while the bureaucrat systematically concentrates on routine matters, the professional focuses on the unique problems of the c l i e n t as a person, emphasizing as well the professional's own unique solutions. Furthermore, the bureaucratic emphasis on f i l e s and records guarantees continuity and s t a b i l i t y , but the e f f e c t of emphasis on the professional's decision making process i s to focus on change. Second, the bureaucrat has less work autonomy than the professional. While bureaucratic p r i n c i p l e s are applied through the mechanism of abstract rules and procedures, professional service to c l i e n t s depends on the exercise of i n i t i a t i v e and judgment of i n d i v i d u a l s . Each bureaucratic s i t u a t i o n i s presumed to be cate g o r i c a l and routine to which a set of uniform rules i s applicable; while situations dealt with by professionals are assumed to be unique, requiring i n d i v i d u a l problem solving and decision making. F i n a l l y , the r e l a t i o n s h i p between the worker and the goal of the bureaucratic organization i s d i f f e r e n t from the r e l a t i o n -ship between the professional and his professional organization. As Francis and Stone stated: "the emphasis i n the professional mode rests upon the r e l a t i o n of an i n d i v i d u a l to the system of organization ... (while) the bureaucratic mode of organization seems to stem from the r e l a t i o n of the in d i v i d u a l to a spe c i a l i z e d type of work."8 8Roy G. Francis and Robert C. Stone, Service and  Procedure i n Bureaucracy, Minneapolis: University of Minnesota Press, 1956, p. 156. 21 The worker's goal of e f f i c i e n c y i n the bureaucracy can be compared to the professional's goal of service to c l i e n t s i n the profession. While the bureaucratic organization focuses on the s p e c i f i c a c t i v i t i e s of the job, the professional organi-zation focuses on service to c l i e n t s . Furthermore, the c l i e n t ' s welfare may not always be equivalent to the welfare of the organization. In such instances, professional and bureaucratic p r i n c i p l e s may c o n f l i c t , which may lead to a c o n f l i c t of l o y a l t y between professional standards and the organized bureaucracy. Therefore, while r o l e conceptions are i n i t i a l l y formed i n educational i n s t i t u t i o n s , they may be modified during the career by experiences encountered i n the hospital,to the extent that persons tend to become " l i k e " t h e i r organization i n order to survive. I I I . Nursing Studies Related to the Problem The composition of the nurse's r o l e , and i n c i p i e n t c o n f l i c t i n r o l e value systems, has been the primary or secondary concern of many investigators studying nursing. Benne and Bennis 9 , were among the f i r s t to investigate the r o l e of the professional nurse. Benne and Bennis, studying ninety nurses working i n the out-patient department 9Kenneth D. Benne and Warren Bennis, "Role Confusion and C o n f l i c t i n Nursing - What i s Real Nursing?" The American  Journal of Nursing, Vol. 59, No. 3, (March 1959), pp. 380-383. Ibid. , pp. 196-19 8. 22 of seven hospitals i n the Boston area, found three areas of tension within nursing. The f i r s t area of tension which they discuss i s the nurse's "blurred s e l f image." They point out that " r e a l " nursing i s considered to be bedside care. Nurses bring t h i s image into nursing school, and often the schools do not dislodge i t . In the work s i t u a t i o n , however, the nurse i s act u a l l y required to perform t e c h n i c a l , administrative, organizational, and educative duties. Conse-quently there i s a sharp d i s c o n t i n u i t y between the nurse's s e l f image and the a c t u a l i t i e s of her work l i f e , and the r e s u l t i s "role deprivation" because B.S.N, nurses do not perform s k i l l s which they expected to perform, and f o r which they were educated. The second area of c o n f l i c t , according to these authors, i s nurse-doctor c o n f l i c t , because of misunderstanding on both sides. The t h i r d area of c o n f l i c t i s the nurse-supervisor one. Nursing as a vocation i s less favored among st a f f nurses than among student nurses. Also, expressed job s a t i s f a c t i o n i s lower among s t a f f nurses,than s a t i s f a c t i o n with educational experience expressed by student nurses. The authors' conclusion (that job s a t i s f a c t i o n and favorableness of the image of the nursing of graduate nurses i s lower than that of students, also success i s less s a t i s f y i n g to graduates than to student nurses) supports the thesis that the impressions of nursing which students bring to t h e i r jobs a f t e r graduation are not e n t i r e l y r e a l i s t i c . Their reduced job s a t i s f a c t i o n and favorableness toward nursing imply that 23 nurses become d i s i l l u s i o n e d a f t e r graduation. ( D i s i l l u s i o n -ment r e s u l t s from an almost i n e v i t a b l e inconsistency between a person's ideas about r e a l i t y and his consequent experience with i t . ) 1 2 13 The s o c i o l o g i s t Corwin also investigated two hundred and ninety-six graduates and student nurses from seven hospitals and four schools of nursing i n a Midwestern metropolis. He established that a difference exists between the r o l e con-ceptions and r o l e configuration of nurses trained i n h o s p i t a l -based programs, and those from college-based programs. In this research he found that B.S.N, nurses maintained high professional r o l e conceptions more frequently than did diploma nurses, combining them with either higher or lower bureau-c r a t i c conceptions. The r e s u l t i s a high i n t e n s i t y of con-f l i c t . Graduate diploma nurses modify t h e i r professional conception a f t e r graduation, whereas B.S.N.'s maintain the professional conception a f t e r employment, while at the same time they increase t h e i r allegiance to the bureaucracy. In another study, Corwin and Tave s 1 4 found that the ^Ronald G. Corwin et a l , "Professional D i s i l l u -sionment", Nursing Research, Vol. 10, No. 3, (Summer 1961), pp. 141 - 144. 1 2 I b i d . , p. 141. 13 Corwin, Role Conception and Mo b i l i t y Aspiration : ... op. c i t . 1 4Ronald G. Corwin and Marvin J . Taves, "Some Concomi-tants of Bureaucratic and Professional Conceptions of the Nurse Role", Nursing Research, Vol. 11, No. 4, ( F a l l 1962), pp. 223 - 227. 24 type of r o l e conception held, the ce r t a i n t y with which i t i s held, and the amount of r o l e deprivation, w i l l be experienced d i f f e r e n t l y by nurses with d i f f e r e n t types of education and in d i f f e r e n t stages of t h e i r careers. Also the type, c l a r i t y , and deprivation of r o l e conception w i l l influence career as p i r a t i o n . The Corwin, and Corwin and Taves studies demonstrated that c o l l e g i a t e nurses are more susceptible to r o l e depriva-t i o n because they hold higher professional r o l e conceptions than do diploma nurses. From another point of view, i n an analysis of thirteen head nurses 1 written evaluations for forty-two s t a f f nurses, and fourteen teachers' evaluation of nursing students, S m i t h 1 5 established that there i s a difference between head nurses* and teachers' conceptions of desirable interpersonal and i n t r a -personal c h a r a c t e r i s t i c s of the nurse. I t was concluded that the two groups place d i f f e r e n t emphasis upon nursing r o l e values - head nurses emphasizing functional t r a i t s such as leadership, group o r i e n t a t i o n , conforming behavior, neatness and helpfulness, - f a c u l t y emphasizing t r a i t s such as inde-pendence, empathy, team orientedness, i n t e r e s t and s k i l l i n teaching patients, and cognitive s k i l l s . Kathryn Smith then l^Kathryn M. Smith, "Discrepancies i n the Role S p e c i f i c Values of Head Nurses and Nursing Educators", Nursing Research, Vol. 14, No. 3, (Summer 1965), pp. 196 -202. 25 analyzed that: "the discrepant conceptions of nursing create for the nursing student a climate i n which she i s continuously exposed to two disparate and p o s i t i v e l y sanctioned sets of expectations oriented to the administrative p r i n c i p l e s . Since the student must adhere to both sets of expectations as she learns to care for patients, she finds herself working under conditions which are hardly conducive to ready conformity to either pat-tern of norms. Thus the neophyte nurse finds herself i n a s i t u a t i o n of c o n f l i c t . "-^ It i s these administrative expectations, more functional i n the organizational s e t t i n g , which may produce role deprivation i n the professional aspirant or employee. By using a questionnaire and interview, Marlene Kramer 1 7 c a r r i e d out a study to f i n d out: "What do new graduates r e a l l y think about t h e i r f i r s t experience i n hos-p i t a l s ? " The r e s u l t shows that a sample of f o r t y - f i v e c o l l e g i a t e graduates seem to be more oriented and l o y a l to t h e i r profession of nursing than to any place of employment. The graduates tend to see h o s p i t a l nursing as a necessary experience to prepare them fo r other nursing pursuits. Marlene Kramer concluded that, i f hospitals want to a t t r a c t and keep graduates of college programs, then perhaps they should l i s t e n to a new graduate nurse who seems to be saying: "Give me more auto-nomy to make judgements and decisions; l e t me use the knowledge and s k i l l s I have; and l e t me be evaluated by the people who see my work."^ i ^ i b i d . , pp. 201 -202. 1 7Marlene Kramer, "The Graduate Speaks", American  Journal of Nursing, Vol. 66, No. 11, (November 1966), pp. 2420 - 2424. I S i b i d . , p. 2424. 26 S i s t e r Agnes M. Reinkemeyer, by t h e use o f a q u e s t i o n -n a i r e and i n t e r v i e w , asked 74 p e r c e n t o f t h e t o t a l s t u d e n t p o p u l a t i o n of f o u r u n i v e r s i t y a s s o c i a t e d n u r s i n g programs i n G r e a t B r i t a i n about t h e i r immediate j o b p l a n s , and a l s o t e n y e a r s a f t e r g r a d u a t i o n . The r e s u l t o f t h e s t u d y showed t h a t o n l y t h i r t e e n o u t o f the one hundred and se v e n t e e n r e s p o n d e n t s i n t e n d e d t o go i n t o a g e n e r a l o r s p e c i a l h o s p i t a l , and t h e n o n l y "tempo-r a r i l y , f o r f u r t h e r p r a c t i c e . " " R i g i d h i e r a r c h i c a l s t r u c t u r e " , " a u t h o r i t a r i a n a t t i t u d e s " and n u r s e s who " c a r r y o u t p r o c e d u r e s l i k e automatons" were some o f t h e r e a s o n s g i v e n by s t u d e n t s f o r t h e i r d e c i s i o n n o t t o p r a c t i s e h o s p i t a l n u r s i n g . S i s t e r Reinkemeyer p o i n t s o u t t h a t t h e r o o t o f t h e problem i s t h e same b o t h i n G r e a t B r i t a i n and i n N o r t h A m e r i c a . She u r g e s l e a d e r s i n n u r s i n g s e r v i c e and n u r s i n g e d u c a t i o n t o j o i n e f f o r t s i n s p e l l i n g o u t , i n t e r p r e t i n g , and p u b l i c i z i n g t h e u n i q u e c o m p e t e n c i e s o f B.S.N, g r a d u a t e s , d e c i d i n g upon and d e f i n i n g o p e r a t i o n a l l y t h e use o f t h e s e c o m p e t e n c i e s , and i n s u r i n g t h a t t h e y a r e employed f o r t h e " r i g h t " r e a s o n s f o r f e a t u r e s w h i c h d i s t i n g u i s h them from o t h e r n u r s i n g s e r v i c e p e r s o n n e l , namely, t h e i r u n i v e r s i t y e d u c a t e d heads and h e a r t s . I n an a t t e m p t t o i n v e s t i g a t e t h e changes i n r o l e c o n c e p t i o n s and magnitude of r o l e d e p r i v a t i o n o f c o l l e g i a t e n u r s e s f o l l o w i n g g r a d u a t i o n and i n i t i a l employment, M a r l e n e K r a m e r 2 0 conducted a l o n g i t u d i n a l s t u d y o f s e v e n t y - n i n e ± y S i s t e r Agnes M. Reinkemeyer, " I t Won't be H o s p i t a l N u r s i n g " , A m e r i c a n J o u r n a l o f N u r s i n g , V o l . 68, No. 9, (September 1968), pp. 1936 - 1940. 2 o M a r l e n e Kramer, "R o l e M o d e l s , R o l e C o n c e p t i o n s , and R o l e D e p r i v a t i o n " , N u r s i n g R e s e a r c h , V o l . 17, No. 2, (March - A p r i l 1968), pp. 115 - 120. 27 graduates from three C a l i f o r n i a state college B.S.N, programs. These nurses were administered the Corwin Role Conception Scales,and a personal data form just before graduation, three months af t e r beginning employment, and then three months l a t e r . She also did standardized tape recorded interviews with them. In t h i s study she found that there i s a s i g n i f i c a n t increase in l o y a l t y to bureaucratic values following employment and s i g n i f i c a n t decrease i n professional values. Also there was a s i g n i f i c a n t increase i n magnitude of r o l e deprivation of the groups as a whole three months af t e r graduation, but i t receded to the graduation l e v e l six months af t e r employment. Besides, the r e s u l t indicated that subjects who l e f t nursing practice, and who changed jobs because of job d i s s a t i s f a c t i o n , or re-turned to school, showed s i g n i f i c a n t l y more ro l e deprivation scores than subjects who remained i n the same job f o r the six-month period of the study. Findings suggested that: (1) The bureaucratic o r i e n t a t i o n of neophyte nurses increases with the length of employment; (2) This increase i n bureaucratic value o r i e n t a t i o n i s related to a s h i f t from a school or p r o f e s s i o n a l l y centered model to a work centered model; (3) Role deprivation i s greater for subjects r e t a i n i n g i n s t r u c t o r r o l e models than for those who s h i f t to work centered models. J-Marlene Kramer, 2 2 i n a report of a two-year follow-up 2 1 I b i d , p. 120. 2 2Marlene Kramer, "The New Graduate Speaks Again," American Journal of Nursing, V o l . 69, No. 9, (September 1969), pp. 1903 - 1906. ' 28 s t u d y o f her o r i g i n a l s a m p l e , ^ i n d i c a t e d i n her f i n d i n g s t h a t many o f t h e s e g r a d u a t e s f e l t u n a b l e t o c h a l l e n g e t h e b u r e a u c r a c y , and had s e t t l e d f o r l e s s than t h e y had wi s h e d f o r a t g r a d u a t i o n . The same i n v e s t i g a t o r , i n the r e p o r t o f a n o t h e r s t u d y i n 19 69, i n d i c a t e d t h a t c o l l e g i a t e n u r s e s seemed much h a p p i e r , e x p r e s s e d more j o b s a t i s f a c t i o n and l e s s r o l e d e p r i v a t i o n w o r k i n g i n o r g a n i z a t i o n s where t h e y were rewarded f o r n u r s i n g r a t h e r than f o r m a n a g i n g . 2 4 An i n t e r v i e w and s c a l e - q u e s t i o n n a i r e s t u d y o f two hundred and twenty c o l l e g i a t e g r a d u a t e n u r s e s w o r k i n g i n t h i r t y - s e v e n m e d i c a l c e n t r e h o s p i t a l s was d e s i g n e d by M a r l e n e Kramer. 3 T h i s was t o t e s t t h r e e hypotheses r e l a t i v e t o r o l e c o n c e p t i o n and r o l e d e p r i v a t i o n o f n u r s e s judged t o be d i f f e r e n t l y s u c c e s s f u l i n h o s p i t a l n u r s i n g . R e s u l t s l e d t o the c o n c l u s i o n s t h a t : (1) H i g h l y s u c c e s s f u l n u r s e s have h i g h e r b u r e a u c r a t i c r o l e c o n c e p t i o n s t h a n do l e s s s u c c e s s f u l n u r s e s ; (2) L e s s s u c c e s s f u l n u r s e s have h i g h e r r o l e d e p r i v a t i o n t h a n e i t h e r t h e average s u c c e s s f u l o r h i g h l y s u c c e s s f u l n u r s e s , ""Marlene Kramer, "The Graduate Speaks," American  J o u r n a l o f N u r s i n g , V o l . 66, No. 11 (November 1966), pp. 2420-2424. 2 4 , " C o l l e g i a t e Graduate N u r s e s i n M e d i c a l C e n t e r H o s p i t a l s : A c t u a l C h a l l e n g e o r D u e l , " N u r s i n g R e s e a r c h , V o l . 18, No. 3, (May-June 1969), pp. 198-210. 25 , " R o l e C o n c e p t i o n o f B a c c a l a u r e a t e Nurses and Success i n H o s p i t a l N u r s i n g , " N u r s i n g R e s e a r c h , V o l . 19, No. 5, (September-October 1970), pp. 428-438. 29 although the r o l e deprivation of highly successful nurses i s also r e l a t i v e l y high. Besides, both highly successful and less successful nurses profess a s i g n i f i c a n t l y higher professional 2 6 r o l e concept than does the average successful nurse. Marlene Kramer discusses that the data from t h i s i n v e s t i g a t i o n would seem to indicate that i t would be much more f r u i t f u l to i d e n t i f y the behavior patterns and r o l e adaptation of highly professional nurses judged to be "highly successful", and to teach these to both our present nursing students as well as to new employees through inservice education. The Colorado League for Nursing decided to study the u t i l i z a t i o n of nurses according to t h e i r education i n health care organizations, and also to get some baseline data from nurses about t h e i r behavior on the job. ' A c l u s t e r analysis of nursing a c t i v i t i e s , as reported by nurses on a questionnaire, shows a gap between the " i d e a l " use of nurses according to t h e i r educational preparation, and t h e i r " r e a l " use by employ-ment agencies. Janelle C. Kruger , who reports the study, believed that t h i s study raised more questions than i t answered. She queried i f the behaviors reported i n her study were related to the professional bureaucratic c o n f l i c t , and wondered who decides how nurses are u t i l i z e d on the job. 2 6 I b i d . , p. 438. 27Janelle C. Krueger, "The Education and U t i l i z a t i o n of Nurses: A Paradox," Nursing Outlook, Vol. 19, No. 10, (October 1971), pp. 676-679. 2 8 I b i d . , p. 679. 30 M a r l e n e Kramer and Constance B a k e r ^ y l o o k i n g a t t h e problem o f exodus i n n u r s i n g c a r r i e d o u t a s t u d y t o f i n d o u t who l e f t n u r s i n g f o r r e a s o n s r e l a t e d t o p r o f e s s i o n a l - b u r e a u c r a t i c c o n f l i c t . The term d r o p o u t was used t o d e s i g n a t e t h o s e n u r s e s who w i t h d r e w from t h e p r a c t i c e o f n u r s i n g because o f d i s s a t i s -f a c t i o n o r a l i e n a t i o n , o r b o t h . The r e s e a r c h e r s e x p l a i n t h a t t h e d i s s a t i s f a c t i o n may be due t o w o r k i n g c o n d i t i o n s , p e r s o n n e l p o l i c i e s , o r , more o f t e n , a d i s i l l u s i o n m e n t because o f what n u r s i n g p r a c t i c e was b e l i e v e d t o be,compared w i t h what t h e y found i t t o be. These a r e f a c t o r s r e l a t e d t o t h e p r o f e s s i o n a l -b u r e a u c r a t i c c o n f l i c t . 3 ^ I n t h i s s t u d y , a n a t i o n w i d e sample o f 220 B.S.N.'s was s e l e c t e d from a p o p u l a t i o n o f B.S.N.'s who were w o r k i n g i n medi-c a l c e n t e r h o s p i t a l s . The r e s u l t g i v e s e v i d e n c e o f a l a c k o f work s a t i s f a c t i o n among n u r s e s , and 29 p e r c e n t d r o p o u t s o f B.S.N.'s ( e x c l u d i n g m a t e r n i t y l e a v e ) . The a l a r m i n g f a c t i s t h a t none o f t h e s e 29 p e r c e n t had any i n t e n t i o n o f r e t u r n i n g t o n u r s i n g , and t h e y have made t h e d e c i s i o n w i t h c o n s i d e r a b l e t h o u g h t . The r e s u l t a l s o showed t h a t t h e m a j o r i t y o f t h e d r o p o u t s had h i g h p r o f e s s i o n a l r o l e c o n c e p t i o n . Kramer and Baker a s s e r t t h a t a B.S.N, g r a d u a t e s w i t h a h i g h p r o f e s s i o n a l r o l e c o n c e p t i o n . I n re s p o n s e t o e n v i r o n m e n t a l p r e s s u r e , she r a i s e s h er b u r e a u c r a t i c • ^ M a r l e n e Kramer and Constance B a k e r , "The Exodus: Can We P r e v e n t I t ? " The J o u r n a l o f N u r s i n g A d m i n i s t r a t i o n , V o l . 1, No. 3, (May-June 1971), pp. 15-30. 3 0 I b i d . , p. 21. 31 r o l e conception, upon employment, If she does t h i s and attempts to r e t a i n her professional values, much discomfort ensues, and there i s a 50 percent chance that she w i l l leave nursing a f t e r trying several jobs i n d i f f e r e n t work local e s . If she doesn't r a i s e her bureaucratic role values, there i s also a 50 percent chance that she w i l l leave n u r s i n g . 3 1 They further discuss that the B.S.N, has been s o c i a l i z e d i n t o a professional system for the organization of work, a system with humanization as i t s central core. Unless the B.S.N, i s encouraged and rewarded for functioning within both systems, the a l i e n a t i o n due to f r u s t r a -t i o n and powerlessness w i l l continue,and both the worker and the patient w i l l be denied the benefit of humanization. ^ In a follow-up study of the same sample, i t was found that nurses with simultaneously high professional and high bureaucratic r o l e con-ceptions and low r o l e deprivation,had s i g n i f i c a n t l y higher i n t e -grative r o l e behavior scores, than did nurses with high profes-s i o n a l , high bureaucratic r o l e conceptions, and high r o l e depri-vation. I t was concluded that the presence of integrative r o l e strategies i n one's behavioral repertoire makes one much less susceptible to r o l e deprivation and possible exodus from nursing. J In a recent survey which was done by Brenda E. Mason and 3 l I b i d . , p. 21. 3 2 I b i d . , p. 26. 3 3Marlene Kramer, "Professional-Bureaucratic C o n f l i c t and Integrative Role Behavior," Communicating Nursing Research: Is the Gap Being Bridged?, ed. Marjorie V. Batey, Boulder, Colo.: Western Interstate Commission for Higher Education, Vol. 4, (1971), pp. 56-71. 32 Sherri Carson - 3 4 of 266 graduates of six d i f f e r e n t nursing programs i n B r i t i s h Columbia (Five h o s p i t a l diploma programs, and the University of B r i t i s h Columbia School of Nursing). They found that most of the graduates had found employment in areas desirable to them, and were s a t i s f i e d with t h e i r jobs and undergraduate nursing programs. The answer to the question "whether or not expectations were being met by the job s i t u a t i o n " was 80 percent affirmative. "Reasons why expectations were not being met by 20 percent of the graduates included not s t a r t i n g i n a p o s i t i o n that they wanted, s t i l l being looked upon as a "student" rather than a graduate nurse, and being given too l i t t l e r e s p o n s i b i l i t y . " 3 ^ The meaning of "job s a t i s f a c t i o n " to the new graduate was explored by asking her to complete "hap-piness i s nur s i n g . . . i f . . . . " Happiness to some meant a well organized ward, where the needs of the patient could comfortably and safely be met; where there was time to f i n i s h the work assignment; and where there was a good rota t i o n , reasonable hours, and adequate s t a f f i n g . To others, happiness depended on more personal needs that focused on a f e e l i n g of accomplish-ment; the opportunity to use a b i l i t i e s and knowledge to the f u l l e s t ; to meet challenges successfully; to be free to question; to be continually able to learn through t h e i r work and through service t r a i n i n g , and to be able to obtain and maintain a patient's t r u s t . The t h i r d facet of happiness centered on communication and team work. Among the points emphasized were team nursing centered on the patient, rapport with the whole team, and maximum 3 4Brenda E. Mason and Sherri Carson, "Happiness i s Nursing...if ," R.N.A.B.C. News, Vol. 7, No. 1 (1975) pp. 13-14. 3 5 I b i d . , p. 13. 33 communication within the doctor-nurse-patient t r i a n g l e . Among these respondents only 37 percent f e l t i n a p o s i t i o n to improve the work situation, whereas the remaining 63 percent f e l t that budgetary considerations, lack of communication with superiors 37 or the administrative hierarchy prevented much change. IV. Summary This reviev; of l i t e r a t u r e was presented i n two parts. The f i r s t part reviewed l i t e r a t u r e from a t h e o r e t i c a l point of view on the professional and bureaucratic system of work organi-zation, and also development of r o l e conception i n such organiza-tions. The l i t e r a t u r e reviewed indicated that r o l e conceptions are influenced by the norms, values, and customs i n such organi-zations. The second part reviewed the related nursing studies. The r e s u l t of these studies suggested that: 1. There i s a professional-bureaucratic c o n f l i c t i n nursing. 2. B.S.N.'s are trained along professional l i n e s of work and have professional r o l e conception at the time of graduation. 3. There i s increased l o y a l t y to bureaucratic values f o l -lowing employment. 4. Because of professional-bureaucratic c o n f l i c t some nurses are showing r o l e deprivation, disillusionment and job d i s s a t i s f a c t i o n . 5. Presence of integrative r o l e behavior makes one less susceptible to r o l e deprivation and possible exodus from nursing. 3 6 I b i d . , p. 14. 3 7 I b i d . , p. 37. 34 The foregoing l i t e r a t u r e also indicates the lack of research study on the subject i n B r i t i s h Columbia. The sc a r c i t y of research pointed to the usefulness of a study to further examine the r o l e behavior of B.S.N, nurses of the University of B r i t i s h Columbia and to f i n d out i f the pattern described by the l i t e r a t u r e i s the same pattern here, and now, or whether i t i s modified, and by what determinant factors. 35 CHAPTER I I I RESEARCH DESIGN AND DEVELOPMENT OF THE STUDY T h i s s t u d y i s an e x p l o r a t o r y r e s e a r c h d e s i g n e d t o i n v e s t i g a t e the f o l l o w i n g q u e s t i o n s : 1. Upon c o m p l e t i o n o f t h e U n i v e r s i t y o f B r i t i s h C olumbia B.S.N, n u r s i n g e d u c a t i o n , what r o l e b e h a v i o r do g r a d u a t e s s e l e c t ? ( P r o f e s s i o n a l , b u r e a u c r a t i c , o r i n t e g r a t i v e , as measured by Mar l e n e Kramer's I n t e g r a t i v e R o l e B e h a v i o r s c a l e . ) 2. What happens t o t h e U n i v e r s i t y o f B r i t i s h Columbia's g r a d u a t e s ' r o l e b e h a v i o r upon employment i n t h e b u r e a u c r a c y o f a h o s p i t a l work s e t t i n g ? (How, i f a t a l l , does r o l e b e h a v i o r s e l e c t i o n change as r e g a r d s p r o f e s s i o n a l , b u r e a u c r a t i c o r i n t e g r a t i v e r o l e b e h a v i o r , as measured by M a r l e n e Kramer's I n t e g r a t i v e R o l e B e h a v i o r s c a l e ? ) 3. What d e t e r m i n a n t f a c t o r s can be i d e n t i f i e d as i n f l u -e n c i n g t h e U n i v e r s i t y o f B r i t i s h Columbia g r a d u a t e s t o d e v e l o p t h e i r r o l e b e h a v i o r ? I . S e l e c t i o n o f t h e Study Group  The S u b j e c t The p o p u l a t i o n c o n s i s t e d o f t h e e n t i r e May, 1976 c l a s s o f t h e b a s i c B.S.N, program o f t h e U n i v e r s i t y o f B r i t i s h C o lumbia S c h o o l o f N u r s i n g . T h i s p o p u l a t i o n was chosen f o l l o w i n g a p p r o v a l by t h e U n i v e r s i t y o f B r i t i s h Columbia S c h o o l o f N u r s i n g . The two c r i t e r i a f o r o r i g i n a l s u b j e c t s e l e c t i o n were: the s u b j e c t ' s w i l l i n g n e s s f o r p a r t i c i p a t i o n i n t h e s t u d y , and 36 lack of experience as a registered nurse i n the h o s p i t a l . (A more detailed description of the subjects w i l l be given i n Chapter 4.) The subjects for t h i s study were chosen from the University of B r i t i s h Columbia School of Nursing because at present i t i s the only school i n B r i t i s h Columbia that has a-; B.S.N, program for nurses. The University of B r i t i s h Columbia School of Nursing conducts two programs leading to the degree of Bachelor of Science i n Nursing. One program i s f i v e years i n length and i s offered to Secondary graduates who have com-pleted a two-year prerequisite at the f i r s t two years u n i v e r s i t y l e v e l . * I t prepares the graduates for being licensed as r e g i s -tered nurses, and for the practice of nursing - both h o s p i t a l and community health. The students of t h i s program are known as basic B.S.N, students. The other baccalaureate program, offered to graduates of non-degree programs i n nursing, i s approximately three years i n length for those without c r e d i t beyond un i v e r s i t y entrance. The subjects for t h i s study are from the basic B.S.N, program, due to t h e i r lack of experience as registered nurses i n the h o s p i t a l . The Setting Hospital settings were chosen as employment* i n s t i t u -t ions, because r o l e c o n f l i c t , a n d the discrepancy between nursing education and nursing practice i s f e l t e s p e c i a l l y *This program, however, has now been changed to four years and i s based on a d i f f e r e n t framework. 37 i n t e n s e l y i n such s e t t i n g s , where b u r e a u c r a c y i s t h e predominant system o f w o r k . 1 I n i t i a l C o n t a c t w i t h t h e S u b j e c t s The i n v e s t i g a t o r s e n t a l e t t e r t o a l l p o t e n t i a l U n i v e r s i t y o f B r i t i s h Columbia b a s i c B.S.N, g r a d u a t e s o f May, 1976, i n t r o d u c i n g h e r s e l f by name,and s t a t i n g t h a t she was a g r a d u a t e s t u d e n t a t t h e U n i v e r s i t y o f B r i t i s h Columbia,and t h a t she was c o n d u c t i n g a s t u d y on t h e n u r s e ' s r o l e . I n t h i s l e t t e r , t h e p o t e n t i a l s u b j e c t s were t o l d t h a t t h e i r p a r t i c i -p a t i o n would i n v o l v e a n s w e r i n g two s e t s o f q u e s t i o n n a i r e s , one b e f o r e g r a d u a t i o n , a n d t h e o t h e r t h r e e months l a t e r . I t was e x p l a i n e d t h a t p a r t i c i p a t i o n was v o l u n t a r y , a n d t h e y were f r e e t o w i t h d r a w from t h e s t u d y any t i m e t h e y w i s h e d . They were a s s u r e d about c o n f i d e n t i a l i t y , and a l s o were i n f o r m e d t h a t t h e f i n d i n g s would be a v a i l a b l e t o them i f t h e y w i s h e d . (A copy o f t h e l e t t e r i s i n c l u d e d i n Appendix A.) From t h e f i f t y - f o u r p o t e n t i a l b a s i c B.S.N, g r a d u a t e s , f o r t y - t h r e e p a r t i c i p a t e d i n t h e s t u d y by a n s w e r i n g t h e f i r s t q u e s t i o n n a i r e . I I . I n s t r u m e n t a t i o n The i n s t r u m e n t s w h i c h were used t o c o l l e c t d a t a f o r t h e s t a t e d p r oblem c o n s i s t e d o f t h e f o l l o w i n g : a p e r s o n a l d a t a form, M a r l e n e Kramer's I n t e g r a t i v e R o l e B e h a v i o r s c a l e , and an open-ended q u e s t i o n n a i r e . ^-Marlene Kramer, R e a l i t y Shock - Why Nurses Leave  N u r s i n g P r a c t i c e , S a i n t L o u i s : C.V. Mosby Company, 1974, p. 194. 38 1. The Personal Data Form. This was used to e l i c i t some background information, and also future work plans of the respondent. I t was completed by the subjects at graduation time. (A copy i s included i n Appendix A.) 2. Kramer's Integrative Role Behavior Scale. This scale was developed by Marlene Kramer 2 to measure the reported action choice that represents a compromise between behaviors that c l e a r l y support professional values, and those that c l e a r l y 3 r e f l e c t allegiance to bureaucratic values. I t consists of a series of seven c o n f l i c t s i t u a t i o n s . The respondent i s asked to state the extent to which she would e l e c t to enact cert a i n behaviors by checking one of the a l t e r n a t i v e responses ranging from "strongly agree", "agree", "undecided", "disagree", and "strongly disagree", which are scored from f i v e to one respec-t i v e l y . The scale y i e l d s three subscores: a professional r o l e behavior, a bureaucratic r o l e behavior, and an inte g r a t i v e role behavior score. The score i s composed of the a r i t h -metic sum of the degree to which the respondent would choose the kinds of behaviors when presented with the c o n f l i c t s i t u a t i o n . This scale does not measure behavior d i r e c t l y . I t i s a statement or a report of what a nurse says she w i l l zMarlene Kramer, "Professional-Bureaucratic C o n f l i c t and Integrative Role Behavior" i n M. Batey, editor: Communi-cating Nursing Research: Is the Gap Being Bridged?, Boulder, Colorado: Western Inter-state Commission for Higher Education, Vol. 4, 1971, pp. 56 - 71 ^Marlene Kramer, R e a l i t y Shock - Why Nurses Leave  Nursing Practice , Saint Louis: C.V. Mosby Company, 19 74, p. 54. 39 do i n a p a r t i c u l a r s i t u a t i o n , b u t i t does not measure what she a c t u a l l y does. The v a l i d i t y and r e l i a b i l i t y o f the t o o l was tested> and p r o v e d t o be v a l i d and r e l i a b l e . 4 P e r m i s s i o n has been o b t a i n e d from Dr. M. Kramer t o use the t o o l . T h i s s c a l e has been a d m i n i s t e r e d t o t h e r e s p o n d e n t s b o t h a t t h e t i m e o f g r a d u a t i o n and t h r e e months a f t e r employment i n t h e h o s p i t a l . (A copy i s i n c l u d e d i n Appendix A ) . I I I . Open-ended Q u e s t i o n n a i r e . The open-ended q u e s t i o n n a i r e was d e v e l o p e d f o l l o w i n g a r e v i e w of l i t e r a t u r e , and i n f o r m a l i n t e r v i e w s w i t h some s t u d e n t n u r s e s , n u r s e e d u c a t o r s , and n u r s i n g s t a f f i n the h o s p i t a l . T h e o r e t i c a l l y , r o l e p r e s c r i b e s c e r t a i n b e h a v i o r . R o l e b e h a v i o r , t h e a c t i o n component, i s the o b s e r v a b l e a c t i o n o r b e h a v i o r o f an i n d i v i d u a l f u n c t i o n i n g i n a g i v e n p o s i t i o n i n a s o c i a l system. The a c t i o n component, o r t h e p e rformance t h a t makes up a r o l e , a r e t h e p r o d u c t s o f l e a r n i n g e x p e r i e n c e s . The l e a r n i n g i s s h a p e d , i n l a r g e p a r t , b y r e i n f o r c e m e n t , by i m i t a t i o n o f the b e h a v i o r o f o t h e r s , o r from o b s e r v i n g a model. ''Marlene Kramer, " P r o f e s s i o n a l - B u r e a u c r a t i c C o n f l i c t and I n t e g r a t i v e R o l e B e h a v i o r , " i n M. B a t e y , ed., Communicating  N u r s i n g R e s e a r c h : I s t h e Gap B e i n g B r i d g e d ? " B o u l d e r , C o l o r a d o : Western I n t e r - s t a t e Commission f o r H i g h e r E d u c a t i o n , V o l . 4, 1971, pp. 56-71. ^Mar l e n e Kramer, "Role C o n c e p t i o n o f B a c c a l a u r e a t e N u r s e s and Success i n H o s p i t a l N u r s i n g , " N u r s i n g R e s e a r c h , V o l . 19, No. 5, (September-October 1970), p. 428. ^Marlene Kramer, "Role M o d e l s , R o l e C o n c e p t i o n s , and R o l e D e p r i v a t i o n , " N u r s i n g R e s e a r c h , V o l . 17, No. 2, (March-A p r i l 1968), p. 118. 40 Much of the learning i s achieved through strong motivation to learn the r o l e , and w i l l occur p r i o r to occupancy of the posi -t i o n through the medium of anticipatory s o c i a l i z a t i o n . Through the mass media of T.V., newspapers and books, as well as through contact with other persons, the i n d i v i d u a l acquires information 7 about roles which he may be required to enact. Expectations for a s p e c i f i c r o l e , and the in t e r l o c k i n g systems of ri g h t s and obligations of a r o l e , w i l l a f f e c t the ro l e behavior. Sat i s f a c t o r y enactment of r o l e behavior i s contingent upon a si t u a t i o n and climate which the actor perceives as being suitable or favorable to r o l e execution. So the role conception and behavior are products not only of the educational program, but also of the impact of postgraduate job experience. Based on t h i s t h e o r e t i c a l basis,and the informal interviews, the questionnaire was designed to obtain information relevant to determinant factors i n achievement of ro l e behaviors by University of B r i t i s h Columbia B.S.N, students. Because t h i s was an exploratory e f f o r t , i t was decided that most of the questions should be open-ended, although i t was evident that t h i s would make i t more d i f f i c u l t to compile r e s u l t s . This questionnaire consisted of four parts. The f i r s t part dealt with some information about each subject's present work s i t u a t i o n . The second part investigated the factors ;Nora I. Parker, Survey of Graduates of the University  of Toronto Baccalaureate Course i n Nursing, School of Nursing, Toronto 5, Ontario, 1968, p. 15~, 8Ronald G. Corwin, "The Professional Employee; A Study of C o n f l i c t i n Nursing Roles," American Journal of Sociology, Vol. 66, No. 6, (1961), p. 604. t h a t o r i g i n a l l y i n f l u e n c e d each s u b j e c t ' s d e c i s i o n t o become a n u r s e . The t h i r d p a r t probed e d u c a t i o n a l f a c t o r s t h a t the s u b j e c t s c o n s i d e r e d h e l p f u l i n achievement of t h e i r r o l e . The l a s t s e c t i o n d e a l t w i t h t h e work s e t t i n g and t h e e f f e c t o f work e x p e r i e n c e on t h e i r r o l e . I n c o n c l u s i o n , t h e s u b j e c t s were asked t o r a n k t e n s t a t e d f a c t o r s i n t h e o r d e r o f s i g n i -f i c a n c e as t o t h e i r e f f e c t on t h e s u b j e c t s ' r o l e b e h a v i o r . T h i s q u e s t i o n n a i r e has been g i v e n t o a group o f t h i r d y e a r s t u d e n t s a t t h e U n i v e r s i t y o f B r i t i s h Columbia (R.N. group) t o f i n d o ut i f t h e q u e s t i o n s a r e c l e a r l y under-s t o o d by them. The r e s u l t i n d i c a t e d t h a t t h i s q u e s t i o n n a i r e was a d e q u a t e l y c l e a r , a n d was a p p r o p r i a t e f o r i t s s t a t e d purpose. T h i s q u e s t i o n n a i r e has been a d m i n i s t e r e d t h r e e months a f t e r g r a d u a t i o n . (A copy i s i n c l u d e d i n Appendix A ) . The p a r t i c u l a r t i m e b e f o r e g r a d u a t i o n was chosen because, d u r i n g e d u c a t i o n , s t u d e n t s w i l l d e v e l o p c e r t a i n v a l u e s 9 and r o l e b e h a v i o r toward t h e i r f u t u r e r o l e as n u r s e s . Three months a f t e r employment was chosen because: a) Most changes i n r o l e c o n c e p t i o n and b e h a v i o r o c c u r d u r i n g t h e f i r s t t h r e e months a f t e r employment. 1^*' 1 1 b) The c o n t r a d i c t i o n w i t h i n t h e work system (which has s i g n i f i c a n t i n f l u e n c e on t h e r o l e b e h a v i o r and r o l e c o n c e p t i o n ) 9 Theodore E. S a r b i n and A l l e n L. V e rnon, " R o l e Theory", i n L i n d z e y , G a r d i n e r and A r o n s o n , E l l i o t , eds., Handbook o f S o c i a l  P s y c h o l o g y , 2nd ed., V o l . 1, M a s s a c h u s s e t t s : Addison-Wesley Co., 1963, p. 544. 1®A. Bandura and R. H. W a l t e r s , S o c i a l L e a r n i n g and P e r - s o n a l i t y Development, New York: H o l t R i n e h a r t & W i n s t o n , 1963. i : L S a r b i n , Op. C i t . , p. 546. 42 i s f e l t more intensely a f t e r graduation. ^ Roth sets of questionnaires were coded. Every respondent had one code number which related to her name and i s known by the investigator only. This was done for con-f i d e n t i a l i t y . I I I . Data Analysis This i n v e s t i g a t i o n i s concerned with: 1. The possible changes i n ro l e behavior of pr o f e s s i o n a l l y s o c i a l i z e d B.S.N, nurses following three months' exposure to bureaucratic work organization. The T. tes t was used to detect any s i g n i f i c a n t changes i n se l e c t i o n of role behaviors at the two designated times. 2. The i d e n t i f i c a t i o n of determinant factors that helped the University of B r i t i s h Columbia B.S.N.'s to develop t h e i r r o l e behavior. The content of the questionnaire, which required more than simple enumeration, was analyzed as follows: The responses to a p a r t i c u l a r question were f i r s t l i s t e d , then categorized so that a summary table could be constructed. Where i t appears that a response i l l u s t r a t e s well a general opinion, a d i r e c t quotation i s used i n the discussion. Tables of percentage d i s t r i b u t i o n s are used to e l i c i t the information. 1 2Marlene Kramer, Some E f f e c t s of Exposure to Employing  Bureaucracies on the Role Conceptions and Role Deprivation of  Neophyte C o l l e g i a t e Nurses, unpublished d i s s e r t a t i o n , Stanford University, 1966, p. 6. 43 IV. Summary This chapter outlined the exploratory method of research used f o r t h i s study. A preliminary description of the sample was presented; a more detailed one w i l l be found i n the f i r s t section of the next chapter. Data-gathering devices were described; samples of these w i l l be found i n Appendix A. F i n a l l y , the method of data analysis was ex-plained . 44 CHAPTER IV ANALYSIS OF THE DATA The data and r e s u l t s w i l l be discussed i n three parts which make up t h i s chapter. Part I - presents the c h a r a c t e r i s t i c s of the population c o n s t i t u t i n g the sample of t h i s study, along with some description about t h e i r work experience i n the hos p i t a l before and afte r graduation. Part II - the data are examined to provide information concerning the sel e c t i o n of r o l e behavior by University of B r i t i s h Columbia B.S.N, graduates upon completion of t h e i r educa-t i o n and following employment i n the hospital settings. The T. test was used to detect any s i g n i f i c a n t changes i n se l e c t i o n of r o l e behavior before graduation and upon employment i n a hos p i t a l s e t t i n g . Part III - examines the r e s u l t of the open-ended ques-tionnaire which was designed to i d e n t i f y the factors which University of B r i t i s h Columbia B.S.N.'s considered h e l p f u l i n developing t h e i r roles as nurses. Descriptive analysis and percentage d i s t r i b u t i o n s were used i n the analysis of the data. Attempts were made to s t a t i s -t i c a l l y analyze the data, but because of the l i m i i t a t i o n imposed by sample number, t h i s was not possible. 45 I C h a r a c t e r i s t i c s of the Study Population. The study population consisted of 43 nurses from the basic B.S.N, program of University of B r i t i s h Columbia School of Nursing, May 197 6, who had participated i n the study by answering the f i r s t questionnaire. Of the 43 nurses p a r t i c i -pating i n thi s study, 42 B.S.N.'s (97.7 percent) had previous hospital work experience and only 1 B.S.N. (2.31 percent) did not. The time, positions of the subjects i n t h e i r previous job(s) and t h e i r plans for future work were asked. The data are described and tabulated. Time Of the 4 2 B.S.N.'s who had previous ho s p i t a l work experience, 32 B.S.N.'s (76 percent) had worked at various times before graduation (that i s , they had checked 2 to 4 options i n response to the question regarding the time of previous work experience); and the other 10 B.S.N.'s (24 percent) had checked only one option. Twenty-nine B.S.N.'s (67.4 percent) had worked upon completion of the t h i r d year of t h e i r program, 28 B.S.N.'s (65.1 percent) worked upon completion of the second year, 36 B.S.N.'s (83.7 percent) worked during the program, and 8 B.S.N.'s (18.6 percent) worked before t h e i r nursing program. Table 1 i l l u s t r a t e s t h i s information. 46 TABLE 1 PERCENTAGE DISTRIBUTION OF THE STUDY POPULATION BY WORK EXPERIENCE Time No.* Percentage* Upon completion of t h i r d year 29 67.4 Upon completion of second year 28 65.1 During Training 36 83.7 Before Training 8 18.6 *32 B.S.N.'s checked two to four options. Po s i t i o n The 42 B.S.N.'s with a previous work experience, had worked i n d i f f e r e n t positions i n the h o s p i t a l . In other words, the 42 B.S.N.'s had checked 2 to 5 options in response to the question r e f e r r i n g to t h e i r hospital positions. Twenty-nine B.S.N.'s (67.4 percent) had worked as aid nurses, 33 (76.7 percent) as p r a c t i c a l nurses. Twenty-eight B.S.N.'s (65.1 percent) worked as s t a f f nurses, 2 3 (53.5 percent) as student nurses, 2 (4.7 percent) as graduate nurses, and 1 (2.3 percent) as a team leader. Two B.S.N.'s (4.7 percent) worked as cl e r k s , 1 (2.3 percent) as a technician and 1 (2.3 percent) as a housekeeper. Table 2 shows t h i s information. 47 TABLE 2 PERCENTAGE DISTRIBUTION OF THE STUDY BY THE POSITION AT WORK POPULATION Po s i t i o n No.* Percentage* Aid Nurse 29 67.4 P r a c t i c a l Nurse 33 76.7 Staff Nurse 28 65.1 Student Nurse 23 53.5 Graduate Nurse 2 4.7 Team Leader 1 2.3 Clerk 2 4.7 Technician 1 2.3 Housekeeping 1 2.3 *A11 42 B.S.N.'s checked 2-5 options. Plan for Work A l l the 43 B.S.N.'s who had pa r t i c i p a t e d i n the study were planning to work as nurses a f t e r graduation. Of these 43 nurses, the majority, i . e . 32 B.S.N.'s (74.4 percent) had planned to work i n a h o s p i t a l , 16 (37.2 percent) as public health nurses, 1 (2.3 percent) i n a doctor's o f f i c e and 1, (2.3 percent) planned to work wherever she could get employment. (As the data indicates, 6 B.S.N.'s checked more than one option). Table 3 i l l u s t r a t e s t h i s information. 48 Among these 43 nurses, 11 B.S.N.'s (25.6 percent) planned to work immediately a f t e r graduation, 22 (51.2 percent) planned to work within 1-2 months afte r graduation, 9 (20.9 percent) planned to work within 3-4 months afte r graduation, and 1, (2.3 percent) 10 months after graduation. Table 4 provides t h i s i n -formation. The findings regarding the B.S.N.'s plan for place of work after graduation support the finding i n a study reported by Kramer. 1 In her study, Kramer found that of the 71 nurses i n the sample, a l l but 6_ chose hospital work as t h e i r i n i t i a l ex-perience. However, the findings of t h i s study are i n contradic-2 ti o n to the findings of Reinkemeyer. The r e s u l t of her i n v e s t i -gation indicates that only one tenth, 13 out of 117 respondents, intended to go into a general or a s p e c i a l h o s p i t a l , and then only "temporarily for further p r a c t i c e " . The r e s u l t of Rein-kemeyer' s study also revealed that the largest segment, one t h i r d or more of the nurses, planned to go into public health; the next largest category, one f i f t h expected to work abroad; and almost another one f i f t h remained undecided. xMarlene Kramer, Some E f f e c t s of Exposure to Employing  Bureaucracies on the Role Conception and Role Deprivation of*  Neophyte C o l l e g i a t e Nurses, unpublished d i s s e r t a t i o n , Stanford University, 1966, pp. 42-43. 2 S i s t e r Agnes M. Reinkemeyer, " I t Won't Be Hospital Nursing," American Journal of Nursing, Vol. 68, No. 9, (September 1968), p. 1937. 49 TABLE 3 PERCENTAGE DISTRIBUTION OF THE STUDY POPULATION BY THE SELECTION OF THE WORK AREA Place No.* Percentage* Hospital 32 74.4 Public Health 16 37.2 Doctor's O f f i c e 1 2.3 Wherever get the job 1 2.3 *6 B.S.N.'s checked more than one option. TABLE 4 PERCENTAGE DISTRIBUTION OF THE BY THE PLAN FOR WORK AFTER STUDY POPULATION GRADUATION Time No. Percentage Immediately a f t e r graduation 11 25.6 Within 1-2 months af t e r graduation 22 51.2 Within 3-4 months afte r graduation 9 20.9 Other (10 months) after graduation 1 2.3 Total 43 100. 50 Description of the Study Population Upon Graduation In September 1976, the second questionnaire was mailed to a l l of the 43 B.S.N.'s who had answered the f i r s t question-naire. The subjects were asked to answer and return the follow-up questionnaire i n the self-contained envelope by October 20, 1976. By t h i s date, 27 B.S.N.'s (62.8 percent) had r e p l i e d to the second questionnaire. On October 30, 1976 a l e t t e r was sent to those B.S.N.'s who had not answered the second questionnaire. They were asked again to answer the second questionnaire. No reply was received. Of the 27 B.S.N.'s who had answered the second question-naire, 10 B.S.N.'s (37 percent) had to be excluded from the sample. The reason for exclusion was that 3 B.S.N.'s were not working, 4 B.S.N.'s were working in Public Health Nursing, and 3 B.S.N.'s had work experience of less than a month. The remaining 17 B.S.N.'s comprise the sample for t h i s study. Because of the low number of B.S.N.'s with adequate work experience, a l l those who had more than one month of work experience are included i n the sample. The samples' work experience i n the hos p i t a l upon graduation i s described and tabulated. Duration of Work Of the 17 B.S.N.'s who were working i n the h o s p i t a l , 2 B.S.N.'s (11.8 percent) had one month's work experience, 4 (23.5 percent) had 2 months work experience, 7 (41.2 percent) had 3 months work experience, and 4 (23.5 percent) had four months of work experience. This information i s shown i n Table 5. 51 TABLE 5 PERCENTAGE DISTRIBUTION OF THE STUDY SAMPLE BY DURATION OF WORK EXPERIENCE IN THE HOSPITAL Duration of Work Experience No. Percentage 1 Month 2 11. 8 2 Months 4 23.5 3 Months 7 41.2 4 Months 4 23.5 Total 17 100. Hospital Description The B.S.N.'s were asked about the hos p i t a l i n which they were working. One B.S.N. (5.9 percent) was working i n a hosp i t a l with less than 100 beds (12 beds), 4 (23.5 percent) i n a hospital which had between 101-200 beds, 5 (29.4 percent) i n a hospital which had between 201-500 beds, and 7 (41.2 per-cent) i n a h o s p i t a l which had more than 500 beds. This informa-t i o n i s given i n Table 6. These findings are supported by the findings of a study reported by Mason and Carson. 3 Although t h e i r c r i t e r i a f or 3Brenda E. Mason and Sherri Carson, "Happiness i s Nursing...if...." R.N.A.B.C. News, Vol. 7, No. 1, 1975, p. 13. 52 hos p i t a l d e s c r i p t i o n are d i f f e r e n t and t h e i r sample comprised of a l l groups of 1973 graduate nurses of B r i t i s h Columbia, t h e i r findings show that the majority of graduates were working i n hospitals with more than 200 beds and only 22 percent i n hospi-t a l s with less than 200 beds. TABLE 6 PERCENTAGE DISTRIBUTION OF THE STUDY SAMPLE BY THE DESCRIPTION OF THE HOSPITAL IN WHICH THEY WERE WORKING Hospital Description No. Percentage Less than 100 beds 1 5.9 Between 101-200 beds 4 23. 5 Between 201-200 beds 5 29.4 More than 500 beds 7 41.2 T o t a l 17 100; Po s i t i o n As shown i n Table 7, the B.S.N.'s were asked about t h e i r p o s i t i o n i n the hospital at the time of study. Of the 17 B.S.N.'s i n the sample, 11 (64.7 percent) were working as s t a f f nurses, 2 (11.8 percent) had positions of team leaders, 1 (5.9 percent) as a general duty nurse i n charge of a 12-bed hos p i t a l and 3, (17.6 percent) as s t a f f nurses and team leaders. 53 TABLE 7 PERCENTAGE DISTRIBUTION OF THE STUDY SAMPLE BY POSITION IN THE HOSPITAL Positi o n No. Percentage Staff Nurse 11 64.7 Team Leader 2 11.8 Incharge Nurse 1 5.9 Staff Nurse and Team Leader 3 17.6 Total 17 100. C l i n i c a l F i e l d The c l i n i c a l area i n which the B.S.N.'s were working was very varied as shown i n Table 8. One B.S.N. (5.9 percent) was working i n a medical ward; 3 (17.6 percent) i n s u r g i c a l wards; 1 (5.9 percent) f l o a t i n g between medical and s u r g i c a l wards; 1 (5.9 percent) i n a psy-c h i a t r i c ward; 4 (23.5 percent) in o b s t e t r i c s ; 2 (11.8 percent) i n p e d i a t r i c s ; 1 (5.9 percent) was f l o a t i n g between o b s t e t r i c and p e d i a t r i c wards; 2 (11.8 percent) i n orthopedics; 1 (5.9 percent) i n a coronary care unit; and 1, (5.9 percent) as a general duty nurse i n a 12-bed h o s p i t a l . The study reported by Mason and Carson 4 shows that 25 Ibid., p. 13. 54 percent of the sample were working i n surgery; 14 percent in ped i a t r i c s ; 12 percent i n medicine; 10 percent in general duty; and 5 percent i n intensive care unit s . TABLE 8 PERCENTAGE DISTRIBUTION OF THE S/TUDY SAMPLE BY THE CLINICAL FIELD IN WHICH THEY WERE WORKING C l i n i c a l F i e l d No. Percentage Medical 1 5.9 Surgical 3 17.6 Medical-Surgical (Floating) 1 5.9 P s y c h i a t r i c 1 5.9 Obstetrics 4 23.5 P e d i a t r i c s 2 11.8 Pe d i a t r i c s - O b s t e t r i c s (Floating) 1 5.9 Orthopedics 2 11.8 Coronary Care Unit 1 5.9 General Duty 1 5.9 Total 17 100. Location The majority of the study sample, 12 B.S.N.'s (7 0.6 percent) have chosen to work i n a hospital which was located i n a large c i t y . Four B.S.N.'s (23.5 percent) were working i n a 55 small c i t y and only one B.S.N. (5.9 percent) was working i n a small community. Table 9 i l l u s t r a t e s t h i s information. These findings are supported by the Mason and Carson study. 5 TABLE 9 PERCENTAGE DISTRIBUTION OF THE STUDY SAMPLE BY THE LOCATION OF THE HOSPITAL IN WHICH THEY WERE WORKING Location of the Hospital No. Percentage In a large c i t y 12 70.6 In a small c i t y 4 23.5 In a small community 1 5.9 Total 17 100. II Selection of Role Behavior Marlene Kramer's Integrative Role Behavior Scale was used to determine the se l e c t i o n of r o l e behavior by University of B r i t i s h Columbia B.S.N.'s at the time of graduation and f o l -lowing employment i n the h o s p i t a l . Analysis of the r e s u l t s of the Integrative Role Behavior Scale indicates that there was a decrease in the se l e c t i o n of 5 I b i d . , p. 13. 56 professional r o l e behavior upon employment i n the h o s p i t a l , s i g n i f i c a n t beyond the 0.05 l e v e l . However there was no s i g n i -f i c a n t difference between the sel e c t i o n of bureaucratic and integrative r o l e behavior at the time of graduation and following employment beyond the 0.01 l e v e l . Table 10 i l l u s t r a t e s t h i s information. TABLE 10 SIGNIFICANCE OF MEAN DIFFERENCES IN SCORES ON SELECTION OF ROLE BEHAVIOR AT GRADUATION TIME AND FOLLOWING EMPLOYMENT Role Selection Mean ® S d ® Mean @ Sd © t x Professional 42.353 4.961 40.529 2.897 -1.801 0.05 Bureaucratic .33.176 6.166 34.824 4.447 1.295 N.S. Integrative 40.411 3.428 41.764 4.023 1.0550 N.S. - High Mean indicates high score on ro l e behavior. - (X) Mean and standard deviation for f i r s t designated time period. - (5) Mean and standard deviation for second designated time period. - x at c r i t e r i o n l e v e l of 0.05. The s i g n i f i c a n t difference between sel e c t i o n of profes-sional r o l e behavior at two designated times i s an important point which must be noted. This difference suggests that the B.S.N.'s are conforming to the p r e v a i l i n g norms and values of the hos p i t a l to the extent that they are los i n g t h e i r "professional values". Although the data did not show any s i g n i f i c a n t difference 57 between the scores of bureaucratic and integrative r o l e behavior at two designated times, a closer look at the scores tends to indicate the trend of change i n ro l e behavior. The comparison of scores on r o l e behaviors obtained upon employment with those at graduation time reveals the f o l -lowing information. Of the 17 B.S.N.'s, 5 (29.4 percent) scored higher on professional r o l e behavior, whereas 10, (58.8 percent) scored lower and 2, (11.8 percent) scored the same. In bureau-c r a t i c r o l e behavior, 12 B.S.N.'s (70.6 percent) scored higher, 4, (23.5 percent) scored lower, and 1, (5.9 percent) scored the same. For integrative r o l e behavior, 10 B.S.N.'s (58.8 percent) scored higher, whereas 6, (35.3 percent) scored lower, and 1, scored the same. Table 11 i l l u s t r a t e s t h i s information. TABLE 11 PERCENTAGE DISTRIBUTION OF STUDY SAMPLE BY COMPARISON OF ROLE BEHAVIOR SCORES FOLLOWING EMPLOYMENT WITH THOSE OF GRADUATION TIME Role Behavior No. Percentage Professional Higher score 5 29.4 Lower score 10 58.8 Same score 12. 11* 8 Total 17 100. Bureaucratic Higher score 12 70.6 Lower score 4 23.5 Same score _1 5.9 Total 17 100. Integrative Higher score 10 58.8 Lower score 6 35.3 Same score __1 5.9 Total 17 100. 58 The r e s u l t s tend to indicate that there i s a response on the part of the professional employee to bureaucratic employ-ment. In other words, upon employment i n the bureaucratic sys-tem of the h o s p i t a l , more than half B.S.N.'s (58.8 percent) scored lower i n the professional r o l e behavior. Moreover, there was a substantial increase i n the percentage of B.S.N.'s who scored higher on bureaucratic r o l e behavior (70.6 percent). This s i g n i -f i e s that these B.S.N.'s were perceiving some discrepancy between nursing education and nursing p r a c t i c e , and were reaching to i t by increasing t h e i r bureaucratic r o l e values and decreasing t h e i r professional values. These r e s u l t s are s i m i l a r to those reported by Corwin and Taves 6, Corwin 7, and K r a m e r 8 ' 9 ' 1 0 ' 1 1 . As Kramer 6Ronald G. Corwin and Marvin J . Taves, "Some Concomitants of Bureaucratic and Professional Conceptions of the Nurse Role," Nursing Research, Vol. 11, No. 4, ( F a l l 1962), pp. 223-227. 7Ronald G. Corwin, "The Professional Employee: A Study of C o n f l i c t i n Nursing Roles," American Journal of Sociology, (1961), pp. 604-615. °Marlene Kramer, "Role Models, Role Conceptions, and Role Deprivation, Nursing Research, Vol. 17, No. 2, (March-April 1968), pp. 115-120. g Marlene Kramer, Some E f f e c t s of Exposure to Employing  Bureaucracies on the Role Conception and Role Deprivation of Neo- phyte Collegiate Nurses, unpublished d i s s e r t a t i o n , Stanford Uni-v e r s i t y , 1966, pp. 42-43. 1 0 and Constance Baker, "The Exodus: Can We Prevent It?" The Journal of Nursina Administration, Vol. 1, No. 3, (May-June 1971), pp. 15-29. 1 1 , "Role Models, Role Conceptions, and Role Deprivation, Nursing Research, Vol. 17, No. 2, (March-April 1968), p. 120. 59 describes i t , c o l l e g i a t e nurses respond to the environmental pressure from the hospital by increasing t h e i r bureaucratic role conception. This constitutes considerable r o l e discomfort and compatability, thus many c o l l e g i a t e nurses abdicate t h e i r professional values. - The r e s u l t i s high professional low bureau-IP c r a t i c r o l e conception. " The data also reveal that over half of the B.S.N.'s (58. R percent) i n the study scored higher on integrative r o l e behavior upon employment. This i s an encouraging trend of change i n r o l e behavior, because according to Kramer 1 3' 1 4 t h i s represents that these B.S.N.'s have developed some degree of growth-producing-c o n f l i c t - r e s o l u t i o n i n t h e i r behavior repertoire and thus are l e s s susceptible to professional bureaucratic c o n f l i c t s . In other words, these nurses are r e f l e c t i n g adherence to both professional and bureaucratic values. However, the B.S.N.'s selected such behavior upon exposure to the bureaucratic system of work. This tends to indicate that these B.S.N.'s had less opportunity to learn about the compromise between the two values, during t h e i r education. ^Marlene Kramer and Constance Baker, "The Exodus: Can We Prevent It?" The Journal of Nursing Administration, Vol. 1, No. 3, (May-June 1971), pp. 15-29. 1 3 Marlene Kramer, Reality Shock - Why Nurses Leave Nursing, Saint Louis; The C. V. Moshy Company, 197 4, p. 54. 1 4 P a t r i c i a Benner and Marlene Kramer, "Role Conception and Integrative Role Behavior of Nurses i n Special Care and Regular Hospital Nursing Units," Nursing Research, Vol. 21, Mo. 1, (January-February 1972), p. 25. 60 III Determinant Factors i n Developing Role Behavior The open-ended questionnaire was designed to i d e n t i f y the determinant factors that helped University of B r i t i s h Columbia B.S.N.'s to develop t h e i r r o l e . This open-ended questionnaire e l i c i t e d useful information, which because of i t s complexity, was d i f f i c u l t to c l a s s i f y . Since the major purpose for gathering data was exploratory i n nature, rigorous analyses of these data were not necessary. However, an attempt was made to do factor analyses and f i n d c o r r e l a t i o n between the factors i d e n t i f i e d and r o l e selected. But because of l i m i t a t i o n of number of sample (17) no s i g n i f i c a n t s t a t i s t i c a l analysis could be.made. Background Factors These questions were designed to find out about the factors that o r i g i n a l l y influenced B.S.N.'s to become a nurse. Age The B.S.N.'s were asked at what age they had decided to become a nurse. The majority of the B.S.N.'s, 13, (76.5 per-cent) decided upon nursing as a career between the ages of 17 to 21; 2, (11.8 percent) between 11 to 16; 1, (5.9 percent) before age 10 and 1, (5.9 percent) had a l i f e long ambition to be a nurse. This, r e s u l t i s s i m i l a r to those reported by Marlene Kramer. 1^ Table 12 i l l u s t r a t e s t h i s information. Marlene Kramer, Some E f f e c t s of Exposure to Employing  Bureaucracies on the Role Conception and Role Deprivation of  Neophyte Collegiate Nurses, unpublished d i s s e r t a t i o n , Stanford University, 1966, pp. 42-43. 61 TABLE 12 PERCENTAGE DISTRIBUTION OF THE SAMPLE BY THE AGE OF DECISION TO BECOME A NURSE Age of Decision No. Percentage Before age 10 1 5.9 Between age 11-16 2 11.8 Between age 17-21 13 76.5 A l l my l i f e 1 5.9 Total - 17 100. Source of Influence Most of the B.S.N.'s i d e n t i f i e d two or three factors as the major sources of influence in t h e i r decision to become a nurse. Every B.S.N, i n the sample, 17 B.S.N.'s, have i d e n t i -f i e d that family and friends' encouragement played an important r o l e i n t h e i r o r i g i n a l decision to become a nurse. The other factors i d e n t i f i e d by B.S.N.'s are: 11, (64.7 percent) indicated personal experience and desire as sources of influence; 4, (23.5 percent) had in t e r e s t i n a health science; 3, (17.6 percent) ex-pressed i n t e r e s t i n a helping profession; and 2, (11.8 percent) mentioned that books and media influenced t h e i r decision to become a nurse. Table 13 shows t h i s information. TABLE 13 PERCENTAGE DISTRIBUTION OF STUDY SAMPLE BY THE MAJOR SOURCE OF INFLUENCE TO BECOME A NURSE Source of Influence No. * Percentage Family and friends' encouragement 17 100. Personal experience and desire 11 64.7 Interest i n health science or medicine 4 23.5 Interest i n a helping profession 3 17.6 Books and media 2 11.8 *Each B.S.N, has i d e n t i f i e d more than one factor • Knowledge about Nurse's Role S l i g h t l y more than half of the B .S.N.'s , 9 B.S.N.' (52.9 percent) did not have adequate knowledge of the ro l e of the nurse at the time they entered the nursing education program. Whereas 8 B.S.N.'s (47.1 percent) did have the knowledge. How-ever, a l l the B.S.N.'s had some knowledge about the ro l e of the nurse. The B.S.N.'s have i d e n t i f i e d d i f f e r e n t factors as the source of information for t h e i r knowledge. Eight B.S.N.'s (47.1 percent) got th e i r information from media and l i t e r a t u r e , 7, (41.2 percent) acquired the information by personal experience -i . e . working i n the h o s p i t a l , experience as a patient or obser-vation i n the h o s p i t a l . 63 S i x B.S.N.'s (36.3 p e r c e n t ) o b t a i n e d t h e i n f o r m a t i o n from f r i e n d s ; 5, (29.4 p e r c e n t ) f rom f a m i l y and r e l a t i v e s ; 4, (23.5 p e r c e n t ) from c a r e e r days and g u i d a n c e c o u r s e s ; 3, (17.6 p e r c e n t ) g o t t h e i r i n f o r m a t i o n by c o n t a c t w i t h h o s p i t a l and p u b l i c h e a l t h n u r s e s . T a b l e 14 shows t h i s i n f o r m a t i o n . TABLE 14 PERCENTAGE DISTRIBUTION OF THE WAYS THE SAMPLE ACQUIRED INFORMATION ABOUT NURSING Source o f I n f o r m a t i o n No.* P e r c e n t a g e * Media and l i t e r a t u r e 8 47.1 P e r s o n a l e x p e r i e n c e 7 41.2 F r i e n d s 6 35.3 F a m i l y and r e l a t i v e s 5 29.4 C a r e e r days and g u i d a n c e c o u r s e s 4 23.5 C o n t a c t w i t h n u r s e s 3 17.6 *Each B.S.N, has i d e n t i f i e d more t h a n one f a c t o r . The f i n d i n g s o f t h i s s e c t i o n i s s u g g e s t i v e s u p p o r t f o r 16 t h e f i n d i n g s o f a s t u d y r e p o r t e d by M a r l e n e Kramer. That s t u d y showed t h a t t h e major s o u r c e o f the p r e - n u r s i n g image was s c h o o l n u r s e and h i g h s c h o o l a c t i v i t i e s ( i . e . g u i d a n c e c o u r s e s , c a r e e r d a y s ) , f o l l o w e d c l o s e l y by books, T.V. and movies. I n t h a t s t u d y 1 6 I b i d . , pp. 38-39. 64 fewer than one-third i d e n t i f i e d family as a major source of a pre-nursing image. A cursory analysis of these tables suggests that both age of decision and major source of influence have some bearing on the i n i t i a l decision to become a nurse. Educational Factors The B.S.N.'s were asked to i d e n t i f y the factors i n the nursing education program that helped them to develop t h e i r r o l e as nurses. In answering the question " i n what way, was your nursing education h e l p f u l i n developing your own perception and image of nursing?", most B.S.N.'s, i n one way or another, expres-sed s i m i l a r f a ctors. The majority of B.S.N.'s, i . e . 9 B.S.N.'s (52.9 percent) responded that nursing education was he l p f u l to them to develop t h e i r perception and image of nursing by "giving the i d e a l image of a nurse, and the h o l i s t i c approach;" "by encouraging decision-making and innovation." Eight B.S.N.'s (47.1 percent) believed that nursing edu-cation had helped them by "giving a wider view of the ro l e of the nurse" and by "the t h e o r e t i c a l discussion about the r o l e . " There were 5 B.S.N.'s (29.4 percent) who found education had helped them by "providing actual experience of being a nurse ( c l i n i c a l experience)." Five B.S.N.'s (29.4 percent) found nursing courses and nursing l i t e r a t u r e were he l p f u l to them i n the develop-ment of t h e i r perception and image of nursing, and two B.S.N.'s (11.8 percent) indicated that instr u c t o r s influenced them by being "role models". Table 15 gives t h i s information. 65 I n g e n e r a l t h e f a c t o r s i d e n t i f i e d by B.S.N.'s can be e x e m p l i f i e d by t h e f o l l o w i n g e x c e r p t : " . . . e d u c a t i o n p r o v i d e d an i d e a l image o f a n u r s e . The emphasis on community based n u r s i n g i n f i r s t y e a r , d i s c u s s i n g r o l e s , b e i n g a b l e t o o b s e r v e d i f f e r e n t r o l e models; t h e wide scope o f n u r s i n g t h a t was c o v e r e d and t h e c r e a t i v i t y t h a t was s t r e s s e d ; t h e v a r i o u s work shops, p a n e l s and d i s c u s s i o n s ; as w e l l as v a r i e d r e a d i n g s a l l h e l p e d t o b o t h broaden and c l a r i f y my own p e r c e p t i o n o f n u r s i n g . The i n s t r u -t o r s had a g r e a t d e a l t o do w i t h t h i s e s p e c i a l l y by p r o v i d i n g p e r s o n a l e x p e r i e n c e f o r s t u d e n t s . " 17 The f i n d i n g s o f D a v i s and O l e s e n s u p p o r t s t h a t e d u c a t i o n i s i n s t r u m e n t a l t o some degree i n t h e development o f r o l e b e h a v i o r . TABLE 15 PERCENTAGE DISTRIBUTION OF THE WAYS THAT THE NURSING EDUCATION PROGRAM HELPED THE STUDY SAMPLE TO DEVELOP THE IMAGE AND PERCEPTION OF NURSING Ways By g i v i n g t h e i d e a l image of a n u r s e By g i v i n g a w i d e r v i e w o f the r o l e o f t h e n u r s e By g i v i n g a c t u a l e x p e r i e n c e o f b e i n g a n u r s e By n u r s i n g c o u r s e s and n u r s i n g l i t e r a t u r e By "Role Models" - i n s t r u c t o r s No.* P e r c e n t a g e * 9 52.9 8 47.1 5 29.4 5 29.4 2 11.8 •Each B.S.N, has i d e n t i f i e d more t h a n one f a c t o r . F. D a v i s and V. O l e s e n , " B a c c a l a u r e a t e s t u d e n t s ' images o f n u r s i n g . " N u r s i n g R e s e a r c h , V o l . 13, No. 1, ( J a n u a r y - F e b r u a r y 1964), pp. 8-15. 66 Influence of Nursing Education on Role The B.S.N.'s were asked i f t h e i r nursing education has influenced the achievement of t h e i r nursing r o l e behavior. Out of 17, 15 B.S.N.'s (88.2 percent) believed that t h e i r nursing education had influenced and shaped t h e i r r o l e as a nurse. Two B.S.N.'s (11.8 percent) believed that t h e i r nursing r o l e was not influenced by t h e i r education. Those who believed i n the influence of nursing education on t h e i r r o l e as a nurse, have i d e n t i f i e d one or more factors as the reason for t h i s influence. Out of 15, 8 B.S.N.'s (53.3 percent) mentioned that emphasis on the following factors as the major source of i n f l u -ence: (1) basic theory and s k i l l s behind nursing actions, high expectation and stress on the i d e a l nursing; (2) decision-making and independent thinking. There were 4 B.S.N.'s (26.6 percent) who i d e n t i f i e d the following factors as the source of influence: (1) p a r t i c i p a t i o n i n the ro l e - through p r a c t i c a l experience; (2) ro l e modeling by i n s t r u c t o r s . Table 16 presents t h i s information. The B.S.N.'s responses can be i l l u s t r a t e d by the f o l -lowing excerpt: " I t influenced and shaped my r o l e . Mainly through r o l e modeling by i n s t r u c t o r s , p r a c t i c a l experience, and reading. C r e a t i v i t y , i n d i v i d u a l i t y , decision-making and r e s p o n s i b i l i t y were the key words to the nursing role behavior that came across to me. This includes cooperation and team work." "Nursing education has had very l i t t l e influence on the achievement of nursing r o l e behavior. I f e e l 67 t h a t i t has opened o r c l o s e d t h e doors on c e r t a i n a c t i o n s , b u t i t was the p e o p l e o r t e a c h e r s as i n d i v i d u a l s whom we d e a l t w i t h w h i c h I f e e l shaped a l a r g e p a r t o f my r o l e b e h a v i o r . " "Very l i t t l e i n f l u e n c e . My summer employment c o n t r i -b u t e d more t o t h e development o f n u r s i n g r o l e be-h a v i o r . " TABLE 16 PERCENTAGE DISTRIBUTION OF EDUCATIONAL FACTORS THAT INFLUENCED STUDY SAMPLE'S ROLE BEHAVIOR F a c t o r s No.* P e r c e n t a g e ' B a s i c t h e o r y and s k i l l s b e h i n d n u r s i n g a c t i o n s 8 53.3 Emphasis on d e c i s i o n - m a k i n g and i n d e p e n d e n t t h i n k i n g 8 53.3 R o l e m o d e l i n g by i n s t r u c t o r s - 4 26.6 P a r t i c i p a t i o n i n r o l e -t h r o u g h p r a c t i c a l e x p e r i e n c e 4 26.6 * T h i s t a b l e shows t h e r e s p o n s e o f 15 B.S.B.'s who b e l i e v e d t h a t t h e i r n u r s i n g e d u c a t i o n had i n f l u e n c e d and shaped t h e i r r o l e . *Each B.S.N, had i d e n t i f i e d more t h a n one f a c t o r as a s o u r c e o f i n f l u e n c e . I n t r o d u c t i o n t o R e s p o n s i b i l i t i e s I n r e s p o n s e t o t h e q u e s t i o n "how has y o u r n u r s i n g e d u c a t i o n i n t r o d u c e d you t o your d u t i e s and r e s p o n s i b i l i t i e s ? " . The m a j o r i t y o f B.S.N.'s, 14 B.S.N.'s (82.4 p e r c e n t ) b e l i e v e d t h a t t h e i r n u r s i n g e d u c a t i o n p r e p a r e d them f o r t h e i r d u t i e s , w h i l e 3 B.S.N.'s (17.6 p e r c e n t ) d i d n o t t h i n k so. 68 These 14 B.S.N.'s i d e n t i f i e d a few ways by which th e i r nursing education introduced them to t h e i r duties. Nine B.S.N.'s (64.3 percent) believed that t h e i r nursing education introduced them to t h e i r r o l e by teaching i d e a l theory and practice and also by teaching professional r o l e of the nurse. Eight B.S.N.'s (57.1 percent) found that the emphasis of nursing education on i n d i v i d u a l i z e d patient care, problem-solving, independent thinking and nursing process have introduced them to t h e i r duties. There were 4 B.S.N.'s (28.5 percent) who found c l i n i c a l experience and working with others with nursing duties introduced them to t h e i r duties. One B.S.N. (7.1 percent) indicated that nursing education f a m i l i a r i z e d her to duties by emphasizing the nurse's duty within a given i n s t i t u t i o n . Table 17 shows t h i s information. The responses of those nurses who believed that nursing education didn't prepare them for t h e i r duties, can be exampli-f i e d by the following excerpts: " I t has not, I found that only by working." " U n r e a l i s t i c a l l y ! I did not learn much about duties and r e s p o n s i b i l i t i e s u n t i l I worked as a graduate nurse." The data presented above shows that the majority of B.S.N.'s p o s i t i v e l y valued t h e i r education by introducing them to t h e i r f i r s t job. This f i n d i n g i s supported by Kramer's study. 1 8Marlene Kramer, "Role Conceptions of Baccalaureate Nurses and Success i n Hospital Nursing," Nursing Research, Vol. 19, No. 5, (September-October 1970), p. 433. 69 However, i n Kramer's s t u d y , 98 p e r c e n t o f t h e sample s t a t e d t h a t t h e i r work e x p e r i e n c e (work f o r pay w h i l e s t u d e n t s ) c o n t r i -b u t e d s i g n i f i c a n t l y t o t h e i r f e e l i n g s o f adequacy i n t h e i r f i r s t j o b . TABLE 17 PERCENTAGE DISTRIBUTION OF EDUCATIONAL FACTORS THAT INTRODUCED STUDY SAMPLE TO THEIR DUTIES* E d u c a t i o n a l F a c t o r s No.* P e r c e n t a g e 1 T e a c h i n g i d e a l t h e o r y and p r a c t i c e and t e a c h i n g p r o f e s s i o n a l r o l e 9 64.3 I n d i v i d u a l i z e d p a t i e n t c a r e , p r o b l e m - s o l v i n g , independent t h i n k i n g and n u r s i n g p r o c e s s 8 57.1 C l i n i c a l e x p e r i e n c e and w o r k i n g w i t h o t h e r s w i t h n u r s i n g d u t i e s 4 28.5 Emphasis on n u r s e ' s d u t y w i t h i n a g i v e n i n s t i t u t i o n 1 7.1 * T h i s t a b l e r e p r e s e n t s t h e r e s p o n s e s o f 14 B.S.N.'s who b e l i e v e d t h a t t h e i r n u r s i n g e d u c a t i o n i n t r o d u c e d them t o t h e i r d u t i e s . *Each B.S.N, i d e n t i f i e d more t h a n one e d u c a t i o n a l f a c t o r . S t r e n g t h s and Weaknesses o f N u r s i n g E d u c a t i o n The s u b j e c t s were asked about t h e s t r e n g t h s and weaknesses of t h e i r n u r s i n g e d u c a t i o n i n terms o f i n t r o d u c i n g them t o t h e i r r o l e . Two B.S.N.'s d i d n ' t r e s p o n d t o t h i s q u e s t i o n . However, 70 the r e s t gave a few reasons f o r strengths and weaknesses of t h e i r nursing education program. The following reasons were given for the weakness of the nursing education program. The majority of B.S.N.'s, 10 B.S.N.'s (66.6 percent), believed lack of enough c l i n i c a l experience and lack of enough r e s p o n s i b i l i t y during t h e i r education were the shortcomings of the nursing education for introducing them to t h e i r r o l e . Five B.S.N.'s (30.6 percent) indicated that t h e i r educa-t i o n was too t h e o r e t i c a l and not r e a l i s t i c i n introducing them to t h e i r r o l e . The responses of B.S.N.'s can be examplified by the following excerpts: "Nursing education was unable to provide the student with the r e a l i t i e s of the nursing f i e l d at work." "Nursing education didn't adjust to the work demand ac t u a l l y present on the ward." There were 2 B.S.N.'s (13.3 percent) who believed that with more "specialized nursing care", e.g. E.R., C.C.U., they had a better chance to learn t h e i r r o l e i n d i f f e r e n t s i t u a t i o n s . Table 18 i l l u s t r a t e s t h i s information. The B.S.N.'s i d e n t i f i e d d i f f e r e n t factors as the strong points i n t h e i r programs i n terms of introducing them to t h e i r r o l e . Almost a l l B.S.N.'s, 14 B.S.N.'s (93.3 percent) believed that emphasis on high ideals i n nursing care, i . e . t o t a l patient care, encouraging problem-solving and independent thinking, opened doors to know t h e i r r o l e . There were 5 B.S.N.'s (30.6 per-cent) who mentioned that good theory basis, strong foundation i n maternity and p s y c h i a t r i c courses plus concurrent class work 71 h e l p e d them t o l e a r n t h e i r r o l e . There were 2 B.S.N.'s (13.3 per cent) who found t h a t w o r k i n g i n d i f f e r e n t h o s p i t a l s and i n s t i t u -t i o n s and a c t u a l c l i n i c a l e x p e r i e n c e were t h e s t r o n g p o i n t s i n t h e i r e d u c a t i o n f o r i n t r o d u c i n g them t o t h e i r r o l e . See T a b l e 19 Some o f t h e r e s p o n s e s i n t h i s r e g a r d a r e : My n u r s i n g e d u c a t i o n h e l p e d me t o l e a r n my r o l e by: " . . . s t r e s s i n g and a c c e p t i n g the i d e a l i n n u r s i n g c a r e and r o l e i n s p i t e o f i n a d e q u a c i e s t h a t e x i s t i n h e a l t h c a r e s e r v i c e s . . . . " " . . . e n c o u r a g i n g t h i n k i n g , and c h a l l e n g i n g p o l i c i e s i f we d i d n ' t u n d e r s t a n d o r d i s a g r e e d . " These f i n d i n g s a r e s u p p o r t e d by s t u d i e s r e p o r t e d by K r a m e r 1 9 and Mason and C a r s o n . 2 0 I n b o t h s t u d i e s the m a j o r i t y o f t h e sample TABLE 18 PERCENTAGE DISTRIBUTION OF THE WEAKNESSES OF NURSING EDUCATION PROGRAMS IN INTRODUCING THE SAMPLE TO THEIR ROLE* Weaknesses No. P e r c e n t a g e Lack o f p r a c t i c a l e x p e r i e n c e and r e s p o n s i b i l i t y 10 66.5 Too much t h e o r e t i c a l - not r e a l i s t i c 5 30.6 Lack o f o p p o r t u n i t y f o r more s p e c i a l i z e d n u r s i n g c a r e 2 13.3 * T h i s t a b l e r e p r e s e n t s t h e r e s p o n s e s o f 15 B.S.N.'s who answered t h e q u e s t i o n . l 9 I b i d . , p. 433. 2 0 B r e n d a E. Mason, and S h e r r i C a r s o n , "Happiness i s N u r s i n g . . . I f . . . . " , R.N.A.B.C. News, V o l . 7, No. 1, 1975, p. 13. 72 v a l u e d n u r s e e d u c a t i o n programs p o s i t i v e l y . However, i n b o t h s t u d i e s , t h e most commonly v o i c e d d e f i c i t i n t h e e d u c a t i o n a l program was l a c k o f adequate c l i n i c a l e x p e r i e n c e . TABLE 19 PERCENTAGE DISTRIBUTION OF THE STRENGTHS OF NURSING EDUCATION PROGRAMS IN INTRODUCING THE SAMPLE TO THEIR ROLE* S t r e n g t h s No. . P e r c e n t a g e H i g h i d e a l s i n n u r s i n g c a r e , i . e . t o t a l p a t i e n t c a r e , p r o b l e m - s o l v i n g , e t c . 14 93.3 S t r o n g t h e o r y b a s i s 5 30.6 Working i n d i f f e r e n t h o s p i t a l s and a c t u a l c l i n i c a l e x p e r i e n c e 2 13.3 * T h i s t a b l e r e p r e s e n t s t h e r e s p o n s e s o f 15 B.S.N.'s who answered t h i s q u e s t i o n . *Each B.S.N, mentioned more t h a n one f a c t o r . E x p e c t a t i o n o f F a c u l t y The B.S.N.'s were asked i f t h e i r f a c u l t y members e x p e c t a t i o n o f t h e p r o f e s s i o n a l r o l e o f t h e n u r s e had any e f f e c t on t h e i r r o l e as a n u r s e . Of t h e 17, 15 B.S.N.'s (88.2 p e r c e n t ) b e l i e v e d t h a t f a c u l t y ' s e x p e c t a t i o n s had a f f e c t e d t h e i r i d e a s about n u r s e ' s r o l e . Two B.S.N.'s (11.8 p e r c e n t ) i n d i c a t e d t h a t f a c u l t y ' s e x p e c t a t i o n s had no e f f e c t on t h e i r i d e a s about n u r s e ' s r o l e . 73 Out o f 15, 9 B.S.N.'s (60 p e r c e n t ) i n d i c a t e d f a c u l t y ' s h i g h e x p e c t a t i o n f o r a h i g h l y r e s p o n s i b l e r o l e "gave me a h i g h e x p e c t a t i o n f o r m y s e l f as a n u r s e . " E i g h t B.S.N.'s (53.3 p e r c e n t ) mentioned f a c u l t y members had changed t h e i r i d e a s about n u r s e ' s r o l e "by b e i n g a r o l e model" and "by i n t r o d u c i n g d i f f e r e n t r o l e s of the n u r s e . " Three B.S.N.'s (20 p e r c e n t ) i n d i c a t e d t h a t f a c u l t y had "bo t h changed and s t r e n g t h e n e d b e l i e f s about n u r s e ' s r o l e . " Three B.S.N.'s (20 p e r c e n t ) mentioned f a c u l t y ' s encourage ment o f in d e p e n d e n t t h i n k i n g and p r o b l e m - s o l v i n g changed t h e i r i d e a s about n u r s e ' s r o l e . See T a b l e 20. The r e s p o n s e s t o t h i s q u e s t i o n , though d e s c r i b e d above, a r e w o r t h m e n t i o n i n g i n t h e f o l l o w i n g e x c e r p t s : "...many o f my i d e a s r e f l e c t t h e i r t h i n k i n g ; t h a t i s n u r s e as p r o b l e m - s o l v e r , t h i n k e r , e t c . . . . " " . . . i t caused me t o d e f i n e t o m y s e l f what I f e l t a p r o f e s s i o n a l ought t o be and have e x p e c t a t i o n s o f m y s e l f as a r e s u l t . " " . . . t o t a l l y b r a i n - w a s h e d t o l o o k a t n u r s e ' s r o l e . . . t h a t t h e r e a r e d i f f e r e n t r o l e s f o r n u r s e s and we ar e e q u a l members o f h e a l t h team." Kramer's s t u d y s u p p o r t s t h e s e f i n d i n g s . x Her r e s u l t s r e v e a l e d t h a t t h e n u r s e ' s r o l e l e a r n e d by s t u d e n t s f r e q u e n t l y r e f l e c t s t h e i n s t r u c t o r ' s i d e a l image o f n u r s i n g and t h e y a r e models f o r t h e i r s t u d e n t s . M a r l e n e Kramer, " R o l e M o d e l s , R o l e C o n c e p t i o n s , and Role D e p r i v a t i o n , " N u r s i n g R e s e a r c h , V o l . 17, No. 2, (March-A p r i l 1968), p. 118. 74 TABLE 20 PERCENTAGE DISTRIBUTION OF THE EFFECT OF FACULTY MEMBER'S EXPECTATION ON THE SAMPLE'S ROLE AS A NURSE* E f f e c t No. * P e r c e n t a g e * H i g h E x p e c t a t i o n 9 60. 0 Ro l e Model 8 53. 3 Changed and S t r e n g t h e n e d b e l i e f about Nurse's R o l e 3 20.0 Independent T h i n k i n g and P r o b l e m - S o l v i n g 3 20. 0 • T h i s t a b l e r e p r e s e n t s i d e a s o f 15 B.S.N.'s who b e l i e v e d t h a t t h e i r f a c u l t y ' s e x p e c t a t i o n had a f f e c t e d t h e i r i d e a about r o l e o f a n u r s e . *Each B.S.N, i n t r o d u c e d more t h a n one f a c t o r . B e h a v i o r s o f I n s t r u c t o r s I n r e s p o n s e t o t h e q u e s t i o n "what b e h a v i o r o f y o u r i n s t r u c t o r , i f any, has h e l p e d you t o d e v e l o p your r o l e as a n u r s e ? " The m a j o r i t y o f B.S.N.'s, 12 B.S.N.'s (76.5 p e r c e n t ) , i n d i c a t e d t h a t t h e i n s t r u c t o r ' s p e r s o n a l c h a r a c t e r i s t i c s were i m p o r t a n t f a c t o r s . They f u r t h e r c l a r i f i e d t h a t t h e i r i n s t r u c t o r s , by " b e i n g human," " b e i n g o r g a n i z e d and u n d e r s t a n d i n g , " " b e l i e v i n g i n what t h e y were t a l k i n g about," " b e i n g c o n s t r u c t i v e and a v a i l -a b l e when needed," and a l s o the i n s t r u c t o r ' s " h o n e s t y , c o n f i d e n c e , s t e a d f a s t n e s s and d e c i s i o n making a b i l i t y " have h e l p e d them t o form p a r t o f t h e i r i d e a s about t h e i r r o l e as a n u r s e . These 75 ideas can be t y p i f i e d by the following excerpt: " . . . t h e i r honesty, willingness to l i s t e n , t h e i r compassion and empathy with t h e i r students, and on the ward with t h e i r patients, t h e i r a b i l i t y to admit and talk over mistakes. I r o l l them a l l into one i d e a l and t h i s d e f i n i t e l y forms part of my ideas of a nurse's r o l e . " Four B.S.N.'s (23.5 percent) mentioned that the ins t r u c t o r ' s a b i l i t y to place the patient before rules and regulations and budget, and t h e i r i n d i v i d u a l i z e d nursing care was also h e l p f u l to them. There were 4 B.S.N.'s (23.5 percent) who indicated that i n s t r u c t o r ' s up-to-date knowledge and t h e i r p o s i t i v e a t t i -tude toward higher education for nurses had helped them to know d i f f e r e n t aspects of t h e i r role as a nurse. Table 21 i l l u s t r a t e s t h i s information. These kinds of reaction toward instruc t o r s were shown TABLE 21 PERCENTAGE DISTRIBUTION OF HELPFUL BEHAVIOR OF INSTRUCTORS ON THE SAMPLE'S ROLE BEHAVIOR* Helpful Behavior No. Percentage Personal C h a r a c t e r i s t i c s Individualized Nursing Care Up-to-date Knowledge 13 4 4 76. 5 23.5 23.5 *Each B.S.N, i d e n t i f i e d more than one h e l p f u l behavior. 76 i n a n o t h e r s t u d y done by Je a n P e a r s o n . " I n t h a t s t u d y , t h e sample p r a i s e d t h e i r i n s t r u c t o r s f o r t h e i r k i n d n e s s , u n d e r s t a n d i n g , h e l p f u l n e s s and energy. They a l s o p r a i s e d t h e i r i n s t r u c t o r s f o r t h e i r knowledge, t h i n k i n g and f r i e n d l i n e s s . C l assmates' A t t i t u d e s The B.S.N.'s were asked i f the a t t i t u d e s and b e l i e f s o f t h e i r c l a s s m a t e s about n u r s i n g had any e f f e c t on t h e i r r o l e as a n u r s e . Of t h e 17, 12 B.S.N.'s (70.6 p e r c e n t ) i n d i c a t e d t h a t t h e i r c l a s s m a t e s ' a t t i t u d e s and b e l i e f s i n f l u e n c e d them i n .part. F i v e , (29.4 p e r c e n t ) t h o u g h t t h a t t h e i r c l a s s m a t e s a t t i t u d e s had no e f f e c t on them. Of t h e 12 B.S.N.'s who i n d i c a t e d the e f f e c t o f t h e i r c l a s s m a t e s ' a t t i t u d e s and b e l i e f s i n t h e i r r o l e , 9 B.S.N.'s (75 p e r c e n t ) i n d i c a t e d t h a t t a l k i n g and d i s c u s s i o n w i t h o t h e r c l a s s m a t e s h e l p e d t o c l a r i f y and expand i d e a s about n u r s e ' s r o l e and r e i n f o r c e d t h e i r b e l i e f s t o some e x t e n t . F i v e B.S.N.'s (41.6 p e r c e n t ) i n d i c a t e d i t was h e l p f u l t o he a r o t h e r v i e w p o i n t s and compare them w i t h t h e i r own i d e a s . Two B.S.N.'s (16.6 p e r -c e n t ) i n d i c a t e d t h a t t h e c l a s s m a t e s ' a t t i t u d e "made t h e r o l e o f t h e n u r s e l e s s u n r e a l i s t i c . " Two B.S.N.'s (16.6 p e r c e n t ) b e l i e v e d t h a t d i s c u s s i o n about t h e i r e x p e r i e n c e i n d i f f e r e n t f i e l d s was h e l p f u l t o them and r e i n f o r c e d t h e i r i d e a s about n u r s e ' s r o l e . See t a b l e 22. ^ J e a n P e a r s o n , " A t t i t u d e s o f Undergraduates t o t h e i r Course," N u r s i n g Times, (May 15, 1975), p. 784. 77 The i d e a s p r e s e n t e d above can be e x a m p l i f i e d by the f o l l o w i n g e x c e r p t s : " c l a s s m a t e s a r e so u n d i n g boards f o r each o t h e r ' s i d e a s , b e l i e f s , and a t t i t u d e s . " " . . . t h e i r d i s c u s s i o n expanded my i d e a s , a t t i m e s t h e y r e i n f o r c e d my i d e a s and even changed some o f my i d e a s . A l s o t h e i r w a t c h i n g , c r i t i c i z i n g , and s h a r i n g c l i n i c a l e x p e r i e n c e s broadened and r e i n f o r c e d t h e r o l e . " " . . . t h e i r p e r s o n a l e x p e r i e n c e i n d i f f e r e n t f i e l d s , and t h e i r a t t i t u d e s e x p r e s s e d and d i s c u s s e d , encouraged me t o t h i n k about t h e i d e a l r o l e o f t h e n u r s e . " TABLE 22 PERCENTAGE DISTRIBUTIONS OF THE EFFECT OF CLASSMATES BELIEF ABOUT NURSING ON THE SAMPLE 1S ROLE* E f f e c t o f t h e C l a s s m a t e s * B e l i e f No.* P e r c e n t a g e * C l a r i f i e d and Expanded Ideas 9 75. Broadened t h e View 5 41.6 Made Nurse's R o l e l e s s U n r e a l i s t i c 2 16.6 R e i n f o r c e d t h e Ide a 2 16.6 * T h i s t a b l e r e p r e s e n t s the r e s p o n s e s o f 12 B.S.N.'s who b e l i e v e d t h a t t h e c l a s s m a t e s ' b e l i e f and a t t i t u d e s had some e f f e c t on t h e i r r o l e . *Each B.S.N, i n d i c a t e d more than one f a c t o r . N u r s i n g and Courses I n r e l a t i o n t o t h e n u r s i n g c o u r s e s , t h e r e were 15 B.S.N.'s (88.2 p e r c e n t ) who b e l i e v e d t h a t t h e n u r s i n g c o u r s e s had h e l p e d them t o l e a r n more about t h e i r r o l e , whereas 2, (11.8 p e r c e n t ) 78 d i d not t h i n k so. Of t h e 15 B.S.N.'s, 3 (20 p e r c e n t ) b e l i e v e d a l l o f the n u r s i n g c o u r s e s were h e l p f u l . Ten B.S.N.'s (66.6 p e r c e n t ) i n d i c a t e d h o s p i t a l o r i e n t e d c o u r s e s (e.g. o b s t e t r i c , p e d i a t r i c , e t c . ) had h e l p e d them t o know t h e i r r o l e . S i x B.S.N.'s (40 p e r c e n t ) mentioned t h e i n f l u e n c e of community h e a l t h n u r s i n g on t h e i r r o l e and 4 B.S.N.'s (26.6 p e r c e n t ) i n d i c a t e d t h e e f f e c t o f a n u r s i n g a d m i n i s t r a t i o n c o u r s e on development of t h e i r r o l e . See T a b l e 23. The i n f l u e n c e o f t h e s e c o u r s e s on t h e sample's r o l e can be d e s c r i b e d by the f o l l o w i n g e x c e r p t s : " . . . p s y c h i a t r i c n u r s i n g h e l p e d my s e l f - a w a r e n e s s i n a n u r s i n g r o l e and the re s p o n s e o f o t h e r s t o me. Community h e a l t h n u r s i n g h e l p e d me t o d e v e l o p a more expanded and r e s p o n s i b l e r o l e . " " . . . n u r s i n g a d m i n i s t r a t i o n made me aware o f t h e ways t h i n g s s h o u l d be r u n i n a h o s p i t a l and made me more aware o f t h e t h i n g s I s h o u l d l o o k f o r . " F i n d i n g s o f Mason and Carson''*3 a r e s u g g e s t i v e s u p p o r t f o r t h e s d a t a . Brenda E. Mason and S h e r r i C a r s o n , "Happiness i s N u r s i n g . . . i f . . . . " R.N.A.B.C. News, V o l . 7, No. 1, 1975, p. 13 79 TABLE 23 PERCENTAGE DISTRIBUTION OF THE NURSING COURSES THAT HELPED IN DEVELOPMENT OF SAMPLE'S ROLE AS A NURSE* Cour s e s No. * P e r c e n t a g e * A l l o f them 3 20.0 H o s p i t a l - o r i e n t e d c o u r s e s 10 66.6 Community h e a l t h n u r s i n g 6 40.0 N u r s i n g a d m i n i s t r a t i o n 4 26. 6 * T h i s t a b l e r e p r e s e n t s t h e r e s p o n s e s o f 15 n u r s e s who i n d i c a t e d t h e i n f l u e n c e o f n u r s i n g c o u r s e s on the d e v e l o p -ment of t h e i r r o l e as a n u r s e . *Each B.S.N, mentioned more th a n one c o u r s e . C l i n i c a l E x p e r i e n c e R e g a r d i n g c l i n i c a l e x p e r i e n c e , the B.S.N.'s were asked i f i t had any i n f l u e n c e on t h e i r i d e a s about t h e n u r s e ' s r o l e . Most B.S.N.'s e x p r e s s e d f a v o r a b l e r e a c t i o n s t o t h e e f f e c t of the c l i n i c a l e x p e r i e n c e on t h e i r r o l e . Ten B.S.N.'s (58.8 p e r -c e n t ) i n d i c a t e d t h a t c l i n i c a l e x p e r i e n c e h e l p e d them t o see what i s e x p e c t e d r e a l i s t i c a l l y from a n u r s e and sense o f r e a l i t y t o t h e i r r o l e . As one B.S.N, e x p r e s s e d : " . . . t h a t i s what makes you r e a l i z e what n u r s i n g i s a l l about." F i v e B.S.N.'s (29.4 p e r c e n t ) i n d i c a t e d t h a t c l i n i c a l e x p e r i e n c e gave them " . . . o p p o r t u n i t y t o a p p l y t h e o r y and i n s t i t u t e new i d e a s . . . . s t r e n g t h e n e d most i d e a s . " 80 One B.S.N. (5.9 percent) mentioned that c l i n i c a l experience "...turned me toward bedside i n the ho s p i t a l area." One B.S.N. (5.9 percent) indicated that the c l i n i c a l experience was "rather u n r e a l i s t i c . " This information i s presented i n table 24. The following excerpts c l a r i f y the above responses: "...most important f o r me. I t helped me to see what goes on during the day and what i n r e a l i t y i s expected of the nurse." "...saw the i d e a l was not always aimed for and often d i f f i c u l t to achieve. "...put many t h e o r e t i c a l ideas into more r e a l i s t i c focus. Also at times expectations were d i f f e r e n t from cl a s s , so changed r o l e a l i t t l e . Also showed many of smaller duties not s p e c i f i c a l l y taught and showed how important ada p t a b i l i t y i s . " These findings contradict the findings of Reinkemeyer * s"* study i n some ways. In that study the sample expressed t h e i r h o s p i t a l experience as students had revealed to them a world of contradictions and of c o n f l i c t i n g values. In a sense, i t served as a prophecy: they f e l t they would be unable to use themselves - t h e i r i n t e l l e c t u a l and creative capacities - i n the h o s p i t a l environment. 2 4 S i s t e r Agnes M. Reinkemeyer, " I t Won't Be Hospital Nursing." American Journal of Nursing, Vol. 68, No. 9, (Sept-ember 1968), p. 1939. 81 TABLE 24 PERCENTAGE DISTRIBUTION OF THE INFLUENCE OF CLINICAL EXPERIENCE ON THE SAMPLE'S ROLE E f f e c t of C l i n i c a l Experience No. Percentage Gave r e a l i t y of the nurse's r o l e 10 58. 8 Provided opportunity to apply theory into practice 5 29.4 Turned to bedside nursing i n the h o s p i t a l 1 5.9 Rather u n r e a l i s t i c 1 5.9 . Preparation for Work In response to the question "do you f e e l that the program at U.B.C. prepared you for what i s expected of you i n your work?" Eight B.S.N.'s (47.1 percent) answered yes, 3 B.S.N.'s (17.6 percent) believed i n t h e o r e t i c a l background "yes" and i n p r a c t i c e "no". Three B.S.N.'s (17.6 percent) indicated "only pa r t l y " and there were 3 B.S.N.'s (17.6 percent) who indicated t h e i r education didn't prepare them for t h e i r work. The responses of the l a t t e r group can be examplified by the following excerpt: "No. If I had not worked as a grad in summer, I would not have had the confidence i n my s k i l l s that are needed to perform safely." This information i s i l l u s t r a t e d i n table 25. In r e l a t i o n to the above question, the B.S.N.'s were 82 asked i f t h e y found s i m i l a r i t y o f e x p e c t a t i o n s between t h e i r n u r s i n g e d u c a t i o n and n u r s i n g p r a c t i c e . Twelve B.S.N.'s (70.6 p e r c e n t ) b e l i e v e d t h a t t h e r e was no s i m i l a r i t y o f e x p e c t a t i o n s , whereas 5 B.S.N.'s (29.4 p e r c e n t ) i n d i c a t e d t h a t t h e r e was some s i m i l a r i t y . The r e s p o n s e s o f B.S.N.'s t o t h i s q u e s t i o n can be e x a m p l i f i e d by t h e f o l l o w i n g e x c e r p t s : "No, e x p e c t a t i o n i n e d u c a t i o n much h i g h e r - w i l l be moving on from t h i s j o b as d i s s a t i s f i e d w i t h t h e use o f my e d u c a t i o n . " "Yes, e x c e p t t h a t so busy t h a t have l i t t l e time f o r p s y c h o l o g i c a l c o n c e r n s . " Those B.S.N.'s who i n d i c a t e d t h a t t h e r e was no s i m i -l a r i t y o f e x p e c t a t i o n s between t h e i r e d u c a t i o n and p r a c t i c e gave t h e f o l l o w i n g r e a s o n s f o r t h e i r b e l i e f . S i x B.S.N.'s e x p r e s s e d t h a t : "work s e t t i n g m a i n l y c o n cerned w i t h s t a n d a r d s on ward b u t i s n o t me e t i n g each p e r s o n ' s p o t e n t i a l . " "no t i m e t o do n u r s i n g t h e way i t was t a u g h t , g e t t i n g t h e work done must be t h e f i r s t p r i o r i t y . . . t h e o r y w h i c h c o u l d n o t be used i n p r a c t i c e . " One B.S.N, i n d i c a t e d t h a t " t h e e x p e c t a t i o n was l o w e r i n p r a c t i c e . " F i v e B.S.N.'s d i d n ' t answer t h i s q u e s t i o n . The d a t a p r e s e n t e d h e r e i s s u p p o r t e d by t h e f i n d i n g s o f K r a m e r . 2 5 ' 2 6 ' 2 7 25 M a r l e n e Kramer, " R o l e C o n c e p t i o n s o f B a c c a l a u r e a t e Nurses and Success i n H o s p i t a l N u r s i n g . " N u r s i n g R e s e a r c h , V o l . 19, No. 5, (September-October 1970), p. 433. 2 6 _ and Constance B a k e r , "The Exodus: Can We P r e v e n t I t ? " The J o u r n a l o f N u r s i n g A d m i n i s t r a t i o n , V o l . 1, No. 3, (May-June 1971), pp. 15-29. 2 7 , R e a l i t y Shock - Why Nurses Leave N u r s i n g P r a c t i c e , S a i n t L o u i s : The C. V. Mosby Company, 1974, pp. 90-91. 83 TABLE 25 PERCENTAGE DISTRIBUTION OF THE STUDY SAMPLE'S RESPONSE ABOUT THEIR PREPARATION FOR WORK BY NURSING EDUCATION Response No. P e r c e n t a g e Yes 8 47.1 I n t h e o r e t i c a l i n p r a c t i c e background yes no 3 17. 6 O n l y p a r t l y 3 17.6 No 3 17.6 T o t a l 17 100. Work S e t t i n g Q u e s t i o n s were d e s i g n e d t o d e t e r m i n e t h e e f f e c t o f work s e t t i n g on the B.S.N.'s r o l e b e h a v i o r . The f i r s t q u e s t i o n probed i f w o r k i n g as a n u r s e i n the h o s p i t a l has changed t h e B.S.N.'s i d e a s about t h e n u r s e ' s r o l e . Of t h e 17 B.S.N.'s, 3 (17.6 p e r c e n t ) d i d n ' t answer t h i s q u e s t i o n . Among t h e 14 B.S.N.'s (82.4 p e r c e n t ) who answered t h i s q u e s t i o n , 5 B.S.N.'s (35.7 p e r c e n t ) e x p r e s s e d f e e l i n g s t y p i f i e d by t h e s e r e s p o n s e s : Working i n t h e h o s p i t a l made me r e a l i z e t h a t : "...you don't have time t o g i v e the k i n d o f n u r s i n g you'd l i k e t o . . . . " " . . . s t a f f n u rse i s q u i t e l i m i t e d i n her a b i l i t y t o c o n t r i b u t e t o t h e w o r k i n g o f a ward and the h o s p i t a l . " 84 "...how paper work and set tasks (routine) can block i n i t i a t i v e and i d e a l nursing care." Four B.S.N.'s (28.6 percent) indicated that working as a nurse i n the h o s p i t a l has not changed t h e i r ideas about nurse's r o l e . But 3 B.S.N.'s (21.4 percent) believed that working i n the ho s p i t a l changed t h e i r idea as expressed i n the following excerpt: "...made me r e a l i z e the greater r e s p o n s i b i l i t y of nurses than imagined when i n school." There were 2 B.S.N.'s (14.3 percent) who indicated that working i n the ho s p i t a l gave them a cl e a r idea of t h e i r own c a p a b i l i t i e s and made them proud of t h e i r q u a l i f i c a t i o n s . This information i s i l l u s t r a t e d i n table 26. In r e l a t i o n to the above question, the B.S.N.'s were asked, i n what way working i n the ho s p i t a l reinforced t h e i r image of the nurse's r o l e . Of the 10 B.S.N.'s who answered t h i s question, the responses of 7 B.S.N.'s can be examplified by the following responses: "...I did indeed become involved and interested i n the patients and want to use my knowledge and s k i l l to help them." Three B.S.N.'s expressed that working as a nurse r e i n -forced t h e i r idea that nursing as a job i s progressing. Some of the responses expressed by the B.S.N.'s in t h i s study are s i m i l a r to those expressed by nurses i n the Kramer 2 8 study. For example, one of the responses i n Kramer's study was 2 8Marlene Kramer, Some Ef f e c t s of Exposure to Employing  Bureaucracies on the Role Conception and Role Deprivation of Neo- phyte C o l l e g i a t e Nurses, unpublished d i s s e r t a t i o n , Stanford University, 1966, p. 48. 85 " . . . i n school, we were so geared to i n d i v i d u a l patient care and i n d i v i d u a l patient needs, and patient centered nursing... and I think, a f t e r you work a while, you see that some of these things aren't put int o p r a c t i c e . You have a l l these ideals i n your background, and then some-times you might even Slide yourself. 9 TABLE 26 THE EFFECT OF WORKING IN THE HOSPITAL ON THE SAMPLE'S IDEAS ABOUT THE NURSE'S ROLE E f f e c t No.* Percentage' No time for i d e a l nursing care 5 35.7 No change 4 28.6 Realizing the great r e s p o n s i b i l i t y of a nurse 3 21.4 Finding a clear idea of own capa-b i l i t i e s and q u a l i f i c a t i o n s _2 14.3 Total 14* 100. •This table represents the responses of 14 B.S.N.'s who answered t h i s question. F a m i l i a r i z a t i o n with R e s p o n s i b i l i t i e s A question was designed to f i n d out about the factors that f a m i l i a r i z e d the B.S.N.'s with t h e i r r e s p o n s i b i l i t i e s i n the h o s p i t a l . In general, a l l B.S.N.'s indicated that they had a very poor or i e n t a t i o n to t h e i r work and r e s p o n s i b i l i t i e s . 2 9 I b i d . , p. 48. 86 However, t h e y have mentioned a few f a c t o r s t h a t h e l p e d them t o some e x t e n t t o be f a m i l i a r w i t h t h e i r work. Ten B.S.N.'s (58.8 p e r c e n t ) mentioned t h a t t h e o r i e n t a -t i o n program was h e l p f u l i n making them f a m i l i a r w i t h t h e i r r e s p o n s i b i l i t i e s . T h r e e, (17.6 p e r c e n t ) i n d i c a t e d i n s e r v i c e e d u c a t i o n , and 3 (17.6 p e r c e n t ) mentioned t h a t o t h e r s t a f f mem-be r s h e l p e d them t o know t h e i r r e s p o n s i b i l i t i e s . One B.S.N. (5.9 p e r c e n t ) i n d i c a t e d t h a t she l e a r n e d h er r e s p o n s i b i l i t i e s by t r i a l and e r r o r . Two, (11.8 p e r c e n t ) , l e a r n e d i t by r e a d i n g the j o b d e s c r i p t i o n , 1, (15.9 p e r c e n t ) , i n d i c a t e d t h a t she had no o r i e n t a t i o n w h atsoever. T a b l e 27 shows t h i s i n f o r m a t i o n . I t i s w o r t h w h i l e t o men t i o n some o f the B.S.N.'s r e s p o n s e s t o t h i s q u e s t i o n h e r e . "None. No o r i e n t a t i o n , i n s e r v i c e or j o b d e s c r i p t i o n . I t was s i n k o r swim - was team l e a d i n g second day a t work. I d i d n o t even know where t o g e t a bed pan." " . . . o r i e n t a t i o n and j o b d e s c r i p t i o n p a r t l y , o t h e r s t a f f members m o s t l y . " I n r e l a t i o n t o t h e above q u e s t i o n , t h e B.S.N.'s were asked i f t h e f a c t o r s t h e y mentioned above had i n f l u e n c e d t h e i r r o l e as a n u r s e . E i g h t B.S.N.'s i n d i c a t e d t h a t t h e i r o r i e n t a t i o n i n f l u e n c e d them t o r e c o g n i z e t h e i r h i g h r e s p o n s i b i l i t y i n t h e h o s p i t a l s e t t i n g . Two mentioned t h a t the o r i e n t a t i o n broadened t h e i r v i e w about h o s p i t a l n u r s i n g , and 2 i n d i c a t e d i t d i s c o u r a g e d them about h o s p i t a l n u r s i n g . F i v e B.S.N.'s d i d n ' t answer t h i s p a r t o f t h e q u e s t i o n . These f i n d i n g s a re s u p p o r t e d by a s t u d y r e p o r t e d by 87 Kramer." 1 1 0 In t h a t s t u d y o n l y 24 of t h e 45 g r a d u a t e s i n d i c a t e d a p o s i t i v e r e a c t i o n t o t h e i r o r i e n t a t i o n program. Those g r a d u -a t e s who e v a l u a t e d t h e i r o r i e n t a t i o n n e g a t i v e l y , gave r e s p o n s e s s i m i l a r t o t h o s e e x p r e s s e d i n t h i s s t u d y . TABLE 27 PERCENTAGE DISTRIBUTION OF FACTORS THAT FAMILIARIZED THE STUDY SAMPLE TO THEIR RESPONSIBILITIES IN THE HOSPITAL F a c t o r s No. * P e r c e n t a g e * O r i e n t a t i o n program 10 58. 8 I n s e r v i c e e d u c a t i o n 3 17.9 O t h e r s t a f f members 3 17.9 Job d e s c r i p t i o n 2 11.8 T r i a l and e r r o r 1 .5.9 None 1 5.9 *Each B.S.N, i d e n t i f i e d more t h a n one f a c t o r . H o s p i t a l P e r s o n n e l The s u b j e c t s were asked i f anybody i n the work s e t t i n g has r e i n f o r c e d o r changed t h e i r i d e a s about t h e n u r s e ' s r o l e . Out o f 17, 8 B.S.N.'s (47.1 p e r c e n t ) b e l i e v e d t h a t s t a f f n u r s e s (co-workers) r e i n f o r c e d t h e i r i d e a s about n u r s e ' s 3 0 M a r l e n e Kramer, "The New Graduate Speaks." American J o u r n a l o f N u r s i n g , (November 1966), p. 2422. 88 r o l e , 2 (11.8 p e r c e n t ) mentioned t h a t i n s e r v i c e c o o r d i n a t o r s r e i n f o r c e d t h e i r i d e a s about n u r s e ' s r o l e . F i v e B.S.N.'s (29.4 p e r c e n t ) i n d i c a t e d no one had such an i n f l u e n c e on them. T a b l e 28 i l l u s t r a t e s t h i s i n f o r m a t i o n . The r e s p o n s e o f one B.S.N, t o t h i s q u e s t i o n shows the dilemma some n u r s e s f e e l i n the h o s p i t a l work s e t t i n g . " . . . c o n c e r n e d n u r s i n g c a r e of co-workers r e i n -f o r c e d my i d e a s of t h e n u r s e ' s r o l e . However, u n d e r s t a f f i n g , l a c k o f equipment, poor work s c h e d u l e s , causes d i s c o u r a g e m e n t so t h a t I sometimes f e e l t h a t n u r s i n g as I would l i k e t o c a r r y o u t t h e r o l e does not e x i s t and i s n o t a l l o w e d t o e x i s t by h o s p i t a l a d m i n i s t r a t o r s and o t h e r s i n t h e d e c i s i o n making r o l e s . " 31 i n a s t u d y r e p o r t e d by H a r r i n g t o n and T h e i s , n u r s e s a t Loeb C e n t e r , mentioned t h e e n t h u s i a s m o f co-workers as a f a c t o r t h a t s t i m u l a t e d them t o p e r f o r m t h e f u n c t i o n s o f p r o -3 ? f e s s i o n a l n u r s i n g . Kramer a l s o found t h a t head n u r s e s , and i n s e r v i c e e d u c a t o r s had i n f l u e n c e on new g r a d u a t e ' s r o l e be-h a v i o r (as " s o c i a l i z i n g a g e n t " ) . 3•'-Helen Ann H a r r i n g t o n and E. C h a r l o t t e T h e i s . " I n s t i t u t i o n a l F a c t o r s P e r c e i v e d by B a c c a l a u r e a t e G r a d u a t e s as I n f l u e n c i n g t h e i r P erformance as S t a f f N u r s e s , " N u r s i n g R e s e a r c h , V o l . 17, No. 3, (May-June 1968), p. 232. 3 2 M a r l e n e Kramer. R e a l i t y Shock - Why Nurses Leave  N u r s i n g P r a c t i c e , S a i n t L o u i s : The C. V. Mosby Company, 1974, pp. 142-143. 89 TABLE 28 PERCENTAGE DISTRIBUTION OF THE EFFECT OF HOSPITAL PERSONNEL ON THE SAMPLE'S IDEAS ABOUT NURSE'S ROLE H o s p i t a l P e r s o n n e l No. P e r c e n t a g e S t a f f n u r s e 8 47.1 Head n u r s e 2 11.8 I n s e r v i c e c o o r d i n a t o r 2 11. 8 No one 5 29.4 T o t a l 17 100. R a n k i n g A t the end, t h e B.S.N.'s were asked t o rank t h e 10 g i v e n f a c t o r s i n o r d e r o f s i g n i f i c a n c e i n h e l p i n g them t o d e v e l o p t h e i r r o l e . T h i s s e c t i o n was d e s i g n e d f o r two pu r p o s e s F i r s t , i n a c o n c r e t e and s t r u c t u r e d way i t shows t h e most s i g n i f i c a n t f a c t o r s t h a t h e l p e d t h e sample t o d e v e l o p t h e i r r o l e , and s e c o n d l y , i t p r o v i d e s a summary o f d e t e r m i n a n t f a c t o r s p r e s e n t e d i n S e c t i o n s I t o I I I o f t h i s c h a p t e r . The mean f o r each f a c t o r was c a l c u l a t e d , and th e n means were r a n k e d . The l o w e r mean i n d i c a t e s the more s i g n i f i -c a n t f a c t o r . T a b l e 29 summarizes t h e d a t a . 90 TABLE 29 MEAN RANKING OF THE FACTORS THAT HELPED THE STUDY SAMPLE TO DEVELOP THEIR ROLE AS A NURSE F a c t o r s X Order of Ranking Your own i d e a s about n u r s i n g and n u r s e ' s r o l e 3.941 1 * Working as a n u r s e 4.118 2 A t t i t u d e s o f i n s t r u c t o r s d u r i n g n u r s i n g e d u c a t i o n 4.118 2* Course c o n t e n t o f n u r s i n g program 4.235 4 C l i n i c a l e x p e r i e n c e d u r i n g n u r s i n g e d u c a t i o n 4.7 06 5 A t t i t u d e s o f o t h e r n u r s e s i n t he work s e t t i n g 5.647 6 C l a s s m a t e s ' b e l i e f s and i d e a s about n u r s i n g 5.765 7 Job d e s c r i p t i o n , o r i e n t a t i o n program, i n s e r v i c e e d u c a t i o n i n t h e h o s p i t a l 6.000 8 Encouragement o f f a m i l y , f r i e n d s , o r c o u n s e l l o r 7.529 9 B e l i e f s about n u r s i n g b e f o r e e n t e r i n g n u r s i n g s c h o o l 8.588 10 *The mean r a n k i n g f o r b o t h f a c t o r s a r e e x a c t l y t h e same, so b o t h c o n s i d e r e d 2nd i n r a n k i n g . IV Summary T h i s c h a p t e r has p r e s e n t e d the r e s u l t s o f t h i s i n v e s t i -g a t i o n . Data were p r e s e n t e d and a n a l y z e d i n t h r e e p a r t s . P a r t 1 91 d e s c r i b e d t h e c h a r a c t e r i s t i c s of the sample. P a r t 2 a n a l y z e d t h e r e s u l t s o f s e l e c t i o n o f r o l e b e h a v i o r a t two d e s i g n a t e d t i m e s . P a r t 3 e x p l o r e d t h e d e t e r m i n a n t f a c t o r s i n s e l e c t i o n o f r o l e b e h a v i o r . I n t h e f i r s t p a r t t h e d a t a showed t h a t t h e m a j o r i t y o f the B.S.N.'s had p r e v i o u s work e x p e r i e n c e i n the h o s p i t a l / i n d i f f e r e n t p o s i t i o n s , a t d i f f e r e n t t i m e s b e f o r e g r a d u a t i o n . A t g r a d u a t i o n t i m e the m a j o r i t y o f B.S.N.'s wanted t o work i n the h o s p i t a l s e t t i n g w i t h i n one t o two months f o l l o w i n g g r a d u a t i o n . P o s t - g r a d u a t i o n f o l l o w - u p r e v e a l e d t h a t the m a j o r i t y o f t h e B.S.N.'s were w o r k i n g i n t h e h o s p i t a l as s t a f f n u r s e s f o r t h r e e months. Data a l s o i n d i c a t e d t h a t most o f t h e s e n u r s e s were w o r k i n g i n a h o s p i t a l w i t h more than 500 beds w h i c h was l o c a t e d i n a l a r g e c i t y . In the second p a r t t h e d a t a showed t h a t t h e r e was no s i g n i f i c a n t d i f f e r e n c e between s e l e c t i o n o f b u r e a u c r a t i c and i n t e g r a t i v e r o l e b e h a v i o r a t two d e s i g n a t e d t i m e s . However, t h e r e was a s i g n i f i c a n t d e c r e a s e i n s e l e c t i o n o f p r o f e s s i o n a l r o l e b e h a v i o r a f t e r employment i n t h e h o s p i t a l . I n the t h i r d p a r t d a t a showed media and p e r s o n a l ex-p e r i e n c e were the major s o u r c e s f o r a c q u i r i n g i n f o r m a t i o n about n u r s i n g b e f o r e e n t e r i n g the n u r s i n g s c h o o l . However, t h i s had the l e a s t e f f e c t on B.S.N.'s r o l e . The d a t a i n d i c a t e d t h a t m a j o r i t y o f B.S.N.'s v a l u e d t h e i r n u r s i n g e d u c a t i o n , i n s t r u c t o r s , c l a s s m a t e s , n u r s i n g c o u r s e s , and c l i n i c a l e x p e r i e n c e p o s i t i v e l y i n terms o f i n t r o d u c i n g them t o t h e i r r o l e . B.S.N.'s e x p r e s s e d t h a t t h e i r i d e a s about n u r s e ' s r o l e were shaped and i n f l u e n c e d by i d e a l e d u c a t i o n ( t e a c h i n g i d e a l t h e o r y and p r a c t i c e ) , h i g h 92 expectations from in s t r u c t o r s , role modeling by t h e i r i n s t r u c t o r s , personal c h a r a c t e r i s t i c s of t h e i r i n s t r u c t o r s , and discussion with classmates, and c l i n i c a l experience. Although the responses to work settings were not p o s i t i v e , the majority of B.S.N.'s indicated working as a nurse was the second most important fac-tor i n helping them to develop t h e i r r o l e . In fact, i t was as he l p f u l to the B.S.N.'s as the attitudes of t h e i r i n s t r u c t o r s (role models) during nursing education. The data revealed that some concerned co-workers reinforced B.S.N.'s ideas about nurse's r o l e , but the e f f e c t of educational factors, that i s , attitudes of inst r u c t o r s , course content and c l i n i c a l experience, were more h e l p f u l and i n f l u e n t i a l . The data revealed that the majority of these B.S.N.'s valued the " i d e a l " type of nursing education they have had during t h e i r school years. They believed that t h e i r education showed them a broader view of nurse's r o l e , provided them with highly q u a l i f i e d "role models" (i n s t r u c t o r s ) , acquainted them with d i f f e r e n t areas of nursing functions by nursing courses, and f a m i l i a r i z e d them with the r e a l world of work by c l i n i c a l p r a c t i c e . The data also shows that some of the B.S.N.'s believe that t h e i r nursing education lacked adequate c l i n i c a l p r a c t i c e , didn't adjust to the r e a l i t i e s of work, and didn't provide opportunity f o r more sp e c i a l i z e d care (e.g. e c u . ) . The data describes that i n the work sett i n g , some B.S.N.'s were not able to practice nursing the way they were taught. Routine tasks and paper work were the reasons for the B.S.N.'s l i m i t a t i o n s for " i d e a l " nursing care. The majority of 93 B.S.N.'s agreed t h e y had a poor o r i e n t a t i o n t o t h e i r work. B e s i d e s i n t h e work s e t t i n g , c o n c erned s t a f f n u r s e s were the ones who h e l p e d the B.S.N.'s t o r e i n f o r c e t h e i r i d e a s about n u r s i n g . 94 CHAPTER V SUMMATION, CONCLUSIONS, IMPLICATIONS AND SUGGESTIONS I . Summation T h i s e x p l o r a t o r y r e s e a r c h was p l a n n e d t o answer t h e f o l l o w i n g q u e s t i o n s : 1. Upon c o m p l e t i o n o f U n i v e r s i t y o f B r i t i s h C olumbia B.S.N, n u r s i n g e d u c a t i o n what r o l e b e h a v i o r do g r a d u a t e s s e l e c t ? (As measured by M a r l e n e Kramer's I n t e g r a t i v e R o l e B e h a v i o r S c a l e ) . 2. What happens t o U n i v e r s i t y o f B r i t i s h C o l u m b i a g r a d u a t e s r o l e b e h a v i o r upon employment i n t h e b u r e a u c r a c y o f a h o s p i t a l s e t t i n g ? (As measured by M a r l e n e Kramer's I n t e g r a t i v e R o l e B e h a v i o r S c a l e ) . 3. What d e t e r m i n a n t f a c t o r s can be i d e n t i f i e d as i n f l u e n c i n g t h e U n i v e r s i t y o f B r i t i s h C olumbia g r a d u a t e s t o d e v e l o p t h e i r r o l e b e h a v i o r ? A r e v i e w o f l i t e r a t u r e was p r e s e n t e d i n two p a r t s . The f i r s t p a r t v i e w e d l i t e r a t u r e from a t h e o r e t i c a l p o i n t o f v i e w on th e p r o f e s s i o n a l and b u r e a u c r a t i c system o f work o r g a n i z a t i o n and a l s o development o f r o l e c o n c e p t i o n i n such o r g a n i z a t i o n s . The second p a r t v i e w e d t h e r e l a t e d n u r s i n g s t u d i e s on t h e s u b j e c t . The l i t e r a t u r e r e v i e w showed t h a t t h e p r o f e s s i o n a l - b u r e a u c r a t i c c o n f l i c t e x i s t s i n n u r s i n g and B.S.N.'s a r e u s u a l l y most a f f e c t e d by t h i s c o n f l i c t . The l i t e r a t u r e r e v i e w a l s o r e v e a l e d t h a t B.S.N.'s have p r o f e s s i o n a l r o l e c o n c e p t i o n upon g r a d u a t i o n , whereas t h e y p e r c e i v e b u r e a u c r a t i c r o l e c o n c e p t i o n upon employment. As a r e s u l t , r o l e d e p r i v a t i o n and d i s s a t i s f a c t i o n and exodus from n u r s i n g have been r e p o r t e d . R e s e a r c h s t u d i e s on t h e s u b j e c t i n B r i t i s h Columbia were s c a r c e and v e r y l i m i t e d . I n s t r u m e n t s used t o o b t a i n d a t a r e l e v a n t t o the ques-95 t i o n s asked by t h e s t u d y were M a r l e n e Kramer's I n t e g r a t i v e R o l e B e h a v i o r s c a l e and open-ended q u e s t i o n n a i r e . The open-ended q u e s t i o n n a i r e was d e v e l o p e d f o l l o w i n g a l i t e r a t u r e r e v i e w and i n f o r m a l i n t e r v i e w w i t h d i f f e r e n t p e o p l e i n v o l v e d i n n u r s i n g . The s t u d y sample c o n s i s t e d o f 17 B.S.N, g r a d u a t e s o f May 197 6, U n i v e r s i t y o f B r i t i s h C olumbia S c h o o l o f N u r s i n g who had answered b o t h q u e s t i o n n a i r e s and were w o r k i n g i n t h e hos-p i t a l s e t t i n g s . The q u e s t i o n n a i r e s were answered by t h e sample t w i c e : f i r s t a t g r a d u a t i o n t i m e , and second f o l l o w i n g employment i n t h e h o s p i t a l (September 197 6 ) . The d a t a c o l l e c t e d by q u e s t i o n n a i r e s ( T o o l and open-ended q u e s t i o n n a i r e ) were d e s c r i p t i v e l y a n a l y z e d . C h a r a c t e r i s t i c s o f t h e s t u d y sample were d e s c r i b e d and shown i n f r e q u e n c y d i s t r i -b u t i o n t a b l e s . The r o l e b e h a v i o r s of B.S.N.'s a t b o t h d e s i g n a t e d t i m e s were d e s c r i b e d by the M a r l e n e Kramer I n t e g r a t i v e R o l e Be-h a v i o r s c a l e . Data p e r t i n e n t t o d e t e r m i n a n t f a c t o r s i n d e v e l o p -ment o f r o l e b e h a v i o r were d e s c r i b e d . T a b l e s c o n t a i n i n g t h i s i n f o r m a t i o n were i n c l u d e d . The T. t e s t was used t o d e t e c t any s i g n i f i c a n t d i f f e r e n c e between r o l e b e h a v i o r s a t t h e two d e s i g -n a t e d t i m e s . The r e s u l t showed t h a t t h e r e was a s i g n i f i c a n t d e c r e a s e i n s e l e c t i o n o f p r o f e s s i o n a l r o l e b e h a v i o r upon employment i n t h e h o s p i t a l . The d a t a a l s o showed t h a t t h e r e were no s i g n i f i -c a n t d i f f e r e n c e s i n s e l e c t i o n o f b u r e a u c r a t i c and i n t e g r a t i v e r o l e b e h a v i o r s a t two d e s i g n a t e d t i m e s . However, a d e s c r i p t i v e a n a l y s i s o f r e s u l t s t e n d s t o i n d i c a t e t h e t r e n d o f change toward 96 s e l e c t i o n o f b u r e a u c r a t i c r o l e b e h a v i o r . Data r e v e a l e d t h a t B.S.N.'s own i d e a s about n u r s i n g and n u r s e ' s r o l e were the most i n f l u e n t i a l f a c t o r s i n t h e development of t h e i r r o l e . The B.S.N.'s i d e a s about n u r s e ' s r o l e were m o s t l y shaped o r i n f l u -enced by t h e i r n u r s i n g e d u c a t i o n , i n s t r u c t o r s and c l a s s m a t e s . Working as a n u r s e and a t t i t u d e s o f i n s t r u c t o r s d u r i n g n u r s i n g e d u c a t i o n were t h e second most i m p o r t a n t f a c t o r s i n h e l p i n g B.S.N.'s t o d e v e l o p t h e i r r o l e . The d a t a r e v e a l e d t h a t some concerned c o - w o r k e r s r e i n f o r c e d B.S.N.'s i d e a s about n u r s e ' s r o l e b u t t h e e f f e c t o f e d u c a t i o n a l f a c t o r s - i . e . a t t i t u d e s o f i n s t r u c t o r s , c o u r s e c o n t e n t and c l i n i c a l e x p e r i e n c e were more h e l p f u l and i n f l u e n t i a l . I I . C o n c l u s i o n The f i n d i n g s o f t h i s s t u d y p r o v i d e t h e f o l l o w i n g c o n c l u -s i o n s as t o where U n i v e r s i t y o f B r i t i s h Columbia g r a d u a t e s a re i n r e l a t i o n t o p r o f e s s i o n a l , b u r e a u c r a t i c , and i n t e g r a t i v e r o l e b e h a v i o r s . 1. The r e s u l t s i n d i c a t e t h a t s t u d e n t n u r s e s g r a d u a t e w i t h p r o f e s s i o n a l v a l u e o r i e n t a t i o n s b u t i t appears t h a t p r o f e s s i o n a l v a l u e s d i m i n i s h r a t h e r q u i c k l y when t h e y b e g i n t o p r a c t i c e n u r s i n g . D a v i s and O l e s e n 1 found t h a t t h e s c h o o l s o c i a l i z a t i o n p r o c e s s was i n s t r u m e n t a l t o some degree i n p r o m o t i n g t h e development o f p r o f e s s i o n a l o r i e n t a t i o n . I n t h e p r e s e n t s t u d y i t was found t h a t t h e s e l e c t i o n o f p r o f e s s i o n a l r o l e b e h a v i o r was s i g n i f i c a n t l y h i g h e r a t g r a d u a t i o n t i m e . I t can be c o n c l u d e d , t h e r e f o r e , t h a t ^F. D a v i s and V. O l e s e n , " B a c c a l a u r e a t e S t u d e n t s ' Images of N u r s i n g , " N u r s i n g R e s e a r c h , V o l . 13, No. 1 ( J a n u a r y - F e b r u a r y 1964), pp. 8-15. 97 the p r o b a b i l i t y i s very high that an aspirant nurse w i l l develop a high professional r o l e o r i e n t a t i o n during nursing education. The s i g n i f i c a n t decrease i n s e l e c t i o n of profes-sional role behavior upon employment tends to indicate that the B.S.N.'s are conforming to the p r e v a i l i n g norms and values of the h o s p i t a l to such an extent that they are losing the "professional values". This i s an alarming f a c t which must be noted because the discovery that school-bred values c o n f l i c t with work world values i s the cause of " r e a l i t y shock", 2 d i s i l -lusionment, 3 r o l e d e p r i v a t i o n , 4 and exodus from n u r s i n g . 5 ' 6 The r e s u l t s showed that B.S.N's were not completely unaware of the bureaucracy of work settings, and experienced i t during summer work i n the h o s p i t a l . Even so, i t s influence was Marlene Kramer, Reality Shock - Why Nurses Leave Nursing  Practice, Saint Louis: The C. V. Mosby Company, 19 74, p. 4. Ronald G. Corwin, Marvin J . Taves and J. Eugene Mass, "Professional Disillusionment," Nursing Research, Vol. 10, No. 3, (Summer 1961), p. 141. ^Ronald G. Corwin and Marvin J . Taves, "Some Concomi-tants of Bureaucratic and Professional Conceptions of the Nurse Role," Nursing Research, Vol. 11, No. 4, ( F a l l 1962), p. 225. 5Marlene Kramer and Constance Baker, "The Exodus: Can We Prevent I t ? , The Journal of Nursing Administration, Vol. 1, No. 3, (May-June 1971), pp. 15-29. 6Marlene Kramer, Some E f f e c t s of Exposure to Employing  Bureaucracies on the Role Conceptions and Role Deprivation of  Neophyte Co l l e g i a t e Nurses, unpublished d i s s e r t a t i o n , Stanford University, 1966, pp. 60-61. 98 ignored i n educational settings where professional functions of nursing were stressed. But employment i n the h o s p i t a l s e t t i n g caused the B.S.N.'s to r e a l i z e more intensely that the profes-s i o n a l ideas stressed i n school confront the bureaucratic p r i n -c i p l e s that operate i n the h o s p i t a l . As a r e s u l t , the B.S.N, had changed due to environmental demand, as shown i n t h i s study. The trend of change i n t h i s study was toward s e l e c t i o n of more 7 8 bureaucratic r o l e values as l i t e r a t u r e suggested. ' Data also reveals that during nursing education, B.S.N.'s have developed within t h e i r behavioral repertoire adaptive ways of responding to the resultant c o n f l i c t s , that i s , integrative r o l e behavior. However, i t seems that t h i s " a n t i c i -patory s o c i a l i z a t i o n " i s incomplete. That i s , the p r a c t i c a l r e a l i t y of bureaucracy i s completely r e a l i z e d only as the gradu-ate's career unfolds and she begins to play out her r o l e . In other words, i t i s af t e r employment i n the hos p i t a l that the B.S.N, tends to compromise more (as shown by higher score on integrative r o l e behavior) between the professional and bureaucratic role values. The questions which must be raised are to what extent these B.S.N.'s tend to compromise professional values i n favour of bureaucratic values?; i s presence of int e g r a t i v e r o l e behavior 7Fox, David J . Fundamentals of Research in Nursing. New York: Appleton-Century-Crofts, 19 66. 8 F r a n c i s , Roy G. and Stone, Robert C. Service and  Procedure in Bureaucracy. Minneapolis, University of Minnesota Press, 1956. 99 upon g r a d u a t i o n t h e r e s u l t o f n u r s i n g e d u c a t i o n o r summer work? A n o t h e r f a c t b r o u g h t t o l i g h t by t h e s e d a t a i s t h a t a l l t h r e e r o l e b e h a v i o r s appeared t o be i m m e d i a t e l y r e s p o n s i v e t o exposure t o b u r e a u c r a t i c work p r i n c i p l e s . The f o r e g o i n g d i s c u s s i o n t e n d s t o s u g g e s t t h a t t h e s e B.S.N.'s a r e c o n f r o n t e d w i t h t h e p r o f e s s i o n a l - b u r e a u c r a t i c c o n f l i c t upon employment i n the h o s p i t a l s . As a r e s u l t , t h e y have changed t h e i r n u r s e ' s r o l e b e h a v i o r . 2. The q u e s t i o n s e x a m i n i n g t h e d e t e r m i n a n t f a c t o r s t h a t h e l p e d t h e U n i v e r s i t y o f B r i t i s h Columbia B.S.N.'s t o d e v e l o p t h e i r r o l e , r e v e a l e d t h a t B.S.N.'s own i d e a s about n u r s i n g and n u r s e ' s r o l e were t h e most i n f l u e n t i a l f a c t o r s i n development o f t h e i r r o l e b e h a v i o r . The B.S.N.'s i d e a s about n u r s e ' s r o l e were m o s t l y shaped by: i d e a l i s t i c e d u c a t i o n ; h i g h e x p e c t a t i o n s from a p r o f e s s i o n a l n u r s e imposed on them d u r i n g e d u c a t i o n ; h u m a n i s t i c b e h a v i o r o f t h e i r i n s t r u c t o r s who were t h e i r r o l e models; and t h e i d e a l i s t i c c l i n i c a l e x p e r i e n c e . Data a l s o show t h a t t h e s e B.S.N.'s were i n f l u e n c e d by t h e a t t i t u d e s o f t h e co-wo r k e r s i n t h e h o s p i t a l . B u t i t was t h e a c t u a l p r a c t i c e , w o r k i n g as n u r s e s , t h a t was the second most i n f l u e n t i a l f a c t o r f o r B.S.N.'s t o d e v e l o p t h e i r r o l e . I t can be c o n c l u d e d t h e n , t h a t r o l e c o n c e p t i o n and development o f t h e r o l e a r e p r o d u c t s o f n o t o n l y t h e e d u c a t i o n a l program b u t a l s o t h e impact of p o s t - g r a d u a t e g j o b e x p e r i e n c e as su g g e s t e d by l i t e r a t u r e . G a r d e ner, L. and E l l i o t , A. Handbook o f S o c i a l P s y cho- l o g y . 2nd ed., V o l . 1, M a s s a c h u s s e t t s : Addison-Wesley Co., 1968. 100 The p o s i t i v e r e s p o n s e s of B.S.N.'s t o t h e i r n u r s i n g e d u c a t i o n program and t h e i r i n s t r u c t o r s , i n h e l p i n g and i n f l u e n c i n g t h e i r n u r s e ' s r o l e b e h a v i o r s t e n d s t o s u g g e s t t h a t p r o f e s s i o n a l n u r s i n g e d u c a t i o n i s a s t r o n g h o l d f o r the n u r t u r e o f human c l i e n t c e n t e r e d v a l u e s . On t h e o t h e r hand, some s t u d e n t s e x p r e s s e d t h e f a c t t h a t t h e i r e d u c a t i o n was u n r e a l i s t i c i n r e g a r d t o t h e demand a t work s e t t i n g s . T h i s r a i s e s t h e q u e s t i o n how t o implement t h e r e a l i t i e s o f work i n t h e " i d e a l " t y p e o f n u r s i n g e d u c a t i o n . The n e g a t i v e r e s p o n s e s t o t h e s e B.S.N.'s r e g a r d i n g t h e i r work s i t u a t i o n f o r p r a c t i c e o f i d e a l n u r s i n g c a r e , t e n d s t o s u g g e s t t h a t t h e h o s p i t a l s i n w h i c h t h e s e B.S.N.'s a r e w o r k i n g a r e n o t y e t p r e p a r e d f o r t h e i r q u a l i f i c a t i o n s . T h i s adds f u r t h e r s u p p o r t f o r t h e s u g g e s t i o n made e a r l i e r , i . e . t h e s e B.S.N.'s were e x p e r i e n c i n g p r o f e s s i o n a l -b u r e a u c r a t i c c o n f l i c t . I I I . I m p l i c a t i o n s I n C h a p t e r I , under t h e s e c t i o n on t h e S i g n i f i c a n c e and I m p l e m e n t a t i o n o f t h e R e s e a r c h Problem t o N u r s i n g , i t was p o i n t e d o u t t h a t B r i t i s h C olumbia e d u c a t o r s and h o s p i t a l a d m i n i -s t r a t o r s a l r e a d y may have m o d i f i e d c u r r i c u l u m and work o r g a n i z a t i o n t o c o u n t e r t h e " r e a l i t y shock" w h i c h n u r s i n g l i t e r a t u r e warned was o c c u r r i n g e l s e w h e r e . The r e s u l t o f t h i s s t u d y s u g g e s t s t h a t such m o d i f i c a t i o n s have n o t t a k e n p l a c e t o t h e e x t e n t o f p r e v e n t i n g p r o f e s s i o n a l - b u r e a u c r a t i c c o n f l i c t . T h e r e f o r e , i n B r i t i s h C o l u m b i a as e l s e w h e r e , t h e r e i s c o n t i n u i n g c h a l l e n g e t o d i r e c t o r s o f n u r s i n g e d u c a t i o n , t o n u r s i n g s e r v i c e a d m i n i s t r a t o r s and t o t h e B.S.N.'s i n v o l v e d i n c o n t i n u i n g t o f a c e t h e problem as t o how 101 education and service can each be oriented so that they form a united front to meet the challenge of health care for the benefit of the c l i e n t . In view of the findings of t h i s study, therefore, the following implications are made: 1. The fact that B.S.N.'s scored higher on professional role behavior upon graduation, and lower upon employment, and also the f a c t that they scored higher on integrative and bureau-c r a t i c role behavior following employment i n the h o s p i t a l tends to imply that the r o l e values taught to the University of B r i t i s h Columbia B.S.N.'s are i n c o n f l i c t with the p r i n c i p l e s valued by the hospitals i n B r i t i s h Columbia. Besides, data tend to suggest that the r e a l i t i e s of work are not introduced comprehensively to these B.S.N.'s during t h e i r education. The challenge for nurse educators i s not only to pre-pare nurses capable of responding to the continually evolving health care needs of society, but also to educate nurses to assume a functional r o l e within the present health care system. To do t h i s , d i f f e r e n t approaches such as "anticipatory s o c i a l i z a t i o n " , 1 0 "values t h e o r y , " l 1 and many others are suggested by l i t e r a t u r e . The more immediate action would be for f a c u l t i e s to know the r e a l world of work, and know the problems, deal with them and ideate about them during t h e i r teaching. Besides, more or less monitoring of "professional" nurses, andhhow they implement professional role 1 0Marlene Kramer, Reality Shock - Why Nurses Leave  Nursing Practice , Saint Louis: The C. V. Mosby Company, 197 4, p. 10. 1 1 L . E. Ruths, M. Harmin, and S. B. Simon, Values and Teaching, Columbus: Charles E. M e r r i l l , 1966. 102 b e h a v i o r s i n r e s p o n s e t o on-going s t r u c t u r a l and f u n c t i o n a l changes i n t h e h o s p i t a l s s h o u l d p r o v i d e t e a c h e r s w i t h u p - t o - d a t e r e a l i s t i c c o n c e p t s and p r a c t i c e o f n u r s i n g . Moreover, c o n t a c t w i t h t h e h o s p i t a l s can h e l p t h e e d u c a t o r s t o i d e n t i f y whether t h e h o s p i t a l s have v a l u e o r i e n t a t i o n s s i m i l a r t o t h o s e o f t h e e d u c a t i o n a l s e t t i n g s o r n o t , t h u s p r e p a r i n g t h e g r a d u a t e s f o r r e a l i t i e s o f work. I f t h i s i s done s u c c e s s f u l l y , t h e n u r s e c o u l d i n t e g r a t e b o t h p r o f e s s i o n a l b u r e a u c r a t i c v a l u e s i n t o t h e performance o f the j o b and would be a b l e t o f u n c t i o n w i t h o u t t h e d i s p a r a t e c o n f l i c t s o f t h e b u r e a u c r a t i c - p r o f e s s i o n a l systems. The n u r s i n g a d m i n i s t r a t o r s must make a d a p t a t i o n s i n the system t o accomodate t h e s e B.S.N.'s. The u t i l i z a t i o n o f a l l B.S.N.'s must be a t a l e v e l t h a t r e s u l t s i n good p a t i e n t c a r e a t l o w e s t p o s s i b l e c o s t . They, t o o , must a c q u a i n t t h e m s e l v e s w i t h the u p - t o - d a t e knowledge of n u r s i n g c a r e t a u g h t i n e d u c a t i o n a l s e t t i n g s and be p r e p a r e d f o r a c c e p t a n c e and u t i l i z a t i o n o f t h e s e B.S.N.'s. Fo r B.S.N.'s the c h a l l e n g e i s t o i d e n t i f y t h e p a r t i c u l a r a s p e c t o f t h e b u r e a u c r a t i c system t h a t f r u s t r a t e s them. They must be open and h o n e s t i n e x p r e s s i n g t h e i r f r u s t r a t i o n w i t h b o t h n u r s e e d u c a t o r s and n u r s e a d m i n i s t r a t o r s and seek q u i d a n c e when needed. These t h r e e groups must sh a r e t h e i r i d e a s and form a u n i t e d f r o n t i n o r d e r t o d e c r e a s e t h e p o s s i b i l i t y o f d i s c r e p a n c y between e d u c a t i o n and p r a c t i c e , and a l s o meet the c h a l l e n g e o f h e a l t h c a r e d e l i v e r y f o r t h e b e n e f i t o f the p a t i e n t . 103 2. Data showed t h a t B.S.N.'s i d e a s about n u r s i n g and n u r s e ' s r o l e were m o s t l y shaped d u r i n g t h e i r e d u c a t i o n . Data r e v e a l e d t h a t the m a j o r i t y of B.S.N.'s n o t o n l y v a l u e d t h e i r " i d e a l " a pproach o f t h e n u r s e e d u c a t i o n program b u t b e l i e v e d t h a t t h i s k i n d o f e d u c a t i o n gave them a b r o a d e r v i e w o f n u r s e ' s r o l e and shaped t h e i r i d e a s o f n u r s e ' s r o l e . Moreover, t h e i r i n s t r u c t o r s p l a y e d an i m p o r t a n t r o l e i n h e l p i n g them t o d e v e l o p t h e i r r o l e by " r o l e models" and h a v i n g h i g h e x p e c t a t i o n s about the r o l e o f a n u r s e . T h i s i m p l i e s t h a t t h e i d e a l t e a c h i n g about n u r s e ' s r o l e must be sought i n an e d u c a t i o n a l s e t t i n g . However, t h e n u r s e e d u c a t o r s must know and r e a l i z e t h e problems o f t h e r e a l w o r l d o f work and t h e o r i z e and t e s t h y p o t h e s e s from them, t h e r e f o r e , c o n t r i b u t e t o b u i l d i n g a b e t t e r w o r l d o f p r a c t i c e . B e s i d e s , s i n c e i n s t r u c t o r s a r e p l a y i n g such an i m p o r t a n t r o l e i n s h a p i n g t h e r o l e b e h a v i o r o f t h e i r s t u d e n t s , t h i s g i v e s t h e c h a l l e n g e t o them i n e d u c a t i o n a l s e t t i n g s t o be r e a l i s t i c and knowledgeable " r o l e models" f o r t h e i r s t u d e n t s . More c l i n i c a l e x p e r i e n c e must be i n c l u d e d i n the e d u c a t i o n a l program t o i n -c r e a s e the B.S.N.'s c o n f i d e n c e f o r s a f e n u r s i n g p r a c t i c e . Data show t h a t w o r k i n g as a n u r s e a f t e r g r a d u a t i o n was as h e l p f u l t o t h e s e B.S.N.'s as t h e i r i n s t r u c t o r s b e h a v i o r i n s h a p i n g t h e i r r o l e . However, t h e B.S.N.'s responded n e g a t i v e l y t o t h e s i t u a t i o n a t work s e t t i n g s . T h i s g i v e s t h e c h a l l e n g e t o the n u r s i n g s e r v i c e a d m i n i s t r a t o r s n o t o n l y t o p r o v i d e a w o r k i n g c o n d i t i o n t h a t t h e h i g h l y v a l u e d e d u c a t i o n of t h e s e B.S.N.'s can be u t i l i z e d , b u t a l s o t h a t the B.S.N.'s i d e a s about n u r s i n g and n u r s e ' s r o l e can be d e v e l o p e d . C e r t a i n l y i t i s a waste o f 104 t i m e , energy and n u r s i n g manpower whenever the B.S.N.'s a r e not a b l e t o p r a c t i c e what t h e y have l e a r n e d and v a l u e d d u r i n g t h e i r n u r s i n g e d u c a t i o n . IV. S u g g e s t i o n s The n a t u r e and development o f t h i s r e s e a r c h , w i t h i n i t s l i m i t s - t i m e and sample - i s n o t an e x t e n s i v e o v e r v i e w o f the macrocosm o f 53 U n i v e r s i t y o f B r i t i s h C olumbia B.S.N, g r a d u a t e s o f May 1976. The n a t u r e o f t h i s s t u d y was an i n t e n s i v e f o c u s on t h e q u a l i f y i n g sample who c o n s t i t u t e a c o n c e n t r a t e d microcosm o f t h e problem under s t u d y . The f i n d i n g s o f t h i s s t u d y , t h e r e f o r e , cannot be g e n e r a l i z e d f o r a l l B.S.N, g r a d u a t e s o f t h e U n i v e r s i t y o f B r i t i s h C o lumbia. The s t u d y r a i s e d many q u e s t i o n s w h i c h w a r r a n t f u r t h e r f o l l o w - u p . A. F u r t h e r R e s e a r c h I t i s s u g g e s t e d t h a t : 1. R e g a r d i n g t h e g e n e r a l n a t u r e o f t h e s t u d y , (a) a s i m i l a r s t u d y w i t h a l a r g e r number o f sample f o r a l o n g e r p e r i o d o f t i m e (e.g. s i x months) be co n d u c t e d ; (b) a b e t t e r method f o r d e t e r m i n i n g the r o l e b e h a v i o r s o f n u r s e s be used; (c) i n s t r u m e n t s f o r d a t a c o l l e c t i o n be p r e s e n t e d on a l a r g e r s c a l e . 2. R e g a r d i n g t h e s e l e c t i o n o f r o l e b e h a v i o r , q u e s t i o n s w h i c h r e q u i r e f u r t h e r i n v e s t i g a t i o n a r e : (a) what a r e t h e conse-quences o f r o l e changes?; (b) a r e t h e consequences s i m i l a r t o t h o s e r e p o r t e d by l i t e r a t u r e ? ; (c) t o what e x t e n t t h e B.S.N.'s a r e i n f o r m e d about t h e r e a l i t y o f work s e t t i n g 105 d u r i n g n u r s i n g e d u c a t i o n ? ; (d) i s the more exposure t o t h e b u r e a u c r a t i c work system t h e r e s u l t o f r o l e change?; (e) i s t h e r e a d i f f e r e n c e i n r o l e b e h a v i o r o f B.S.N.'s who have had p r e v i o u s work e x p e r i e n c e and t h o s e who have n o t ? 3. R e g a r d i n g t h e d e t e r m i n a n t f a c t o r s , t h e q u e s t i o n s w h i c h w a r r a n t f u r t h e r r e s e a r c h a r e : (a) i s t h e r e a r e l a t i o n s h i p between t h e s e l e c t i o n o f r o l e b e h a v i o r and d e t e r m i n a n t f a c t o r s ? ; (b) can t h e admired c h a r a c t e r i s t i c s and a t t r i b u t e s of t h e i n s t r u c t o r s ( " r o l e models") be i d e n t i f i e d i n t h e r o l e b e h a v i o r o f t h e m o d e l e r ? ; (c) does exposure t o work system r e s u l t i n change o f r o l e models? B. S u b s t a n t i v e C o n s i d e r a t i o n s As s t a t e d i n t h e i n t r o d u c t i o n o f t h i s t h e s i s (Chapter I , Page 7) i t was f e l t t h a t a s t u d y on r o l e b e h a v i o r o f B.S.N, n u r s e s g r a d u a t e d from t h e U n i v e r s i t y of B r i t i s h C o l u m b i a S c h o o l o f N u r s i n g w i l l p r o v i d e more i n s i g h t f o r the t r a i n i n g o f f u t u r e n u r s e s a t t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a S c h o o l o f N u r s i n g and f o r t h e u t i l i z a t i o n of B.S.N.'s i n t h e h o s p i t a l s t h r o u g h o u t B r i t i s h C o l u m b i a . S i n c e t h e f i n d i n g s s u g g e s t t h a t B r i t i s h C o l u m b i a has n o t escaped nor s o l v e d t h e problems p r e v a l e n t i n t h e l i t e r a t u r e o f Ch a p t e r 2, i t behooves t o a p p l y p r e v i o u s e x p e r i e n c e s t o t h e s i t u a -t i o n s h e r e and r e f l e c t on i t f o r i n s i g h t f u l s i g n i f i c a n c e . To do t h i s , may be i t i s n e c e s s a r y f i r s t t o d e t e r m i n e : 1. A t p r e s e n t how i m p o r t a n t i n B r i t i s h C o l u m b i a , i s the prime p o s i t i o n o f n u r s e e d u c a t o r and n u r s i n g s e r v i c e a d m i n i s t r a t o r t o i n f l u e n c e p r e s e n t o r f u t u r e p a t t e r n s o f n u r s i n g p r a c t i c e ? 106 2. 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" B a c c a l a u r e a t e E d u c a t i o n and P r o f e s s i o n a l P r a c t i c e , " N u r s i n g O u t l o o k , V o l . 15, (Janua r y 1967), pp. 50-52. Reeder, Mary K. " N u r s i n g P r a c t i c e : A S t u d e n t ' s P e r s p e c t i v e , " N u r s i n g C l i n i c s o f N o r t h A m e r i c a , V o l . 3, No. 1, (March 1968), pp. 135-142. Reinkemeyer, S i s t e r Agnes M. " I t Won't Be H o s p i t a l N u r s i n g , " A m e r i c a n J o u r n a l o f N u r s i n g , V o l . 68, No. 9, (September 1968), pp. 1936-1940. Reinkemeyer, S i s t e r Agnes M. "New Approaches t o P r o f e s s i o n a l P r e p a r a t i o n s , " N u r s i n g Forum, V o l . 9, No. 1, (1970), pp. 27-40. S c h m i t t , E d i t h . " T r a n s i t i o n From S t u d e n t t o Graduate," A m e rican J o u r n a l o f N u r s i n g , V o l . 67, No. 12, (December 1967), pp. 2573-2575. Seward, J o a n F. " P r o f e s s i o n a l P r a c t i c e i n a B u r e a u c r a t i c S t r u c t u r e , " N u r s i n g O u t l o o k , (December 1969), pp. 58-61. S i n g h , A m a r j i t . " A t t i t u d e s o f S t u d e n t s Towards N u r s i n g E d u c a t i o n C o u r s e s , " I n t e r n a t i o n a l J o u r n a l o f N u r s i n g S t u d i e s , V o l . 9, (1972), pp. 3-18. 113 S m i t h , D a v i d . " O r g a n i z a t i o n a l Theory and The H o s p i t a l , " J o u r n a l o f N u r s i n g A d m i n i s t r a t i o n , V o l . 11, No. 3, (May-June 1972), pp. 19-25. S m i t h , Dorothy M. " E d u c a t i o n and S e r v i c e Under One A d m i n i -s t r a t i o n , " N u r s i n g O u t l o o k , ( F e b r u a r y 1965), pp. 54-56. S m i t h , Dorothy M. "Some Problems of B a c c a l a u r e a t e Programs," Am e r i c a n J o u r n a l o f N u r s i n g , V o l . 70, No. 1, (J a n u a r y 1970), pp. 120-123. S m i t h , K a t h r y n M. " D i s c r e p a n c i e s I n The R o l e - S p e c i f i c V a l u e s o f Head Nurses and N u r s i n g E d u c a t o r s , " N u r s i n g R e s e a r c h , V o l . 14, No. 3, (Summer 1965), pp. 196-202. Thomas, L. " I s N u r s i n g S e r v i c e A d m i n i s t r a t i o n P r e p a r e d f o r t h e P r o f e s s i o n a l Nurse?" J o u r n a l o f N u r s i n g E d u c a t i o n , V o l . 4, No. 1, (1965), pp. 5-7. Waters, V. e t a l . " T e c h n i c a l and P r o f e s s i o n a l N u r s i n g ; An E x p l o r a t o r y Study," N u r s i n g R e s e a r c h , V o l . 21, No.. 2, ( M a r c h - A p r i l 1972), pp. 124-131. W o l f e , D. M. and Snoek, I . D. "A Study o f T e n s i o n s and A d j u s t -ment Under R o l e C o n f l i c t , " J o u r n a l o f S o c i a l I s s u e s , V o l . 18, (1962), pp. 102-121. Other B e n n i s , Warren. The Coming Death o f B u r e a u c r a c y . Notes and Quotes, C o n n e c t i c u t : G e n e r a l L i f e I n s u r a n c e Company, 1966. C o r w i n , R o n a l d G. R o l e C o n c e p t i o n and M o b i l i t y A s p i r a t i o n s : A Study I n the F o r m a t i o n and T r a n s f o r m a t i o n o f Bureau- c r a t i c , P r o f e s s i o n a l and H u m a n i t a r i a n N u r s i n g I d e n t i t i e s . U n p u b l i s h e d D o c t o r a l D i s s e r t a t i o n , U n i v e r s i t y o f M i n n e s o t a , 196 0. G l a s s , H e l e n P. E d u c a t i o n and S e r v i c e : A D e v e l o p i n g R e l a t i o n - s h i p . M a r i o n Woodward L e c t u r e , F r i d a y , November 15, 1974. Kramer, M a r l e n e . Some E f f e c t s of Exposure t o Emp l o y i n g Bureau- c r a c i e s on the R o l e C o n c e p t i o n s and R o l e D e p r i v a t i o n  o f Neophyte C o l l e g i a t e N u r s e s . U n p u b l i s h e d D o c t o r a l d i s s e r t a t i o n , S t a n f o r d U n i v e r s i t y , 1966. P a r k e r , Nora L. Survey of Graduates o f t h e U n i v e r s i t y o f T o r o n t o B a c c a l a u r e a t e Course i n N u r s i n g , S c h o o l o f N u r s i n g , T o r o n t o 5, O n t a r i o , 1968. The U n i v e r s i t y o f B r i t i s h C o l u m b i a , S i x t y - F i r s t S e s s i o n C a l e n d a r , Vancouver, B. C., 19 75. APPENDIX (A) L e t t e r o f I n t r o d u c t i o n p r e s e n t e d t o the sample. (B) F i r s t Q u e s t i o n n a i r e . (C) F o l l o w - u p l e t t e r accompanying second q u e s t i o n n a i r e . (D) Second q u e s t i o n n a i r e . Code Number Dear My name i s Mahnaz Farhang Mehr, and I am a graduate student of Nursing at the U n i v e r s i t y of B r i t i s h Columbia. I am conducting a survey about the opinions of BS.N. graduates i n regard to nurse's ro l e s and I would appreciate i t very much i f you would a s s i s t me i n my study. Your p a r t i c i p a t i o n would involve answering two sets of questionnaires, one now (upon your agreement for p a r t i -cipation) , and another three months l a t e r which w i l l be mailed to your address. You are asked to return i t to me in the stamped envelope enclosed. The questionnaire w i l l be coded with numbers to protect your i d e n t i t y . Your r e p l i e s w i l l be kept comple-t e l y anonymous and c o n f i d e n t i a l . No one w i l l see t h i s information except me. If you f e e l that you do not wish to p a r t i c i p a t e , please do not f e e l o b ligated. You are free to withdraw from the survey at any time. If you wish to know the r e s u l t , findings w i l l be av a i l a b l e to you upon completion of t h i s study. Thank you very much for your co-operation. Mahnaz Farhang Mehr 116 INSTRUCTIONS: The following pages c o n s i s t of 7 s i t u a t i o n s which leave the nurse at a point of d e c i s i o n . Several possible responses are given f o r each s i t u a t i o n . There are no i n c o r r e c t responses nor are a l l pos- s i b l e responses l i s t e d . A l l of the responses are actions that nurses have a c t u a l l y performed when confronted with these s i t u a t i o n s . Each of the 7 s i t u a t i o n s has from 4 to 10 s t a t e -ments des c r i b i n g p o s s i b l e nurse actions. Respond to each statement by placing a check (v/) i n the box at the r i g h t which most c l o s e l y describes the degree to which you would or would not take each acti o n . 9-1117 It is a hospital policy that patients must have written permission , to v i s i t on other floors and when doing this, they must be trans-ported within the hospital either on a stretcher or in a wheelchair. Mrs. Jean Roberts was admitted to your floor a week ago after an automobile accident in. which she and her husband were both injured. Mrs. Roberts has a fractured clavicle and i s now having physio-therapy. Mr. Roberts, admitted to another floor, has a fractered pelvis, hip and femur and i s to have surgery in the morning. Mrs. Roberts has her doctor's permission to v i s i t her husband but objects to using a wheelchair as she i s up and about as desired, and fears the wheelchair w i l l increase her husband's anxiety for her. You agree with her but there i s a hospital rule. YOUR EXTENT OF AGREEMENT WITH EACH OF THE FOLLOWING ACTIONS IS A. C a l l Mrs. Roberts' physician and discuss her concerns with him. Check with him that i t i s a l l right for Mrs. Roberts to walk to her husband's room. A B. Follow the hospital rule and have Mrs. Roberts use the wheelchair to v i s i t her husband. This i s a rule made for the benefit and safety of a l l arid i t should be followed. B C. Explain to Mrs. Roberts that you understand how she feels but she may become dizzy and/or faint, and i t would be unsafe for her to walk that far. Have her use the wheelchair. • c D. Have the orderly push Mrs. Roberts to Mr. Roberts' room in a wheelchair and then allow her to walk into his room. n E. Let Mrs. Roberts walk to her husband's room since i t i s more important to allay her hus-band's anxiety before surgery, than to uphold the hospital rule. E >--j IS id UJ cr o UJ a UJ -4 , J ) 2. You are a staff nurse on a surgical unit. The head nurse enjoys running her unit smoothly and e f f i c i e n t l y but seldom has contact with the patients. The other nurses on the unit vary i n their con-cern and care of the patients. Mrs. Smith who i s to have surgery in two days has been assigned to you. The surgery i s elective and Mrs. Smith appears prepared for the procedure. She i s an i n t e l l i g e n t person and verbally expresses an understanding of the purpose of her surgery. She has stated to you during your care that she w i l l have an indwelling catheter prior to surgery and she asks you when this i s to be done. You t e l l her that i t i s routine to insert catheters either the evening before or early in'the morning on the day of surgery. That afternoon Mr. Smith comes to the nursing station greatly dis-turbed. His wife has told him that she i s to have a tube inserted and he forbids this. In talking to Mr. Smith, you learn that Mr. Smith's mother had a tube inserted and she died two days lat e r . A. C a l l Mrs. Smiths' physician and discuss with him possible approaches you might use to a l -leviate the Smiths' anxiety. B. Check the procedure book for preparation of patients for surgery and follow the sugges-tions written there. B C. Chart your observations and conversation, and plan to spend more time with both Mr. and Mrs. Smith. Give them an opportunity to talk about the impending surgery, and what i t means to them. Q D. Sot up a team conference for that afternoon with the physician and the nurses on both the day and evening shifts to discuss the Smiths' concerns and possible approaches to them. n E . Report your concern about the conversation to your head nurse and use the solution suggested by her. E ^ / S UJ $ UJ W. vy UJ i*> uj uj UI UJ ^ 1*1 % vo ^ 3 co Q You arc a day staff nurse on a busy post partum floor. Perineal lamps are to bo routinely used shortly after the noon meal. This i s required and rtor,ired for many reasons: a) this is the most stable, undisturbed length of time during the s h i f t , b) i t i s before v i s i t i n g hours and after doctor rounds, and c) babiea are not due for feeding during this period. You question this routine because most of the mothers complain of the lack of a rest period. They are up early .in the morning for bathing and feed-ing procedures, and they continue to be busy u n t i l the noon meal. V i s i t i n g hours begin at two o'clock. You are concerned about the lack of oppor-tunity for the mothers to rest. You talk to your head nurse about this matter. She discusses with you the rationale for the time set for this procedure. You decide to accept the routine and follow i t through. YOUR EXTENT OF AGREEMENT WITH EACH OF THE FOLLOWING RATIONALES IS: 11:8 A. I t i s more important for the mothers to see the doctors, feed their babies, and complete . their treatment, than to have rest periods. B. Follow the routine because, in your judge-ment, i t v / i l l permit the best possible care to be given to the largest number of patients, C. For those mothers who do not object, you'll follow the routine. For those who appear to need extra rest, you'll break the routine and do the procedure at another time. D. The explanation of the supervisor was rea-sonable. Mature professional personnel should be s e l f - d i s c i p l i n e d and be able to work with one's superiors. E. This routine was decided upon by knowledge-able people and they know what i s best in this situation'. F. You are an employee of the hospital and i t i s only right that you follow certain p o l i -cies and rules. C O Id lb 5 -J 'u 4. The hospital has i n i t i a t e d a policy that the quantity of linens per private room be limited to two complete changes a day. The laundry has complained that an excess i s being used unnecessarily and the laundry i s overburdened to .a point of delaying scheduled replacement of supplies. The head nurse on days i s required to submit a request s l i p for the limited linen supply for each patient in the private rooms. Mr. Brown, who is recovering from a stroke that paralized his right side and i s reestablishing his dependency in self care and feeding, is known to be constantly s o i l i n g his top linens from s p i l l i n g food or drink as he attempts to feed himself. The two comp-lete linen changes per day do not f i t this patient's needs and the head nurse, in discussing this problem with the laundry supervisor, has re-ceived no satisfactory solution. To satisfy Mr. Brown's needs, the head nurse has been sending in linen orders for a l l private patients including those who are being discharged or transferred. Since they w i l l not require this much linen, the extra .supply can be used for Mr. Brown. You are in charge on the evening s h i f t . The laundry supervisor phones you to inquire about the discrepancy in your linen order. Your order does not " account for discharges or transfers. YOUR EXTENT OF AGREEMENT WITH EACH OF THE FOLLOWING ACTIONS IS: A. Give the laundry supervisor a thorough explan-ation of Mr. Brown's needs. If the supervisor asks about the discharged patients, t e l l her that you arc sure the head nurse's order is cor-rect as she knows the patients' needs very well./v| B. T e l l the laundry supervisor that in order to give good care to your patients, you need the order as submitted. If the order i s n ' t comp-letely f i l l e d , arrange with the nurses on other units to get some linens even though this pro-cedure i s against hospital rules. B C. T e l l the laundry supervisor that the quantity ordered i s correct except for two patients who were discharged that clay. Cancel their orders, c D. C a l l your nursing supervisor. Explain Mr.Brown's unusual needs for linen and the problem about the linen supply. Follow her suggestions. D VJ Vi) vi> V. V) UJ ^ <•< < Vi, 0 119 You are the evening charge nurse on a ten crib precmie unit. There has been a l o t of staff illnesses so that you are relieved for your evening meal by a float nurse. You have just returned from dinner and your r e l i e f i s turning the unit back, to you. While you were away, the med-surg supervisor who i s . r e l i e v i n g the regular super-visor on your floor, came by. She has l e f t two messages for you. The f i r s t message is that the pharmacy w i l l be closed for a two day period and you are to order a s u f f i c i e n t amount for-your unit for the period they w i l l be closed. The second message is that the supervisor, in checking the babies, noted that many of the infants were very red in the face and she thinks that you have the temperature in the incubators turned up too high. She turned a few of them down and says for you to turn the others down at least one degree. The r e l i e f nurse also reports that surgery has just returned Baby Jane after completing her exchange transfusion and that there i s a small amount of bleeding around the umbilicus. YOUR EXTENT OF AGREEMENT WITH EACH OF THE FOLLOWING ACTIONS IS: A. Order the drugs, doubling the amount requested on the l a s t order sheet. j B. Check the ward procedure manual for the sug-gested temperature setting and follow the directions stated there. E C. Continue with your other r e s p o n s i b i l i t i e s . If questioned by the supervisor, explain that you d i d not readjust the temperatures in the incubators because you checked the infants' body temperatures and the incuba-tor instructional manual, and the environ-mental temperature i s at the desired setting, c D. Call the supervisor and explain that the flushed skin of the preemies i s more re-lated to thin skin and lack of subcutaneous fat than temperature in the incubators. E E. Check the preemies temperature and the temp-erature i n the incubators. If in your judge-ment, the temperature setting i s correct, leave i t as i t i s . E F. C a l l the supervisor, and ask her advice on the care of a seeping umbilicus. Follow her suggestions. F G. Check the ward manual for the proper pro-cedure to use in the care of wound dressings, G H. Observe Baby Jane closely for any additional bleeding, or for bleeding from any other source. If no further bleeding occurs, assume that the bleeding i s i n c i s i o n a l , and apply a dry s t e r i l e dressing. H I. Call the doctor, report the infant's general condition and the spotted dressing. T e l l him that you have checked the infant's v i t a l signs and they are stabilized and that you w i l l notify him i f there i s any change in Baby Jane's condition. I J. Ignore the supervisor's order because you know your patients and their needs well, and you are a competent nurse. j lis UJ — * s — ' \u ft •a; ^  120 6. I t is general ward policy that a l l patients are to have a bath every day. One of your patients, Mrs. J. is a severe a r t h r i t i c who finds i t very painful to be bathed each day. She would rather have you s i t and l i s t e n to her talk about her son. You and Mrs. J. have reached an agreement wherein she w i l l have a complete bath every other day with hands and face only on the alternate days. Although you know from past experiences that the head nurse strongly disapproves of deviations from established ward routine, you discuss your plan with her as you are about to record i t on Mrs. J.'s care plan card. The head nurse indicates strong disapproval because she believes the ward policy should be followed and that a l l patients need a bath every day. YOUR EXTENT OF AGREEMENT WITH EACH OF THE FOLLOWING ACTIONS IS: A. At some appropriate time, t e l l the head nurse that you would l i k e to discuss this policy with the supervisor and see i f i t cannot be modified for some patients. B. Discuss your plan with Mrs. J.'s physician and ask him to write an order for Mrs. J. to have a bath only every other day. C. Go ahead with your care plan for Mrs. J. quietly and discreetly. Do what in your judgement is best for the patient. D. Follow the ward routine; gently bathe Mrs. J. every day. The head nurse has had a great deal of experience and she probably knows what is best. 1 I 1 7. You are a staff nurse i n Intensive Care Unit on nights. You have no-ticed that one of the other staff nurses (Miss Jarson) always seems to be s i t t i n g at the desk. Furthermore, when you pass her patients, they frequently make requests of you. Towards morning, you observe that one of Miss Jarson's patients i s un-usually pale and i s diaphoresing. You c a l l this to her attention; she checks the patient's blood pressure and finds i t to be 60/40. The physician is notified; he responds and the patient's condition i s re-stabilized. Afterward the physician expresses surprise that the blood pressure dropped so rapidly when according to the patient's chart, i t had been stabilized at 100/60 on the q h hour checks in the e a r l i e r part of the night. You know for a fact that Miss Jarson has not been taking the patient's blood pressure q h hour as ordered and charted. YOUR EXTENT OF AGREEMENT WITH EACH OF THE FOLLOWING ACTIONS IS: A. T e l l the physician that Miss Jarson had not been taking the patient's blood pressure during the night. B. Don't do anything right now, but later on t e l l Miss Jarson that you thought her nursing care was very inadequate and that i f this happens again, you intend to discuss i t with the head nurse. C. T e l l Miss Jarson that you are going to report her to the night supervisor and then do so. D. Talk to Miss Jarson right away. Urge her to . discuss with the physician what she has not done so that her omission w i l l not effect the physician's treatment plan. E. Watch Miss Jarson's patients closely after this, and see that they got good care cither by doing i t yourself or by t e l l i n g her at the time that something needs to be done. 1 $ IS Dear My name i s Mahnaz Farhang Mehr As you w i l l r e c a l l , i n May 1976 you have agreed to p a r t i c i p a t e i n a survey about the nurse's r o l e by answering two sets of questionnaires. Thank you very much for answering the f i r s t questionnaire i n the spring. I have already analyzed them and am encouraged by the answers you and your classmates provided. I look forward with great i n t e r e s t to receiving the feedback from the enclosed four part follow up question-n a i r e , (second questionnaire). I r e a l i z e you are probably s t i l l a very busy person and I w i l l do my very best to warrant your cooperation. I t i s my hope that a l l question-naires w i l l be returned as soon as f e a s i b l e for maximum data information. Together we may indeed make a worthwhile c o n t r i b u t i o n f o r future nursing education at U.B.C. and f o r nursing p r a c t i c e i n B r i t i s h Columbia. A reasonable deadline date must be October 20, 1976 i f I am to complete my th e s i s during the f a l l of 1976. Thank you very much f o r your cooperation. Yours s i n c e r e l y and g r a t e f u l l y , Mahnaz Farhang Mehr 122 INSTRUCTIONS: The f o l l o w i n g pages c o n s i s t o f 7 s i t u a t i o n s w h i c h l e a v e t h e n u r s e a t a p o i n t o f d e c i s i o n . S e v e r a l p o s s i b l e r e s p o n s e s a r e g i v e n f o r each s i t u a t i o n . T h ere a r e no i n c o r r e c t r e s p o n s e s n o r a r e a l l p o s - s i b l e r e s p o n s e s l i s t e d . A l l o f t h e r e s p o n s e s a r e a c t i o n s t h a t n u r s e s have a c t u a l l y p e r f o r m e d when c o n f r o n t e d w i t h t h e s e s i t u a t i o n s . Each o f t h e 7 s i t u a t i o n s has f r o m 4 t o 10 s t a t e -ments d e s c r i b i n g p o s s i b l e n u r s e a c t i o n s . Respond t o each s t a t e m e n t by p l a c i n g a check (v/) i n t h e box a t t h e r i g h t w h i c h most c l o s e l y d e s c r i b e s t h e d e g r e e t o w h i c h y o u w o u l d o r w o u l d n o t t a k e each a c t i o n . 0 1. It is a hospital policy that patients must have written permission < to v i s i t on other floors and when doing this, they must be trans-ported within the hospital either on a stretcher or in a wheelchair. Mrs. Jean Roberts was admitted to your floor a week ago after an automobile accident in which she and her husband were both injured. Mrs. Roberts has a fractured clavicle and i s now having physio-therapy. Mr. Roberts, admitted to another floor, has a fractered pelvis, hip and femur and is to have surgery in the morning. Mrs. Roberts has her doctor's permission to v i s i t her husband but objects to using a wheelchair as she i s up and about as desired, and fears the wheelchair w i l l increase her husband's anxiety for her. ^ ^ ^ L h e r b u t t h e r e i s a hospital rule! Y o u B C a l l Mrs. Roberts' concerns with him. all right for Mrs. room. husband's physician and discuss her Check with him that i t i s Roberts to walk to her Follow the hospital rule and have Mrs. Roberts use the wheelchair to v i s i t her husband. This is a rule made for the benefit and safety of a l l arid i t should be followed. C. Explain to Mrs. Roberts that you understand how she feels but she may become dizzy and/or faint, and i t would be unsafe for her to walk that far. Have her use the wheelchair. D. Have the orderly push Mrs. Roberts to Mr. Roberts' room in a wheelchair and then allow her to walk into his room. E. Let Mrs. Roberts walk to her husband's room since i t i s more important to allay her hus-band's anxiety before surgery, than to uphold the hospital rule. >-•J !N o ui U IB UJ UJ CI to cr o UJ Q 5t •3 UJ U) ^ <X B 2. Y o u are a sta f f nurse on a surgical unit. The head nurse enjoys running her unit smoothly and e f f i c i e n t l y but seldom has contact w i t h the patients. The other nurses on the unit vary in their con-cern and care of the patients. Mrs. Smith who i s to have surgery in two days has been assigned t o y o u . The surgery i s elective and Mrs. Smith appears prepared for t h e procedure. She i s an i n t e l l i g e n t person and verbally expresses an understanding of the purpose of her surgery. She has stated to y o u during your care that she w i l l have an indwelling catheter prior t o surgery and she asks you when this i s to be done. You t e l l her t h a t i t i s routine to insert catheters either the evening before or early i n the morning on the day of surgery. That afternoon Mr. Smith comes to the nursing station greatly d i s -turbed. His wife has told him that she i s to have a tube inserted and he forbids t h i s . In talking to Mr. Smith, you learn that Mr. ; Smith's mother had a tube inserted and she died two days later. YOUR PXTPMT 1 flT? flr,T>T?r*Mr'Mm t . T - r m r t ^ ~ — E A. C a l l Mrs. Smiths' physician and discuss with him possible approaches you might use to a l ->leviate the Smiths' anxiety. B. Check the procedure book for preparation of patients for surgery and follow the sugges-tions written there. C. Chart your observations and conversation, and plan to spend more time with both Mr. and Mrs. Smith. Give them an opportunity to talk about the impending surgery, and what i t means to them. D. Set up a team conference for that afternoon with the physician nnd the nurses on both the day and evening s h i f t s to discuss the Smiths' concerns and possible approaches to them. Report your concern about the conversation to your head nurso and use the solution suggested b y hnr. E $ UJ >- ^ UJ 9 Ul UJ ^ Ju vo CO C> Z I 3. You are a day staff nurse on a busy post partum floor. Perineal lamps are to be routinely used shortly after the noon meal. This is required and desired for many reasons: a) this is the most stable, undisturbed length of time during the s h i f t , b) i t is before v i s i t i n g hours and after doctor rounds, and c) babies arc not due for feeding during this pericd. You question thi3 routine because most of the mothers complain of the lack of a rest period. They are up early in the morning for bathing and feed-ing procedures, and they continue to be busy u n t i l the noon meal. V i s i t i n g hours begin at two o'clock. You are concerned about the lack of oppor-tunity for the mothers to rest. You talk to your head nurse about this matter. She discusses with you the rationale for the time set for this procedure. You decide to accept the routine and follow i t through. YOUR EXTENT OF AGREEMENT WITH EACH OF THE FOLLOWING RATIONALES IS: 124 B. I t i s more important for the mothers to see the doctors, feed their babies, and complete their treatment, than to have rest periods. Follow the routine because, in your judge-ment, i t w i l l permit the best possible care to be given to the largest number of patients, C. For those mothers who do not object, you'll follow the routine. For those who appear to need extra rest, ycu'11 break the routine and do the procedure at another time. D. The explanation of the supervisor was rea-sonable. Mature professional personnel should be s e l f - d i s c i p l i n e d and be able to work with one's superiors. E . This routine was decided upon by knowledge-able people and they knov; what i s best in this situation. You are an employee of the hospital and i t i s only right that you follow certain p o l i -cies and rules. -J UJ UJ lb •j 'a £2 F. 4. The hospital has i n i t i a t e d a policy that the quantity of linens per private room be limited to two complete changes a day. The laundry has complained that an excess i s being used unnecessarily and the laundry is overburdened to a point of delaying scheduled replacement of supplies. The head nurse on days i s required to submit a request s l i p for the limited linen supply for each patient in the private rooms. Mr. Brown, who is recovering from a stroke that paralized his right side and i s reestablishing his dependency in self care and feeding, i s known to be constantly soiling his top linens from s p i l l i n g food or drink as he attempts to feed himself. The two comp-lete linen changes per day do not f i t this patient's needs and the head nurse, in discussing this problem with the laundry supervisor, has re-ceived no satisfactory solution. To satisfy Mr. Brown's needs, the head nurse has been sending in linen ordars for a l l private patients including those who are being discharged or transferred. Since they w i l l not require this much linen, the extra supply can be used for Mr. Brown. You are in charge on the evening s h i f t . The laundry supervisor phones you to inquire about the discrepancy in your linen order. Your order does not account for discharges or transfers. YOUR EXTENT OF AGREEMENT WITH EACH OF THE FOLLOWING ACTIONS IS: A. Give the laundry supervisor a thorough explan-ation of Mr. Brown's needs. If the supervisor asks about the discharged patients, t e l l her that you are sure the head nurse's order is cor-rect as she knows the patients' needs very WC11.A| B. T e l l the laundry supervisor that in order to give good care to your patients, you need the order as submitted. If the order i s n ' t comp-letely f i l l e d , arrange with the nurses on other units to get some linens even though this pro-cedure is against hospital rules. B C. T e l l the laundry supervisor that the quantity ordered i s correct except for two patients who were discharged that day. Cancel "their orders, c D. C a l l your nursing supervisor. Explain Mr.Brown's unusual needs for linen and the problem about the linen supply. Follow her suggestions. D k V!) V) < <6 S -a . You are the evening charge nurse on a ten crib precraie unit. There has been a l o t of staff illnesses so that you are relieved for your < " evening meal by a float nurse. You have just returned from dinner and your r e l i e f i s turning the unit back to you. While you were away, the med-surg supervisor who i s . r e l i e v i n g the regular super-visor on your floor, came by. She has l e f t two messages for you. The f i r s t message is that the pharmacy w i l l bo closed for a two day period and you are to order a s u f f i c i e n t amount for-your unit for the period they w i l l be closed. The second message i s that the supervisor, in checking the babies, noted that many of the infants were very red in the face and she thinks that you have the temperature in the incubators turned up too high. She turned a few of them down and says for you to turn the others down at least one degree. The r e l i e f nurse also reports that surgery has just returned Baby Jane after completing her exchange transfusion and that there i s a small amount of bleeding around the umbilicus. YOUR EXTENT OF AGREEMENT WITH EACH OF THE FOLLOWING ACTIONS IS: A. Order the drugs, doubling the amount requested on the l a s t order sheet. ^ B. Check the ward procedure manual for the sug-gested temperature setting and follow the directions stated there. B C. Continue with your other r e s p o n s i b i l i t i e s . If questioned by the supervisor, explain that you did not readjust the temperatures in the incubators because you checked the infants' body temperatures and the incuba-tor instructional manual, and the environ-mental temperature i s at the desired setting, c D. C a l l the supervisor and explain that the flushed skin of the preemies i s more re-lated to thin skin and lack of subcutaneous fat than temperature in the incubators. n E . Check the preemies temperature and the temp-erature in the incubators. If in your judge-ment, the temperature setting i s correct, leave i t as i t i s . E F. C a l l the supervisor, and ask her advice on the care of a seeping umbilicus. Follow her suggestions. . F G. Check the ward manual for the proper pro-cedure to use in the care of wound dressings, G H. Observe Baby Jane closely for any additional bleeding, or for bleeding from any other source. If no further bleeding occurs, assume that the bleeding i s i n c i s i o n a l , and apply a dry s t e r i l e dressing. H I. Call the doctor, report the infant's general condition and the spotted dressing. T e l l him that you have checked the infant's v i t a l signs and they are stabilized and that you w i l l notify him i f there i s any change in Baby Jane's condition. I J. Ignore the supervisor's order because you know your patients and their needs well, and you are a competent nurse. J UJ Ua 126 6. It i s yeneral ward policy that a l l patients are to have a bath overy day. One of your patients, Mrs. J. is a severe a r t h r i t i c who finds i t very painful to be bathed.each day. She would rather have you s i t * and l i s t e n to her talk about her son. You and Mrs. J. have reached an agreement wherein she w i l l have a complete bath every other day with hands and face only on the alternate days. Although you know from past experiences that the head nurse strongly disapproves of deviations from established ward routine, you discuss your plan with-her as you are about to record i t on Mrs. J.'s care plan card. The head nurse indicates strong disapproval because she believes the ward policy should be followed and that a l l patients need a bath every day. YOUR EXTENT OF AGREEMENT WITH EACH OF THE FOLLOWING ACTIONS IS: A. At some appropriate time, t e l l the head nurse that you would l i k e to discuss this policy with the supervisor and see i f i t cannot be modified for some patients. B. Discuss your plan with Mrs. J.'s physician and ask him to write an order for Mrs. J. to have a bath only every other day. C. Go ahead with your care plan for Mrs. J. quietly and discreetly. Do what in your judgement i s best for the patient. D. Follow the ward routine; gently bathe Mrs. J . every day. The head nurse has had a great deal of experience and she probably knows what i s best. Is M § t 1 Uj 1 ! 1 X U/ SIS ^ s 7. You are a staff nurse i n Intensive Care Unit on nights. You have no-ticed that one of the other staff nurses (Miss Jarson) always seems to be s i t t i n g at the desk. Furthermore, when you pass her patients, they frequently make requests of you. Towards morning, you observe that one of Miss Jarson's patients i s un-usually pale and is diaphoresing. You c a l l this to her attention; she checks the patient's blood pressure and finds i t to be 60/40. The physician is notified; he responds and the patient's condition i s re-stabilized. Afterward the physician expresses surprise that the blood pressure dropped so rapidly when according to the patient's chart, i t had been stabilized at 100/60 on the q h hour checks i n the e a r l i e r part of the night. You know for a fact that Miss Jarson has not been taking the patient's blood pressure q \ hour as ordered and charted. YOUR EXTENT OF AGREEMENT WITH EACH OF THE FOLLOWING ACTIONS IS: A. T e l l the physician that Miss Jarson had not been taking the patient's blood pressure during the night. B. Don't do anything right now, but later on t e l l Miss Jarson that you thought her nursing care was very inadequate and that i f this happens again, you intend to discuss i t with the head nurse. C. T e l l Miss Jarson that you are going to report her to the night supervisor and then do so. D. Talk to Miss Jarson right away. Urge her to discuss with the physician what she has not done so that her omission w i l l not effect the physician's treatment plan. E . Watch Miss Jarson's patients closely after this, and see that they get good care either by doing i t yourself or by t e l l i n g her at the time that something needs to be done. 1 V* 8. i § s *5 -"vi PART II This section deals with some information about your present work. Please answer every question. 1. Are you working now? a . No b . Yes 2. If yes, for how long? a . One month b . Two months c. Three months d. Other Please specify 3. Please check the closest description to the hospital you are working now. a . Less than 100 beds b . Between 101-200 beds c. Between 201-500 beds d. More than 500 beds 4. Please check your position in the hospital. a . Staff Nurse b . Team Leader c. Assistant Head Nurse d. Head Nurse e . Supervisor f. Other Please specify 5. Please check the c l i n i c a l f i e l d in'which you work. a . Medical b . Surgical c. Psychiatry d. Obstetrics e . Pediatrics • f. Geriatrics, extended care g. Hospital c l i n i c s h. Other Please specify If a speciality within one of the above (eg. I.C.U.) please specif y 6. Where i s the location of the hospital? a . In a large c i t y , eg. Vancouver, Victoria b . In a smaller c i t y , eg. Kamloops, Nanaimo c. In a small town. d. Other Please specify 0 PART III The following are questions which are designed to identify the ; :. factors which you may consider helpful in developing your role as a nurse. Please answer every question with a brief explanation. - Background factors refers to your orig i n a l decision to become a nurse. - Factors related to the educational setting refers to U.B.C. School of Nursing. - Factors related to work setting refers to the hospital in which you are employed. SECTION A. BACKGROUND FACTORS 1. At what age did you decide to become a nurse? 2. What were the major influences in your decision to become a nurse? (eg. family encouragement, teacher, friends, personal experience, etc.) 3. At the time you enrolled i n the nursing education program did you have what you would now consider adequate knowledge of the role of the nurse? How did you acquire the information you had? (eg. guidance courses, career days, friends, etc.) SECTION B. EDUCATIONAL FACTORS 1. In what way, was your nursing education helpful in developing your own perception and image of nursing? 2. In what way do you consider your nurse education program had an influence on the achievement of nursing role behavior? 3. How has your nursiny education introduced you to your duties and responsibilities? 4. What do you think were the special strengths or weakness of your, basic education in terms of introducing you to your role? Weakness: Strengths: 5. How did faculty members' expectations of the role of the profes-sional nurse affect your ideas about your role as a nurse? 6. What behaviors of your instructors, i f any, have helped you to develop your own role as a nurse? 7. How did the attitudes, and beliefs of your classmates about nursing help you to understand the role of the nurse? 8. Which nursing courses, i f any, in your education influenced the development of your role? (please specify courses and suggest their influence) 9. How did c l i n i c a l experience influence your ideas about the nurses role? 10. Do you f e c i that the program at U.B.C. prepared you for what i s expected of you in your work? If yes, did you find s i m i l a r i t y of expectation between your education and practice? If no, how i s i t different? SECTION C. WORK SETTING 1. In what way, has working as a nurse in the hospital changed your ideas about the nurse's role? In what way, did working as a nurse reinforce your image of the nurse's role? 2. What factor(s) in the hospital, i f any, were important in f a m i l i a r i -zation with your responsibilities? (eg. orientation, job description, inservice education, etc.) In what way, do you consider the factors (you mentioned above) influenced your role as a nurse? 3. In your work setting who, i f any, has reinforced or has changed your ideas of the nurse's role? 0 131 PACT IV The following are factors which you may consider to be helpful for developing your present role as a nurse. Please rank them from 1 to 10 i n order of significance to you. The most helpful _1 The least helpful 10 Beliefs about nursing before entering nursing school. Encouragement of family, friends, or counsellor. Attitude of instructors during nursing education. Classmates beliefs and ideas about nursing. Course content of nursing program. C l i n i c a l experience during nursing education. Working as a nurse. Job description, orientation program, inservice education in the hospital. Attitude of other nurses i n the work setting.' Your own ideas about nursing and nurse's role. 

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