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The development of an instrument to measure the professional role attitudes of diploma nursing students Peregrym, Elinor Jill 1983

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THE DEVELOPMENT OF AN INSTRUMENT TO MEASURE THE PROFESSIONAL ROLE ATTITUDES OF DIPLOMA NURSING STUDENTS By ELINOR JILL PEREGRYM .S.N., The University of B r i t i s h Columbia, 1976 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING in THE FACULTY OF GRADUATE STUDIES (School of Nursing) We accept t h i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA October 1983 (c) E l i n o r J i l l Peregrym, I 9 8 3 In presenting t h i s thesis i n p a r t i a l f u l f i l m e n t of the requirements for an advanced degree at the University of B r i t i s h Columbia, I agree that the Library s h a l l make i t f r e e l y available for reference and study. I further agree that permission for extensive copying of t h i s thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. I t i s understood that copying or publication of t h i s thesis for f i n a n c i a l gain s h a l l not be allowed without my written permission. Department of NURSING The University of B r i t i s h Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date October 6 , 1983 DE-6 (3/81) ABSTRACT The purpose of t h i s study was to develop and t e s t an instrument that would measure the p r o f e s s i o n a l r o l e a t t i t u d e s of diploma n u r s i n g students. A L i k e r t s cale was constructed to f u l f i l l the above purpose. Items were designed to address the f o l l o w i n g s i x c h a r a c t e r i s t i c s of p r o f e s s i o n a l n ursing e x t r a c t e d from the l i t e r a t u r e : commit-ment to education, s e r v i c e o r i e n t a t i o n , autonomy, p a r t i c i p a -t i o n i n the p r o f e s s i o n a l a s s o c i a t i o n , a c c o u n t a b i l i t y , and expectation of appropriate remuneration. The items were c r i t i q u e d by a panel of n u r s i n g i n s t r u c t o r s and r e v i s e d p r i o r to a d m i n i s t r a t i o n . The o r i g i n a l instrument, which c o n s i s t e d of 60 items, was completed by 407 diploma n u r s i n g students from k schools of nursing i n B r i t i s h Columbia. On the b a s i s of the c o r r e l a -t i o n of each item w i t h the t o t a l score, kO items were s e l e c t e d f o r the f i n a l instrument i n the study. Data a n a l y s i s i n d i c a t e d that the instrument r e q u i r e s r e v i s i o n before i t w i l l be s u i t a b l e f o r use. Two of the items were found to be ambiguous, and a number of others were found to be i n s u f f i c i e n t l y d i s c r i m i n a t i n g . The r e l i a b i l i t y index f o r the f i n a l instrument was high enough to be considered acceptable f o r use i n b a s i c research on groups. Although the r e s u l t s of f a c t o r a n a l y s i s were i n c o n c l u s i v e , i t was found t h a t , w i t h the exception of education and accountability, items did not cluster i n accordance with the six c h a r a c t e r i s t i c s of professional nursing extracted from the l i t e r a t u r e . Factor analysis also suggested that the concept of professional attitudes might be too broad to measure i n one homogeneous scale. Content v a l i d i t y was considered to be inherent i n the methods employed f o r instrument construction. TABLE OF CONTENTS ABSTRACT i i LIST OF TABLES v i i ACKNOWLEDGEMENTS v i i i CHAPTER I INTRODUCTION 1 Rationale f o r the Study 1 Statement of the Problem 3 Purpose of the Study 4 De f i n i t i o n of Terms 4 Limitations 5 II REVIEW OF THE LITERATURE 7 Overview 7 Theoretical Framework 8 Studies of Professional S o c i a l i z a t i o n from the F i e l d s of Psychology and Sociology 14 Role Acquisition 14 Role C o n f l i c t 19 Studies of Professional S o c i a l i z a t i o n That Focus on the Health Professions ... 23 Professional S o c i a l i z a t i o n in Nursing .... 27 Role Acqui s i t i o n 27 Role C o n f l i c t 33 Professionalism and Nursing 36 The Measurement of Attitudes 41 Summary and Implications f o r the Current Study 44' i v V CHAPTER I I I METHODOLOGY . . . 46 O v e r v i e w , 46 Deve lopment o f the O r i g i n a l I tem P o o l 47 N a t u r e o f the S t a t e m e n t s 47 Number o f I tems 47 Number o f S t e p s on the S c a l e 48 V a l i d i t y 49 S e l e c t i o n o f the Sample 52 P r o c e d u r e f o r D a t a C o l l e c t i o n . . . '54 S t a t i s t i c a l P r o c e d u r e s 55 S c o r i n g 55 I t e m E l i m i n a t i o n and R e t e n t i o n . . . . 55 R e l i a b i l i t y 57 F a c t o r A n a l y s i s 58 S i g n i f i c a n c e L e v e l 59 Demograph ic D a t a 59 IV PRESENTATION AND DISCUSSION OF FINDINGS 60 D e s c r i p t i o n o f the Sample 60 I t em A n a l y s i s 64 I n t e r p r e t a t i o n D i f f i c u l t y 64 V a r i a n c e 64 C o r r e l a t i o n o f I n d i v i d u a l I tems w i t h t he T o t a l S c o r e 67 I t em E l i m i n a t i o n . 69 R e l i a b i l i t y 70 v i CHAPTER Facto r A n a l y s i s 70 V a l i d i t y 75 Summary 75 V SUMMARY AND CONCLUSIONS, IMPLICATIONS AND RECOMMENDATIONS 78 Summary and Conclusions 78 I m p l i c a t i o n s f o r Nursing Education 80 Recommendations f o r Further Research ... 81 BIBLIOGRAPHY '83 APPENDICES A I n t r o d u c t i o n to the Research Instrument 91 B O r i g i n a l Instrument 93 C F i n a l Instrument 102 D R e l a t i o n s h i p of Items i n the F i n a l Instrument to P r o f e s s i o n a l C h a r a c t e r i s t i c s I d e n t i f i e d i n the L i t e r a t u r e 108 E Demographic Data Questionnaire 110 LIST OF TABLES TABLE I Table of Spec i f i c a t i o n s f o r Content Sampling 51 II Relationship of Items i n the Or i g i n a l Instrument to Professional C h a r a c t e r i s t i c s I d e n t i f i e d i n the Liter a t u r e 53 III Composition of the Sample According to School of Nursing (N=407) 6l IV Composition of the Sample According to Age, Sex, and Pre-Nursing School Education (N=40?) 62 V Composition of the Sample According to Pre-Nursing School Employment i n Health Care Agencies (N=40?) 63 VI Number of Students Indicating Interpretation, D i f f i c u l t y for Items In the Ori g i n a l Instrument (N=407) . . . . . . 65 VII Variance of Items i n the Or i g i n a l Instrument (N=407) 66 VIII Correlation of Individual Items with the Total Score of the Original Instrument (N=407) 68 IX Item Clusters I d e n t i f i e d by Factor Analysis (N=407) 71 X Relationship of Items i n the F i n a l Instrument to Professional C h a r a c t e r i s t i c s I d e n t i f i e d i n the Liter a t u r e 109 v i i ACKNOWLEDGEMENTS Sincere a p p r e c i a t i o n i s extended to the members of my t h e s i s committee, C a r o l J i l l i n g s , chairman, and Dr. Margaret Campbell, f o r the i n v a l u a b l e advice which r e f l e c t e d t h e i r knowledge and e x p e r t i s e , f o r t h e i r e d i t o r i a l comments, and f o r t h e i r patience w i t h the t r i a l s of long distance communication. I wish to thank the a d m i n i s t r a t i o n and nursing f a c u l t y of B r i t i s h Columbia I n s t i t u t e of Technology, Okanagan Colle g e , S e l k i r k C o l l e g e , and Vancouver Community C o l l e g e , f o r a l l o w i n g me access to t h e i r nursing students. G r a t e f u l l y acknowledged i s the w i l l i n g p a r t i c i p a t i o n of the nursing students who completed my research instrument; without t h e i r cooperation t h i s study would not have been p o s s i b l e . To the f o l l o w i n g nursing i n s t r u c t o r s , who devoted con-s i d e r a b l e time and thought to c r i t i q u i n g the items f o r my a t t i t u d e s c a l e , I owe s p e c i a l g r a t i t u d e : C l a i r e Budgen, Do r i s Callaghan, Judy McAulay, L e s l i e McCreary, C a r o l McFadyen, Margaret P e r r y , G a i l Prowse, and Mohammed R a j a b a l l y from Okanagan Co l l e g e ; arid Sandra F o s t e r , Margaret N i c k l e , . L o u i s e l l e O u e l l e t , and Kathleen Pinckney from S e l k i r k College. For the sharing of t h e i r computer know-how I am indebted to John Breckenridge and Ri c h a r d H a l l e t t of S e l k i r k C o l l e g e . The time and f i n a n c i a l a s s i s t a n c e r e q u i r e d f o r t h i s study were granted by S e l k i r k College i n the form of a s i x -month a s s i s t e d leave from my p o s i t i o n . v i i i CHAPTER I INTRODUCTION Rationale f o r the Study Nursing i s currently embroiled in a drive for pro-f e s s i o n a l i z a t i o n ; t h i s commitment stems from the f a c t that nursing has not yet gained universal recognition and accep-tance as a profession. In terms of c r i t e r i a f o r profession-alism, nursing has "been assessed "by S c h l o t f e l d t (1981) as weak, directed and controlled by others, and unclear about i t s fundamental mission (pp. 2 9 6 - 2 9 7 ) . I t i s c r u c i a l that nursing, as an aspiring profession, make a coordinated and concerted e f f o r t to change t h i s s i t u a -t i o n . Such change w i l l come about only i f nurses who are tr u l y professional assert t h e i r b e l i e f s and values by functioning as agents f o r change (Schlotfeldt, I98I, p. 2 9 6 ) . Professional s o c i a l i z a t i o n of nurses i s accomplished primarily by formal nursing education programmes (Watson, I98I, p. 1 9 ) . Watson (I98I) and D.alme (I983) hold nursing education account-able for the s o c i a l i z a t i o n of nursing students into the values of the profession. Given that professional s o c i a l i z a t i o n constitutes a legitimate and important goal f o r nurse-educators, i t follows that nursing f a c u l t y are required to encourage i n th e i r 1 2 students the development of p r o f e s s i o n a l a b i l i t i e s , a t t i t u d e s , and other c h a r a c t e r i s t i c s (Jacox, 1978, p. 1 8 ) . I t a l s o seems l o g i c a l t h a t n u r s i n g f a c u l t y need some means of assessing student achievement of o b j e c t i v e s r e l a t e d to p r o f e s s i o n a l i s m . There i s v i r t u a l l y unanimous agreement i n the l i t e r a t u r e on p r o f e s s i o n a l s o c i a l i z a t i o n that a t t i t u d e s and values com-p r i s e a major component of any p r o f e s s i o n a l r o l e ; t h e r e f o r e , an instrument which measures p r o f e s s i o n a l a t t i t u d e s of n u r s i n g students would appear to have s i g n i f i c a n t worth. Ward and F e t l e r (1979) i n c l u d e i n t h e i r anthology of research instruments a number of instruments which measure pro-f e s s i o n a l a t t i t u d e s and which are designed to be administered to nursing students, graduate nurses, and/or other h e a l t h p r o f e s s i o n a l s . For various reasons these instruments are considered by the i n v e s t i g a t o r to be u n s u i t a b l e f o r the purpose of t h i s i n q u i r y . Corwin's Nursing Role Conception Scale (Ward & F e t l e r , 1979. PP- 413-424) was developed i n I 9 6 0 , before the widespread acceptance of two major profes-s i o n a l i s m - r e l a t e d concepts--namely, the n u r s i n g process and the use of a conceptual model f o r n u r s i n g as the b a s i s f o r nursing p r a c t i c e (Adam, I 9 8 O , p. v i i ; Canadian Nurses A s s o c i a -t i o n , 1 9 8 0 ) . H i s instrument, t h e r e f o r e , does not address these concepts. A f u r t h e r disadvantage of h i s t o o l i s t h a t the concept of s e r v i c e i s measured s e p a r a t e l y from t h a t of p r o f e s s i o n a l i s m , despite the f a c t that an a l t r u i s t i c , s e r v i c e o r i e n t a t i o n i s widely accepted as a c h a r a c t e r i s t i c of 3 p r o f e s s i o n a l i s m . This concern i s supported "by Minehan ( 1 9 7 7 ) . who conducted an a n a l y s i s of Corwin's scale as part of a p r o j e c t f o r developing a contemporary, corresponding instrument. S i g n i f i c a n t i n t e r i t e m c o r r e l a t i o n s were found w i t h i n the p r o f e s s i o n a l and s e r v i c e s c a l e s . F a c t o r a n a l y s i s revealed f o u r major dimensions to the s c a l e , r a t h e r than the three which the instrument was designed to measure. Minehan's f i n d i n g s , however, must be i n t e r p r e t e d w i t h caution because of the very small sample s i z e f o r her study (48). P i e t a ' s 1976 m o d i f i c a t i o n and modernization of Corwin's scale (Ward & F e t l e r , 1 9 7 9 , pp. 4 2 5 - 4 3 9 ) shares some of the same drawbacks. V a i l l o t ' s P r o f e s s i o n a l i z a t i o n S c a l e s , developed i n 1962 (Ward & F e t l e r , 1 9 7 9 , pp. 5 9 2 - 5 9 9 ) , i s very complex and a l s o outdated. The H e a l t h Care P r o f e s s i o n a l A t t i t u d e Inventory, developed by Stone and Knopke i n 1976 (Ward & F e t l e r , 1 9 7 9 , PP- 1 7 7 - 1 8 2 ) , r e q u i r e s respondents to make s o p h i s t i c a t e d , e v a l u a t i v e d e c i s i o n s about broad concepts r e l a t e d to the American h e a l t h care system i n general. Because of the current d r i v e toward the p r o f e s s i o n a l i z a -t i o n of n u r s i n g , and the l a c k of p r o f e s s i o n a l a t t i t u d e i n s t r u -ments deemed s u i t a b l e f o r the purpose of t h i s work, the development of an instrument of t h i s nature seems p r o p i t i o u s . Statement of the Problem Nursing i s c u r r e n t l y embroiled i n a d r i v e f o r p r o f e s -s i o n a l i z a t i o n . A major r e s p o n s i b i l i t y of n u r s i n g educators i s to f a c i l i t a t e the s o c i a l i z a t i o n of n u r s i n g students i n t o 4 the p r o f e s s i o n a l r o l e . Since values and a t t i t u d e s c o n s t i t u t e a major component of p r o f e s s i o n a l i s m , some means of assess-i n g the p r o f e s s i o n a l r o l e a t t i t u d e s of nu r s i n g students i s a necessary component of curriculum e v a l u a t i o n . At present there i s a l a c k of appropriate, r e l i a b l e instruments f o r assessing the p r o f e s s i o n a l r o l e a t t i t u d e s of nursing students. Purpose of the Study The purpose of the study was to develop and p r e - t e s t an instrument which measures the p r o f e s s i o n a l r o l e a t t i t u d e s of diploma n u r s i n g students. The s p e c i f i c o b j e c t i v e s were: (a) to develop an i n s t r u -ment f o r the above purpose that would be easy to administer, (b) to estimate r e l i a b i l i t y of the instrument, and (c) to develop as v a l i d an instrument as p o s s i b l e w i t h i n the time and f i s c a l r e s t r a i n t s of the study. D e f i n i t i o n of Terms The f o l l o w i n g terms are defined as they are used i n t h i s study: NORM: A r u l e or standard which guides behaviour. (Adapted from Hardy, 1978a, p. 3) OPINION: An expressed a t t i t u d e . (Katz, c i t e d i n Hinshaw, 1978, p. 275) PROFESSION: An occupational group that: (a) possesses a body of s p e c i a l i z e d knowledge and s k i l l s , and i s committed to continuing l e a r n i n g and s c h o l a r l y , s c i e n t i f i c methods of i n v e s t i g a t i o n ; (b) i s 5 organized i n t e r n a l l y and i s s e l f - r e g u l a t i n g ; (cj maintains s p e c i a l education centres; (d) i s a l t r u i s t i c i n o r i e n t a t i o n ; (e) seeks sanction to p r a c t i c e through l i c e n s i n g or c e r t i f i c a t i o n ; . (f) emphasizes i n d i v i d u a l r e s p o n s i b i l i t y through i n t e r n a l i z e d norms; and (g) i s o r i e n t e d to autono-mous p r a c t i c e , w i t h c o n t r o l of i t s f u n c t i o n s i n the work s e t t i n g . (Adapted from Jacox, 1978, p. 10; Kramer, 1966, p. 4) PROFESSIONAL SOCIALIZATION: The process of i n t e r n a l i z i n g the values and a t t i t u d e s , and l e a r n i n g the knowledge and s k i l l s r e q u i r e d to enact a p a r t i c u l a r pro-f e s s i o n a l r o l e . (Adapted from Hinshaw, 1978, p. 276) REFERENCE GROUP: Any group to which a person r e l a t e s h i s a t t i t u d e s , or any group that i n f l u e n c e s h i s a t t i t u d e s . (Lum, 1978, p. 138) ROLE: A set of expectations impinging on an incumbent of a s o c i a l p o s i t i o n . (Thornton & N a r d i , 1975f P- 872) ROLE AMBIGUITY: A c o n d i t i o n i n which e x i s t i n g r o l e expecta-t i o n s are vague, i l l - d e f i n e d , or unclear. (Hardy, 1978b, p. 81) ROLE ATTITUDE: The readiness, tendency, or set of a r o l e enactor to act or react to some s o c i a l object or event i n a p a r t i c u l a r way. Role a t t i t u d e s are i n d i c a t o r s of und e r l y i n g values. (Adapted from Hinshaw, 1978, p. 277) ROLE CONFLICT: A c o n d i t i o n i n which e x i s t i n g r o l e expecta-t i o n s are c o n t r a d i c t o r y or mutually e x c l u s i v e . (Hardy, 1978b, p. 81) ROLE ENACTOR: A person who holds a s o c i a l p o s i t i o n . VALUE: An idea h e l d i n common by members of a s o c i a l s t r u c t u r e that guides the i d e n t i f i c a t i o n and p r i o r i t i z i n g of goals or o b j e c t i v e s . ( S c o t t ; c i t e d i n Hinshaw, 1978, p. 275) L i m i t a t i o n s 1. The instrument developed f o r t h i s study i s a s e l f - r e p o r t measure of a t t i t u d e s ; t h i s type of instrument 6 i s " l i m i t e d to what i n d i v i d u a l s know about t h e i r a t t i t u d e s and are w i l l i n g to r e l a t e " (Nunnally, 1978 , p. 5 9 1 ) . CHAPTER I I REVIEW OF THE LITERATURE Overview Because the problem under study r e l a t e s to the concepts of p r o f e s s i o n a l i s m and p r o f e s s i o n a l s o c i a l i z a t i o n , and he-cause p r o f e s s i o n a l s o c i a l i z a t i o n has "been defined i n terms of l e a r n i n g the knowledge, s k i l l s , a t t i t u d e s and values neces-sary to enact a r o l e , the l i t e r a t u r e on p r o f e s s i o n a l s o c i a l i -z a t i o n from a r o l e perspective was reviewed to provide a b a s i s f o r understanding the process which leads to the goal of p r o f e s s i o n a l i z a t i o n f o r n u r s i n g . The l i t e r a t u r e review i s presented i n seven s e c t i o n s , the f i r s t of which d e l i n e a t e s the t h e o r e t i c a l framework s e l e c t e d as the b a s i s f o r examining the process of p r o f e s s i o n a l r o l e a c q u i s i t i o n . The second s e c t i o n reviews other w r i t i n g s i n psychology and s o c i o l o g y about the process of p r o f e s s i o n a l s o c i a l i z a t i o n from a r o l e p e r s p e c t i v e . An overview of s t u d i e s of p r o f e s s i o n a l s o c i a l i z a t i o n that focus on the h e a l t h p r o f e s s i o n s i s undertaken i n the t h i r d s e c t i o n , i n order to r e l a t e theory from psychology and s o c i o l o g y to the s o c i a l i z a t i o n of h e a l t h p r o f e s s i o n a l s . The f o u r t h s e c t i o n summarizes the nu r s i n g l i t e r a t u r e on p r o f e s s i o n a l s o c i a l i z a t i o n , i n order to r e l a t e t h e o r i e s of p r o f e s s i o n a l s o c i a l i z a t i o n s p e c i f i c a l l y to n u r s i n g . 7 8 In the f i f t h s e c t i o n , c h a r a c t e r i s t i c s of p r o f e s s i o n a l i s m as they r e l a t e to n u r s i n g are e x t r a c t e d from the l i t e r a t u r e on p r o f e s s i o n a l i s m i n general and p r o f e s s i o n a l i s m i n n u r s i n g , as the b a s i s f o r development of the instrument f o r t h i s study. The s i x t h s e c t i o n reviews the l i t e r a t u r e regarding the measurement of a t t i t u d e s , i n order to j u s t i f y the methodology s e l e c t e d f o r the study. F i n a l l y , the seventh s e c t i o n summarizes the previous s e c t i o n s and o u t l i n e s the i m p l i c a t i o n s of the l i t e r a t u r e review f o r t h i s study. T h e o r e t i c a l Framework The t h e o r e t i c a l framework s e l e c t e d f o r t h i s study was developed by two s o c i o l o g i s t s , Thornton and Nardi ( 1 9 7 5 ) -They view p r o f e s s i o n a l s o c i a l i z a t i o n as a part of the develop-mental process of a c q u i r i n g a r o l e ; t h i s process i s seen as i n v o l v i n g i n t e r a c t i o n between person and r o l e . I n d i v i d u a l p e r s o n a l i t y c h a r a c t e r i s t i c s are h e a v i l y emphasized i n t h e i r theory. Thornton and N a r d i (1975) define r o l e as "a set of expectations impinging on an incumbent of a s o c i a l p o s i t i o n " (p. 8 7 2 ) . These expectations a r i s e from a number of sources, which correspond to e n t i t i e s l a b e l l e d by other w r i t e r s as reference groups (Lum, 1978; Sarbin & A l l e n , 1968; pp. 5 3 2 - 5 3 3 ; Turner, 1 9 5 6 , p. 327)• Three types of sources are i d e n t i f i e d : g e n e r a l i z e d sources, members of the r o l e s e t , and the r o l e enactor h i m s e l f (Thornton & N a r d i , 1 9 7 5 , P> 8 7 2 ) . G e n e r a l i z e d 9 s o u r c e s come from s o c i e t y a t l a r g e , f o r example, the mass media and p e o p l e i n g e n e r a l . Members o f the r o l e s e t c o n s t i t u t e a r e f e r e n c e group c o n s i s t i n g o f peopl e e n a c t i n g s i m i l a r r o l e s as the f o c a l p e r s o n ( s i m i l a r - r o l e o t h e r s ) , and people e n a c t i n g r e c i p r o c a l r o l e s ( r e c i p r o c a l - r o l e o t h e r s ) . The c o n t e n t o f r o l e e x p e c t a t i o n s may be b e h a v i o u r a l , a t t i t u d i n a l , o r c o g n i t i v e . R o l e e x p e c t a t i o n s may be p r e s e n t e d e x p l i c i t l y o r i m p l i c i t l y , and may gen e r a t e c o n f u s i o n and/or c o n f l i c t depending upon t h e degree o f i n t e r and i n t r a -r e f e r e n c e group consensus p e r c e i v e d by the r o l e e n a c t o r . H i g h degrees o f " d i s s e n s u s " can i n t e r f e r e m a r k e d l y w i t h the p r o c e s s o f r o l e a c q u i s i t i o n ( T h o r n t o n & N a r d i , 1 9 7 5 , P- 8 7 3 ) . T h o r n t o n and N a r d i propose t h r e e p o s s i b l e r e a c t i o n s t o r o l e e x p e c t a t i o n s : s o c i a l a d j u s t m e n t , p s y c h o l o g i c a l a d j u s t -ment, and a d a p t a t i o n . S o c i a l a d j u s t m e n t i s "the adequate m e e t i n g o f r o l e e x p e c t a t i o n s and performance i n accordance w i t h them" (Th o r n t o n & N a r d i , 1 9 7 5 . p. 8 7 3 ) . P s y c h o l o g i c a l a d j u s tment i s "the achievement o f c o n g r u i t y between i n d i v i d u a l p s y c h o l o g i c a l needs and d e s i r e s and the r o l e " (p. 8 7 3 ) - When the r o l e i s i n t e r n a l i z e d and a s s i m i l a t e d , a d a p t a t i o n has o c c u r r e d . R o l e a c q u i s i t i o n i s seen as a p r o g r e s s i o n t h r o u g h f o u r s t a g e s : a n t i c i p a t o r y , f o r m a l , i n f o r m a l , and p e r s o n a l s t a g e s . The a n t i c i p a t o r y s t a g e spans the time p e r i o d from b e f o r e the b e g i n n i n g o f f o r m a l e d u c a t i o n f o r a r o l e t o the time when the p r o f e s s i o n a l r o l e i s assumed i n the work s e t t i n g , and c o n s i s t s o f two phases. D u r i n g the p r e - e d u e a t i o n phase o f t h i s s t a g e , 10 the most i n f l u e n t i a l source of r o l e expectations i s g e n e r a l i z e d sources w i t h a high degree of consensus. Thornton and Nard i cl a i m that r o l e conceptions formed i n t h i s phase tend to be stereotyped, i d e a l i z e d , hazy, and incomplete ( 1 9 7 5 » PP- 8 7 4 -875)• The process of p r o f e s s i o n a l s o c i a l i z a t i o n i s viewed as the next phase of t h i s stage, and spans the time p e r i o d of the formal b a s i c educational p r e p a r a t i o n f o r the p r o f e s s i o n a l r o l e ( 1 9 7 5 , P- 8 7 5 ) . According to the authors the a n t i c i p a -t o r y stage may impede adjustment af r o l e expectations of t h i s stage are incongruous w i t h those of subsequent stages ( 1 9 7 5 , pp. 8 7 5 - 8 7 6 ) . The formal stage of r o l e a c q u i s i t i o n begins when the r o l e i s assumed i n the work s e t t i n g . E x p e c t a t i o n s a r i s e mainly from members of the r o l e s e t , and f r e q u e n t l y take the form of o r g a n i z a t i o n a l l y defined r i g h t s and d u t i e s which emphasize expected a b i l i t i e s and behaviours r a t h e r than a t t i t u d e s . During t h i s stage the neophyte p r o f e s s i o n a l postpones h i s own mode of meeting r o l e expectations; he tends to adjust s o c i a l l y by meeting, r a t h e r than modifying, requirements. Psycho-l o g i c a l adjustment often occurs through p l a y i n g at r o l e s (or per f u n c t o r y r o l e enactment) r a t h e r than t r u l y enacting them (Thornton & N a r d i , 1 9 7 5 , PP- 8 7 6 - 8 7 8 ) . The i n f o r m a l stage occurs simultaneously w i t h the formal stage and i s c h a r a c t e r i z e d by u n o f f i c i a l or inf o r m a l expecta-t i o n s . O c c a s i o n a l l y i n f o r m a l expectations c o n t r a d i c t formal ones. Role colleagues are seen as the main source of expecta-t i o n s throughout t h i s stage, and dissensus among expectations 11 may be high. Thornton and Nard i (1975) c l a i m that i n d i v i d u a l s begin to place g r e a t e r weight on t h e i r own r o l e expectations upon encountering t h i s stage (p. 8 7 8 ) , and begin to shape the r o l e to f i t themselves (p. 8 7 9 ) . P s y c h o l o g i c a l adjustment begins during t h i s stage. The personal stage provides f o r the i n t e g r a t i o n of i n d i v i d u a l p e r s o n a l i t y c h a r a c t e r i s t i c s w i t h the enactment of the r o l e . During t h i s stage i n d i v i d u a l s i n f l u e n c e the expecta-t i o n s others h o l d f o r them, and impose t h e i r own s t y l e on t h e i r r o l e performance ( 1 9 7 5 . pp. 880-881). S o c i a l a d j u s t -ment takes the form of r o l e m o d i f i c a t i o n , r a t h e r than the conformity of e a r l i e r stages. P s y c h o l o g i c a l adjustment continues, and i s thought to be completed when the i n d i v i d u a l i s able to r e l a t e h i s own ps y c h o l o g i c a l needs to the r e q u i r e -ments of the modified r o l e . Adaptation, or i n t e r n a l i z a t i o n of the r o l e , may now occur. Thornton and Nardi view the importance of each stage as being v a r i a b l e , depending on the nature of the r o l e . They a l s o a l l o w f o r v a r i a t i o n i n the a c q u i s i t i o n of the same type of r o l e , depending upon the s e t t i n g and the p e r s o n a l i t y c h a r a c t e r i s t i c s of v a r i o u s s o c i a l i z e e s . Role performance i s thought to be more e f f e c t i v e i n l a t e r stages; personal s a t i s f a c t i o n from the r o l e i s thought to be at i t s peak w i t h the occurrence of i n t e g r a t i o n of the s e l f w i t h the r o l e . Thornton and Nardi's theory has been s e l e c t e d as the t h e o r e t i c a l framework f o r t h i s study f o r a number of reasons. The authors claim that t h e i r model can be a p p l i e d to v i r t u a l l y 12 any role which may he acquired (Thornton & Nardi, 1975, P- 871). The basic concepts of t h e i r theory are representative of concepts of concern i n t h i s study. The personal stage of t h i s theory takes i t beyond most other works by allowing the f o c a l person to influence others' expectations and thus modify the role which w i l l be enacted. This l a s t idea i s representative of what must happen i f nursing i s to achieve p r o f e s s i o n a l i z a t i o n . F i n a l l y , with one exception, the theory i s consistent with most of the l i t e r a t u r e on professional s o c i a l i z a t i o n . The exception referred to above necessitates making one modification to the theory. The authors perceive the process of professional s o c i a l i z a t i o n as an extended period of the anticipatory stage of role a c q u i s i t i o n (1975» P. 875); the remaining stages of role a c q u i s i t i o n are viewed as occurring a f t e r completion of the professional education programme and assumption of the professional role i n the work setting. In other words, the process of professional s o c i a l i z a t i o n i s viewed as part of role a c q u i s i t i o n , and i s seen as being completed at the end of the educational programme. This idea i s inconsistent with other writers who view professional s o c i a l i z a t i o n as an ongoing process which continues long a f t e r graduation (Cotanch, 1981, p. 6; Jacox, 1978, p. 16; L o r t i e , 1966, pp. 100-101; Lum, 1978, p. 15 ;^ M i l l e r & Wager, 1971, p. 161; Olesen & Whittaker, 1970, p. 217; Schein, 1968, p. 37). Furthermore, the structure of most basic nursing education programmes involves varying l e v e l s and forms of assumption of the nursing role i n the work milieu during the educational process. The l i t e r a t u r e on p r o f e s s i o n a l s o c i a l i z a t i o n p o i n t s to the "belief t h a t the process of p r o f e s s i o n a l s o c i a l i z a t i o n represents one type of r o l e a c q u i s i t i o n (Hinshaw, 1 9 7 8 , p. 276; Sarbin & A l l e n , 1968 , p. 5 ^ 6 ) . Therefore, f o r the purposes of t h i s study, the process of p r o f e s s i o n a l s o c i a l i z a t i o n i s considered as encompassing a l l of Thornton and Nardi's stages to v a r y i n g extents. The concepts i n Thornton and Nardi's model can r e a d i l y be a p p l i e d to the p r o f e s s i o n a l s o c i a l i z a t i o n of n u r s i n g students. Lay conceptions of the n u r s i n g r o l e are drawn from g e n e r a l i z e d sources such as t e l e v i s i o n ; Cherry Ames nov e l s ; acquaintances who may have been p a t i e n t s , nurses, or p h y s i c i a n s and personal experiences as p a t i e n t s . Subsequent reference groups i n c l u d e n u r s i n g f a c u l t y , peers, s t a f f nurses, p a t i e n t s , p h y s i c i a n s , and other h e a l t h care workers. Because n u r s i n g students are r e q u i r e d to assume a n u r s i n g r o l e i n the work s e t t i n g during t h e i r b a s i c n u r s i n g education, some form of s o r t i e i n t o the formal, i n f o r m a l , and personal stages can be seen to occur during the educational process. Dissensus among the r o l e expectations of the v a r i o u s stages i s common; the n u r s i n g l i t e r a t u r e i s r e p l e t e w i t h d i s c u s s i o n s of pro-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 the education-service dichotomy. The personal stage, i n c l u d i n g adaptation, i s complete when the nurse has achieved a balance among c o n f l i c t i n g e x pectations, a harmony w i t h the demands of other r o l e s , and a m o d i f i c a t i o n of the n u r s i n g r o l e which i s congruent w i t h i n d i v i d u a l p e r s o n a l i t y c h a r a c t e r i s t i c s . 14 Studies of Professional S o c i a l i z a t i o n from the  F i e l d s of Psychology and Sociology Role Acquis i t i o n Over the past several decades psychologists and soc i o l o g i s t s have developed theories of role and role a c q u i s i t i o n which vary along three major dimensions. The f i r s t of these dimensions i s complexity; theories tend to become more complex over the years. Likewise, recent theories tend to depict the role enactor as a more active agent i n his own s o c i a l i z a t i o n than do e a r l i e r theories. "Increasingly, s o c i a l i z a t i o n has come to be viewed as an in t e r a c t i o n a l and reci p r o c a l process i n which the so c i a l i z e e and s o c i a l i z e r are mutually influenced" (Hurley, 1978, p. 31)• F i n a l l y , theories of role a c q u i s i t i o n have t r a d i -t i o n a l l y been written from either the micro (individual) or macro (organizational or occupational) perspective; however, the study of role and ro l e a c q u i s i t i o n i s increasingly addressing the issue of integrating theories of in d i v i d u a l human personality and i n s t i t u t i o n a l theory (Goode, i960, p. 246; Sarbin & Al l e n , 1968, p. 490). Of the writers of the 1950's, Turner (1956) proposes a theory which i s one of the more complex of the period. Written from the micro-perspective, his theory i s based on the following d e f i n i t i o n of role: a c o l l e c t i o n of patterns of behavior which are thought to constitute a meaningful unit and deemed appropriate to a person occupying a p a r t i c u l a r status i n society 15 (e.g., doctor or f a t h e r ) , occupying an i n f o r m a l l y defined p o s i t i o n i n i n t e r p e r s o n a l r e l a t i o n s (e.g., leader or compromiser), or i d e n t i f i e d w i t h a p a r t i c u l a r value i n s o c i e t y (e.g., honest man or p a t r i o t ) . (p. 316) This d e f i n i t i o n emphasizes the behavioural component of r o l e ; a t t i t u d i n a l and c o g n i t i v e elements are a l l u d e d to only i m p l i c i t l y . Role i s described as a "normative concept" because the behaviours of the r o l e enactor are measured against standards of c r i t e r i a f o r appropriateness (p. 3 1 7 ) • Turner views r o l e a c q u i s i t i o n as a process of " r o l e - t a k i n g , " which proceeds i n a v a r i a b l e manner i n accordance w i t h two c r i t e r i a — s t a n d p o i n t and r e f l e x i v e n e s s . The concept of standpoint r e f e r s to the extent to which the r o l e - t a k e r adopts the r o l e expectations of v a r i o u s reference groups ( 1 9 5 6 , p. 3 2 1 ) . R e f l e x i v e n e s s r e f e r s to the extent to which "the a t t e n t i o n of the r o l e - t a k e r i s focused upon the way i n which he appears to the other" ( 1 9 5 6 , P« 3 2 2 ) . The type of r o l e - t a k i n g adopted by the i n d i v i d u a l i s dependent upon the d i r e c t i o n taken from the s e l f - o t h e r r e l a t i o n s h i p ; s i x types of r o l e - t a k i n g are i d e n t i f i e d , i n accordance w i t h v a r i o u s combinations of the concepts standpoint and r e f l e x i v e n e s s ( 1 9 5 6 , pp. 3 2 2 - 3 2 3 ) . Turner's theory i s s u f f i c i e n t l y complex to account f o r a wide v a r i e t y of human behaviour. Although h i s theory does al l o w the i n d i v i d u a l some d i s c r e t i o n i n shaping h i s own r o l e behaviour, i t does not provide f o r m o d i f i c a t i o n of the r o l e i t s e l f , i n the sense of a l t e r i n g others' expectations. In c o n t r a s t to Turner's theory, Becker and Carper (1956) have developed a r e l a t i v e l y simple concept of r o l e a c q u i s i t i o n 16 from a macro-perspective. They view professional s o c i a l i z a t i o n as i d e n t i f i c a t i o n with an occupation--a process which i s dependent on four variables: (a) the symbolic meaning associated with an occupational t i t l e , (b) commitment to task, (c) commitment to s p e c i f i c organizations or positions within i n s t i t u t i o n s , and (d) significance of the occupation for one's position i n the s o c i a l s t r a t i f i c a t i o n system of society (1956, p. 3^1). Their model i s based on a study of graduate students i n three f i e l d s : physiology, mechanical engineering, and philosophy. Their view of professional s o c i a l i z a t i o n as an occupationally oriented concept r e s u l t s from the considerable degree of inner consistency found within each of the three groups studied. During the 1960's the concept of role a c q u i s i t i o n gradually came to be viewed as more complex. Whereas previous theories had l a r g e l y been l i m i t e d to a consideration of overt role behaviours, i n d i v i d u a l a t t i t u d e s , values, s k i l l s , and knowledge now became recognized as s i g n i f i c a n t variables which underlie and give meaning to overt conduct. L o r t i e (1966), who studied the professional s o c i a l i z a t i o n of law students, concluded that "the development of a professional self-conception involves a complicated chain of perceptions, s k i l l s , values, and interactions" (p. 98). He also found that young lawyers " l e f t law school with a hazy and incomplete conception of what lawyers' work consists of"(p. 100), and concluded that "law school i s but a beginning of professional s o c i a l i z a t i o n " (p. 101). Sarbin and A l l e n assert that l i t t l e research has been 17 done on the process of r o l e a c q u i s i t i o n ( 1 9 6 8 , p. 5 4 4 ) . T h e i r concept of r o l e i s based on a set of complex i n t e r -r e l a t i o n s h i p s among v a r i a b l e s such as r o l e enactment, r o l e e x pectations, r o l e l o c a t i o n , r o l e demands, r o l e s k i l l s , r o l e - s e l f congruence, and complex r o l e phenomena ( 1 9 6 8 , pp. 4 8 9 - 5 3 8 ). They describe r o l e as an "organized set of behaviours" (p. 5 4 5 ), and s t r e s s that the s o c i a l i z e e must l e a r n the e n t i r e r o l e set, which i n c l u d e s "the i n t e r l o c k i n g system of r i g h t s and o b l i g a t i o n s of a r o l e and complementary r o l e s " (p. 5 4 6 ) . Thier a s s e r t i o n that s e l f - r o l e congruence leads to more e f f e c t i v e r o l e enactment ( 1 9 6 8 , p. 524) i s analogous to the b e l i e f s expressed by Thornton and Nardi regarding congruence of s e l f and r o l e i n the personal stage. Olesen and Whittaker, i n t h e i r c r i t i q u e of s o c i o l o g i c a l s t u d i e s of p r o f e s s i o n a l s o c i a l i z a t i o n , deplore the s i m p l i c i t y of most t h e o r i e s and t h e i r tendency to view p r o f e s s i o n a l r o l e a c q u i s i t i o n as a process f o r producing a "standard pro-duct" which f u l f i l l s the needs of s o c i e t y ( 1 9 7 0 , pp. 1 9 0 - 1 9 1 ) . They perceive the s o c i a l i z e e as an i n d i v i d u a l "engaged i n conscious, choice-making and i n t e n t i o n a l behaviours" ( 1 9 7 0 , p. 2 0 8 ) — a n i n d i v i d u a l w i t h a dynamic, p r o a c t i v e character i n a drama. E l l i o t t ' s concept of p r o f e s s i o n a l s o c i a l i z a t i o n i s c o n s i s t e n t w i t h the trend toward i n c r e a s i n g complexity; i n c r e a s i n g emphasis on norms, a t t i t u d e s , and values ( 1 9 7 2 , p. 8 9 ); and the i n c r e a s i n g p r o a c t i v i t y of the i n d i v i d u a l s o c i a l i z e e ( 1 9 7 2 , p. 9 2 ) . He als o b e l i e v e s that the teaching s t a f f of an educational i n s t i t u t i o n plays an important par t 18 i n the process of r o l e a c q u i s i t i o n ( 1 9 7 2 , p. 86)--an argu-ment which supports Watson's opinion t h a t n u r s i n g education i s accountable f o r the s o c i a l i z a t i o n of n u r s i n g students i n t o the values of the p r o f e s s i o n (Watson, 1981, p. 24). Lum (1978) s t u d i e d reference groups i n r e l a t i o n to p r o f e s s i o n a l s o c i a l i z a t i o n and concluded t h a t they p l a y a s i g n i f i c a n t p a r t i n the s o c i a l i z a t i o n process (p. 1 3 7 ) . L i k e Thornton and N a r d i , she maintains t h a t reference groups provide sources of values f o r the i n d i v i d u a l which he s e l e c t s to c o n s t i t u t e a frame of reference and provide d i r e c t i o n f o r behaviour (1978, p. 1 3 7 ) . Three types of reference groups are i d e n t i f i e d : normative groups, comparison groups, and audience groups. A normative group sets norms and v a l u e s , makes i t s expectations known, and assumes compliance on the part of the s o c i a l i z e e (Lum, 1978, pp. 139-140). Comparison groups demonstrate standards of behaviour against which the i n d i v i d u a l can compare him s e l f (Lum, 1978, pp. 140-141). Audience groups are groups to which the s o c i a l i z e e a t t r i b u t e s c e r t a i n v a l u e s ; he attempts to a t t r a c t the a t t e n t i o n of an audience group and behave i n accordance w i t h i t s values (Lum, 1978, p. 141') . Lum b e l i e v e s that the v a r i o u s types of reference groups may not be d i s c r e t e e n t i t i e s , but r a t h e r overlapping and b l u r r i n g f r e q u e n t l y occur among reference groups (p. 141). Lum goes on to i d e n t i f y e i g h t c h a r a c t e r i s t i c s common to the process of p r o f e s s i o n a l s o c i a l i z a t i o n : (a) The educational process has both formal and i n f o r m a l aspects, (b) The s o c i a l i z e e i s exposed to m u l t i p l e agents of s o c i a l i z a -19 t i o n . S o c i a l i z a t i o n may be either f a c i l i t a t e d or hindered, depending on the degree of congruity among the expectations of multiple agents. (c) There frequently exists a simul-taneous, additional dimension of developmental s o c i a l i z a t i o n - -namely, the t r a n s i t i o n from adolescence to adulthood, (d) Both students and s o c i a l i z i n g agents are heterogenous groups. (e) Hazing, r i t u a l i s m , and monopoly of students' time frequently occur. (f) A technical language must be learned. (g) The profession may be i n a state of f l u x (as she i d e n t i f i e s f o r nursing), a factor which complicates the s o c i a l i z a t i o n process. (h) The existence of a student culture can either hinder or f a c i l i t a t e the s o c i a l i z a t i o n process (Lum, 1 9 7 8 , pp. 1 4 6 - 1 5 2 ) . Role C o n f l i c t Role c o n f l i c t i s a phenomenon c h a r a c t e r i s t i c of v i r t u a l l y a l l r o l e s , both s o c i a l and occupational; i t s existence i s the normal state of a f f a i r s i n society ( E l l i o t t , 1 9 7 2 , p. 8 6 ; Goode, 1960b, p. 4 9 5 ; L o r t i e , 1966, p. 9 9 ; Merton, 1966, p. 2 8 3 ; Ofshe, 1972, p. 9 3 ; Sarbin & A l l e n , 1 9 6 8 , pp. 5 3 4 - 5 5 8 ; Scott, I 9 6 6 , p. 2 6 9 ) . There i s general agreement i n the l i t e r a t u r e about the nature of the problem; however, differences i n the terminology associated with t h i s concept lead to some confusion. Labels which have been attached to t h i s concept include role stress, r o l e s t r a i n , role ambiguity, role incongruity, and role overload. For the sake of c l a r i t y the subject of role c o n f l i c t w i l l be 20 considered w i t h i n the terms of Hardy's d e f i n i t i o n ( 1 9 7 8 b , p. 81) provided on page 5-S a r b i n and A l l e n (1968) i d e n t i f y two types of r o l e c o n f l i c t : i n t e r r o l e c o n f l i c t and i n t r a r o l e c o n f l i c t (p. 5^*0). The f i r s t i s generated by the s i t u a t i o n of simultaneous occupancy of two r o l e s , each having r o l e expectations which are incompatible w i t h those of the other. The second type of r o l e c o n f l i c t i n v o l v e s c o n t r a d i c t o r y r o l e expectations h e l d by two or more reference groups regarding the same r o l e . Four adaptive techniques f o r r e s o l v i n g r o l e c o n f l i c t are proposed by Sa r b i n and A l l e n ( 1 9 6 8 , pp. 5 4 1 - 5 ^ 4 ) . (a) Instrumental a c t s are behaviours aimed at modifying the e x t e r n a l sources of the c o n f l i c t . Separation of c o n f l i c t i n g r o l e s so that only one i s enacted at a time i s an example. Another instr u m e n t a l act might i n v o l v e f l i g h t from a c o n f l i c t s i t u a t i o n . (b) A t t e n t i o n deployment i s a technique which does not a l t e r the source of the r o l e c o n f l i c t , but r a t h e r d i v e r t s a t t e n t i o n from one of the incompatible i n p u t s , (c) A t h i r d technique i s f o r the r o l e enactor to change h i s b e l i e f s about one or both i n p u t s . In other words, a d i f f e r e n t i n t e r p r e t a t i o n i s placed on r o l e expectations, making them compatible. (d) The use of t r a n q u i l i z e r s and r e l e a s e r s i s a technique which momentarily reduces f e e l i n g s of d i s t r e s s , a n x i e t y , and te n s i o n a s s o c i a t e d w i t h the c o n f l i c t . T r a n q u i l i z e r s u s u a l l y c o n s i s t of chemicals, sleep, or food. Releasers u s u a l l y i n v o l v e some form of intense motor a c t i v i t y , such as vigorous e x e r c i s e or scrubbing the f l o o r . S a r b i n and A l l e n suggest t h a t the choice of technique i s dependent 21 upon three f a c t o r s : past success w i t h a technique, s o c i a l reinforcement, and a v a i l a b i l i t y ( 1 9 6 8 , p. 5 4 4 ) . Studies of r o l e c o n f l i c t i n o r g a n i z a t i o n s have l e n t support to the b e l i e f that such c o n f l i c t must be considered w i t h i n the context of i n d i v i d u a l human p e r s o n a l i t y theory (Wolfe & Snoek, 1962; Kahn, Wolfe, Quinn, Snoek, & Rosenthal, 1966). Wolfe and Snoek, i n t h e i r study of r o l e c o n f l i c t experienced by va r i o u s l e v e l s of management personnel i n the o i l , automobile, and defense i n d u s t r i e s , r e p o r t e d that r o l e c o n f l i c t was highest i n i n d i v i d u a l s at the middle management l e v e l , i n d i v i d u a l s w i t h u n i v e r s i t y education, younger i n d i v i d u a l s , i n d i v i d u a l s who t e s t high f o r the p e r s o n a l i t y c h a r a c t e r i s t i c " f l e x i b i l i t y ' , ' , and i n d i v i d u a l s who tend toward i n t r o v e r s i o n ( 1 9 6 2 , pp. 1 1 2 - 1 1 7 ) . Kahn et a l . (1966) found that r o l e c o n f l i c t i n employees leads to low job s a t i s f a c t i o n , decreased confidence i n the o r g a n i z a t i o n , and high degrees of t e n s i o n r e l a t e d to the job. Ofshe, i n h i s study of r o l e c o n f l i c t i n r e l a t i o n to reference groups, i d e n t i f i e s three types of reference groups: normative, comparative, and i n f o r m a t i o n a l ( 1 9 7 2 , pp; 9 0 - 9 2 ). H i s d e s c r i p t i o n of normative and comparative reference groups corresponds p r e c i s e l y to Lum's d e s c r i p t i o n s ( 1 9 7 8 , pp. 139-141); however, Ofshe also p o i n t s out that a s i n g l e i n d i v i d u a l can comprise a reference group ( 1 9 7 2 , pp. 9 0 - 9 2 ). Because the r o l e enactor i s f r e q u e n t l y evaluated by normative r e f e r e n t s , Ofshe b e l i e v e s that most r o l e c o n f l i c t i s r e l a t e d to t h i s type of reference group ( 1 9 7 2 , pp, 22 9 2 - 1 1 3 ) • Ondrack, who conducted a comparative study of s o c i a l i z a t i o n i n professional schools, concluded that a high degree of dissensus among reference groups r e s u l t s i n role c o n f l i c t and i n f e r i o r professional s o c i a l i z a t i o n (Ondrack, 1 9 7 5 ) . Much has been written about professional-bureaucratic c o n f l i c t , which i s considered a p a r t i c u l a r type of role c o n f l i c t (Corwin, I960; Kramer, - .197^; M i l l e r & Wager, 1 9 7 1 ; Sorensen & Sorensen, 1 9 7 4 ) . Lieberman (1970) and Schein (1968) focus on the education place-work place dichotomy, a v a r i a t i o n on t h i s phonomenon. This type of c o n f l i c t i s said to be the r e s u l t of c o n f l i c t i n g values and expecta-tions held by professional reference groups (including professional associations, professional colleagues, and educational i n s t i t u t i o n s ) and bureaucratic reference groups (such as employers and management personnel i n bureaucratic organizations). Scott (I966) has i d e n t i f i e d four d i s t i n c t areas of c o n f l i c t : (1) the p r o f e s s i o n a l ' s resistance to bureaucratic r u l e s ; (2) the p r o f e s s i o n a l ' s r e j e c t i o n of bureaucratic standards; (3) the p r o f e s s i o n a l ' s resistance to bureau-c r a t i c supervision; and (4) the p r o f e s s i o n a l ' s conditional l o y a l t y to the bureaucracy. (p. 269) In p r a c t i c e , many professionals compromise t h e i r professional ideals i n favour of meeting the demands of the organization (Scott, 1966 , p. 2 6 9 ) . Incompetent job performance, job d i s s a t i s f a c t i o n , and job migration often accompany professional-bureaucratic c o n f l i c t . I t has been suggested that even the most established professions are being deprofessionalized by the increasing 23 b u r e a u c r a t i z a t i o n o f s o c i e t y (Haug, 1 9 7 3 , P. 196; Y a r m o l i n s k y , 1978 , p. 1 6 ? ). Conway ( 1978) has i d e n t i f i e d the achievement o f a b a l a n c e between p r o f e s s i o n a l i d e a l s and b u r e a u c r a t i c v a l u e s as a c r u c i a l o b j e c t i v e f o r p r o f e s s i o n a l s who w i s h t o m a i n t a i n t h e i r autonomy (p. 1 3 5 ) • S t u d i e s o f P r o f e s s i o n a l S o c i a l i z a t i o n That Focus on the H e a l t h P r o f e s s i o n s There i s a d e a r t h o f r e s e a r c h documented i n the l i t e r a t u r e about t h e . a c t u a l p r o f e s s i o n a l s o c i a l i z a t i o n p r o c e s s o f h e a l t h p r o f e s s i o n a l s ; by f a r the g r e a t e s t a t t e n t i o n has been p a i d t o the s o c i a l i z a t i o n o f m e d i c a l s t u d e n t s . F i v e s t u d i e s have been i d e n t i f i e d and w i l l be b r i e f l y d e s c r i b e d . J a c o b s o n ( 1980) conducted a s t u d y o f pre and p o s t -p r o f e s s i o n a l e d u c a t i o n c o n c e p t i o n s o f the r o l e o f p h y s i c a l t h e r a p i s t . The t e s t i n g i n s t r u m e n t , a " p h y s i c a l t h e r a p i s t c h a r a c t e r i s t i c s Q s o r t " , was a d m i n i s t e r e d to 320 p h y s i c a l t h e r a p y s t u d e n t s a t the b e g i n n i n g and a t the end o f t h e i r e d u c a t i o n a l programme (p. 1 9 0 ). The c o n c l u s i o n o f the s t u d y was t h a t s t u d e n t s ' r o l e c o n c e p t i o n s b e f o r e and a f t e r t h e i r programme changed v e r y l i t t l e ( 1 9 8 0 , p. 1 9 3 ) - T h i s con-c l u s i o n i s i n d i r e c t c o n f l i c t w i t h the f i n d i n g s o f o t h e r r e s e a r c h e r s ( B e c k e r & Ge e r , 1958 , p. 5 1 ; Feldman & Newcomb, 1 9 6 9 , p. 7 1 ; L o r t i e , 1966; O l e s e n & W h i t t a k e r , 1968, pp. 91-108; T h o r n t o n & N a r d i , 1978 , p. 8 7 4 ) . S o c i o l o g i s t s S h e r l o c k and M o r r i s (1967) d e v e l o p e d a paradigm f o r the p r o f e s s i o n a l s o c i a l i z a t i o n o f d e n t a l s t u d e n t s { 24 the paradigm formed the h a s i s of a seven-year l o n g i -t u d i n a l study which f o l l o w e d dental students from pre-dental courses s t a r t i n g i n 1962 i n t o t h e i r f i r s t year of p r a c t i c e i n 19^9- They conceptualize the development of a p r o f e s s i o n a l i d e n t i t y as o c c u r r i n g i n three stages: recruitment, p r o f e s s i o n a l s o c i a l i z a t i o n , and p r o f e s s i o n a l outcomes. The p r o f e s s i o n a l s o c i a l i z a t i o n stage c o n s i s t s of a s e r i e s of s o c i a l i z a t i o n processes: s e l e c t the appropriate r e c r u i t s ( s e l e c t i o n ) ; i s o l a t e them from competing i n f l u e n c e s ( s e q u e s t r a t i o n ) ; i n c u l c a t e necessary knowledge ( d i d a c t i c i n s t r u c t i o n ) ; develop s k i l l s , values and r o l e models ( a p p r e n t i c e s h i p i n s t r u c t i o n ) ; motivate them to a t t a i n these goals ( s a n c t i o n i n g ) ; c e r t i f y those i n d i v i d u a l s who are demonstrably competent ( c e r t i f i c a t i o n ) ; and f i n a l l y , launch the n e w l y - c e r t i f i e d p r o f e s s i o n a l colleague upon h i s career (sponsorship). (pp. 3 2 - 3 3 ) Student response to these i n s t i t u t i o n a l processes i s seen as c o n s i s t i n g of two phases: the development of student s o l i d a r i t y (or s t u d e n t s h i p ) , and an app r e n t i c e s h i p phase during which students begin to i d e n t i f y w i t h f a c u l t y and i n t e r n a l i z e t h e i r values (Sherlock & M o r r i s , 1 9 6 7 , p. 41). These student responses are s i m i l a r to those observed i n medical students by Becker, Greer, Hughes, and Strauss ( 1 9 6 1 , pp. ? 0 - l 8 4 ) , and i n n u r s i n g students by Olesen and Whittaker ( 1 9 6 8 , chap. V I ) . Feldman ( 1977 ) conducted a comparative study of the o r g a n i z a t i o n a l s o c i a l i z a t i o n of f i v e groups of h o s p i t a l employees: engineers, accounting c l e r k s , r a d i o l o g y tech-n o l o g i s t s , r e g i s t e r e d nurses, and n u r s i n g t e c h n i c i a n s ( o r d e r l i e s and nurse's a i d e s ) . He reported that p r o f e s s i o n a l nurses had the highest scores on i n i t i a t i o n to the task 25 (becoming competent a t r e q u i r e d tasks) and i n i t i a t i o n to the group (becoming accepted and t r u s t e d by co-workers); however, p r o f e s s i o n a l nurses had the most d i f f i c u l t time i n d e f i n i n g r o l e s f o r themselves and i n coming to agreement w i t h s u p e r v i s o r s over s u i t a b l e c r i t e r i a f o r performance e v a l u a t i o n . He a l s o found' that the r e g i s t e r e d nurses had the severest r o l e c o n f l i c t s . In a study of medical students conducted at Western Reserve U n i v e r s i t y School of Medicine, U n i v e r s i t y of Pennysylvania School of Medicine, and C o r n e l l U n i v e r s i t y M e d i c a l College (Huntington, 1 9 5 7 ) , medical students at the end of each school year were asked the question: In the most recent dealings you have had w i t h p a t i e n t s , how have you tended to t h i n k of y o u r s e l f , p r i m a r i l y as a doctor r a t h e r than as a student, or p r i m a r i l y as a student r a t h e r than as a doctor? (p. 180) P r e d i c t a b l y , the percentage of students who thought of themselves p r i m a r i l y as doctors increased p r o g r e s s i v e l y w i t h years of medical school. But Huntington i d e n t i f i e d f a c t o r s other than s e n i o r i t y i n medical school which i n f l u e n c e d the students' p r o f e s s i o n a l self-image: (a) I n d i v i d u a l students tend to r e f l e c t the image which they perceive others have of them. This i s e s p e c i a l l y evident i n student-patient r e l a -t i o n s h i p s , (b) Students i n the e a r l y years of medical school, who have the opportunity to provide a c t u a l s e r v i c e of a medical nature to p a t i e n t s , show a greater tendency to develop a p r o f e s s i o n a l self-image than do other students. Becker et a l . ( 1961 ) conducted what i s now acknowledged as a c l a s s i c , q u a l i t a t i v e study of the development of a t t i t u d e s 26 and values i n medical school at the U n i v e r s i t y of Kansas. T h e i r major method of i n v e s t i g a t i o n was p a r t i c i p a n t o bservation, which was combined with the use of i n c i d e n t s and i n t e r v i e w s ; data a n a l y s i s and data gathering proceeded simultaneously (pp. 4 - 4 9 ) • T h e i r most s i g n i f i c a n t f i n d i n g s are r e l a t e d to the " f a t e of i d e a l i s m " (Becker & Geer, 1 9 5 8 ) . Becker et a l . (1961) r e p o r t that students enter medical school w i t h i d e a l i s -t i c , humanitarian, s e r v i c e - o r i e n t e d a t t i t u d e s about the prac-t i c e of medicine; however, they q u i c k l y l e a r n that the exigencies of g e t t i n g through medical school n e c e s s i t a t e s e t t i n g aside these i d e a l s and addressing t h e i r a t t e n t i o n to matters of immediate concern, such as passing examinations and favourably impressing f a c u l t y . Although t h e i r a t t i t u d e s may appear c y n i c a l to o u t s i d e r s , the researchers found that the s i t u a t i o n was that of postponment of i d e a l s to a futu r e time. Toward the end of the f o u r t h year, as graduation approaches, the student regains h i s former i d e a l i s m , but i n a more informed v e r s i o n (Becker et a l . , chap. 2 1 ) . A major dimension of t h e i r a n a l y s i s i s the i d e n t i f i c a t i o n and d e s c r i p t i o n of "student c u l t u r e " , which occurs i n response to the need f o r mutual support i n the development of s t r a t e g i e s and s h o r t - c u t s f o r d i s c o v e r i n g "what the f a c u l t y wants them to know" and a s s i s t i n g each other to l e a r n i t . The c l a s s becomes a c o l l e c t i v e , cohesive group which maintains i t s s o l i d a r i t y throughout medical school (Becker et a l . , 1 9 6 1 , pp. 7 0 - 1 9 6 ; 4 3 5 - 4 3 7 ) . 27 P r o f e s s i o n a l S o c i a l i z a t i o n i n Nursing Role A c q u i s i t i o n Although most authors have w r i t t e n t h e o r e t i c a l d i s c u s s i o n s about p r o f e s s i o n a l s o c i a l i z a t i o n i n n u r s i n g , a number of s t u d i e s based on e m p i r i c a l data have generated s i g n i f i c a n t f i n d i n g s . Most of these s t u d i e s were l i m i t e d to the examination of f a i r l y narrow aspects of p r o f e s s i o n a l s o c i a l i z a t i o n , and n e i t h e r t e s t e d nor c o n t r i b u t e d to the f o r m u l a t i o n of a conceptual framework f o r the process as a whole. Olesen and Whittaker (1968) conducted an i n t e n s i v e q u a l i t a t i v e research p r o j e c t on the c l a s s of n u r s i n g students entering the baccalaureate programme at the U n i v e r s i t y of C a l i f o r n i a School of Nursing (San Francisco) i n the f a l l of i960. Over a p e r i o d of three years they used p a r t i c i p a n t observation as t h e i r major data c o l l e c t i o n method, combined w i t h q u e s t i o n n a i r e s , i n t e r v i e w s , and p s y c h o l o g i c a l measure-ments (chap. I I ) . The study d i d not r e s u l t i n the d e f i n i t i o n of a model or a s e q u e n t i a l process f o r p r o f e s s i o n a l s o c i a l i z a t i o n , but r a t h e r confined i t s e l f to d e t a i l e d d e s c r i p t i o n s e>f phenomena observed during the process. Most of these phenomena were comparable to phenomena p r e v i o u s l y observed by the authors during the p r o f e s s i o n a l s o c i a l i z a t i o n of students i n law, medicine, theology, teaching, and s o c i a l work. Two aspects of the authors' d e s c r i p t i o n s and i n s i g h t s are d i f f e r e n t from t r a d i t i o n a l s o c i o l o g i c a l w r i t i n g s about 28 p r o f e s s i o n a l s o c i a l i z a t i o n to that date. F i r s t , Olesen and Whittaker ( 1968 ) perceive students as i n d i v i d u a l s who shape t h e i r r o l e and are a c t i v e l y i n v o l v e d i n t h e i r own education (p. 7 ) ; t h i s p e r s p e c t i v e comes close to Thornton and Nardi's concept of r o l e m o d i f i c a t i o n during the personal stage ( 1 9 7 5 ) ' The second poi n t made "by Olesen and Whittaker i s t h a t , f o r most students, the developmental process of s o c i a l i z a t i o n from the adolescent to the a d u l t r o l e occurs simultaneously w i t h p r o f e s s i o n a l s o c i a l i z a t i o n ; these " l a t e r a l l i f e r o l e s " may blend harmoniously, or a l t e r n a t i v e l y q u i t e uncomfortably, w i t h the process of r o l e a c q u i s i t i o n (PP. 9 - 1 0 ). Most d i s c u s s i o n s of p r o f e s s i o n a l s o c i a l i z a t i o n overlook these mutually i n f l u e n c i n g types of s o c i a l i z a t i o n . Some of the phenomena perceived by Olesen and Whittaker (1968) as inherent i n the process w i l l now be described. T h e i r d e s c r i p t i o n s of the students' pre-nursing school image of n u r s i n g correspond e x a c t l y to Thornton and Nardi's d e s c r i p t i o n of r o l e conceptions during the a n t i c i p a t o r y stage. Questionnaires administered by Olesen and Whittaker i n d i c a t e d that most of the students' e n t e r i n g views of n u r s i n g and of themselves as nur s i n g students tended to be non-s e l e c t i v e , u n d i f f e r e n t i a t e d , and i d e a l i s t i c ( 1 9 6 8 , p. 1 0 6 ) . Furthermore, most students entered n u r s i n g school very confident of success and s a t i s f a c t i o n — a phenomenon l a b e l l e d by the authors as " i n i t i a l bravado". R e l a t i v e l y few students a n t i c i -pated s i g n i f i c a n t l e v e l s of a n x i e t y or s t r e s s (pp. 1 0 2 - 1 0 6 ) . A set of s t r a t e g i e s and p e r s p e c t i v e s , adopted by i n d i v i d u a l 29 students.to v a r y i n g degrees, and f r e q u e n t l y hidden from f a c u l t y view, are l a b e l l e d "by Olesen and Whittaker as "studentmanship" ( 1 9 6 8 , chap. V I ) . The s t r a t e g i e s - a r e very s i m i l a r to those described by Becker et a l . (196l) as student c u l t u r e i n medical school. According to Olesen and Whittaker, studentmanship f u n c t i o n s to suggest answers to a p e r p e t u a l l y prob-l e m a t i c i s s u e a how to get through school w i t h the gr e a t e s t comfort and the l e a s t e f f o r t , p r e s e r v i n g oneself as a person, while at the same time being a success and a t t a i n i n g the n e c e s s i t i e s f o r one's fu t u r e l i f e . (p. 150) Included i n the a r t of studentmanship are s t r a t e g i e s such as "psyching out" the i n s t r u c t o r s i n order to a r r i v e at a determination of t h e i r exact expectations; " f r o n t i n g " , or p r o j e c t i n g an image which the student b e l i e v e s w i l l be favourable i n the eyes of f a c u l t y , and "cooperation", a c o l l e c t i v e s t r a t e g y which i n v o l v e s p r e s e n t i n g the appearance of being more u n s o c i a l i z e d than one a c t u a l l y i s . This l a s t s t r a t e g y i s f o r the purpose of maintaining an impression of c o l l e c t i v e m e d i o c r i t y i n order to p r o t e c t students who cannot, or do not wish t o , e x c e l . Another phenomenon inherent i n r o l e a c q u i s i t i o n i s " l e g i t i m a t i o n , the process of others s a n c t i o n i n g the students' claims to the r o l e s of nurse, a d u l t , and woman" (Olesen & Whittaker, 1968, p. 201). L e g i t i m a t i o n i s sought by the student from m u l t i p l e agents of s o c i a l i z a t i o n i n c l u d i n g f a c u l t y , p a t i e n t s , p h y s i c i a n s , s t a f f nurses, and u n o f f i c i a l agents such as parents and f r i e n d s . Olesen and Whittaker 30 c l a i m "that the e n t i r e process of p r o f e s s i o n a l s o c i a l i z a t i o n can he thought of as an "agenda f o r l e g i t i m a t i o n " ( 1 9 6 8 , p. 2 0 2 ). The emergence of self-awareness i s another concept deemed s i g n i f i c a n t by the researchers to i n t e g r a t i o n of the s e l f w i t h the i d e n t i t y and r o l e of nurse ( 1 9 6 8 , chap. V I I I ) — a b e l i e f h e l d i n common wit h Thornton and N a r d i . Jones ( 1 9 7 6 ) , a s o c i o l o g i s t and a nurse, examined the comparative i n f l u e n c e of two sources of student r o l e conceptions: type of nu r s i n g programme, and demographic v a r i a b l e s of p a r e n t a l income, f a t h e r ' s education, mother's education, age, race, m a r i t a l s t a t u s , and post-secondary non-nursing education. B e v i s ' m o d i f i c a t i o n of Corwin's Nursing Role Conception Scale was the primary data c o l l e c t i o n instrument. Although the demographic v a r i a b l e s were found to c o n t r i b u t e i n d i r e c t l y to student r o l e conceptions, Jones concluded that i t was the type of n u r s i n g programme which exerted the g r e a t e s t i n f l u e n c e on eventual n u r s i n g r o l e conceptions. A s i m i l a r study (Warner & Jones, 1 9 8 1 ), a l s o u s i n g the B e v i s m o d i f i c a t i o n of Corwin's s c a l e , i n d i c a t e d t h a t , as students progress i n the baccalaureate n u r s i n g programme, t h e i r p r o f e s s i o n a l and s e r v i c e o r i e n t a t i o n s increase and bur e a u c r a t i c o r i e n t a t i o n s decrease. I t was als o found th a t students w i t h a h e a l t h p r o f e s s i o n a l i n the f a m i l y never became as p r o f e s s i o n a l l y o r i e n t e d as other students, and te s t e d higher f o r b u r e a u c r a t i c values at graduation. Way ( 1981 ) used Corwin's s c a l e to measure the 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 se r v i c e r o l e conceptions and r o l e d e p r i v a t i o n 31 of the 1980 generic and p o s t - b a s i c graduates from the U n i v e r s i t y of B r i t i s h Columbia School of Nursing. The instrument was administered to 77 students one month p r i o r to graduation, and to 37 of the same i n d i v i d u a l s s i x months a f t e r employment i n a h o s p i t a l s e t t i n g . R e s u l t s i n d i c a t e d t h a t there were no s i g n i f i c a n t d i f f e r e n c e s between the r o l e conception scores of generic and post-basic students at e i t h e r a d m i n i s t r a t i o n ( I 9 8 I , p. 37)» despite major d i f -ferences i n the educational process. A study of student perceptions of the i n f l u e n c e of s o c i a l i z i n g groups (peers, f a c u l t y , and s t a f f nurses) on p r o f e s s i o n a l i d e n t i t y development (Dalme, 1983) revealed that f i r s t year baccalaureate students appear to have l e s s t r u s t and confidence i n f a c u l t y members than do second year students. I t was a l s o found t h a t , as students progress through the programme, the i n f l u e n c e of f a c u l t y members becomes more s i g n i f i c a n t . Cohen ( 1981 ) proposes a four-stage model f o r p r o f e s s i o n a l s o c i a l i z a t i o n which i s c o n c e p t u a l l y r e l a t e d to P i a g e t ' s s t u d i e s of c o g n i t i v e development i n c h i l d r e n . The four stages, which b u i l d on each other, i n v o l v e (a) i n i t i a l acceptance and r e l i a n c e on a u t h o r i t y , f o l l o w e d by (b) c o g n i t i v e r e b e l l i o n , (c) a beginning c a p a c i t y f o r e v a l u a t i v e t h i n k i n g and i n c o r p o r a t i o n of others' ideas, and (d) i n t e g r a t i o n of independence and m u t u a l i t y . But a number of obstacles inherent i n the s t r u c t u r e of n u r s i n g education and the nature of the n u r s i n g p r o f e s s i o n are perceived by Cohen as impediments to student progression through these stages ( 1 9 8 1 , chap. 4 ) . 32 Such obstacles include an a u t h o r i t a t i v e c u l t u r e , a t r a d i t i o n of obedience and subservience, an obsession w i t h p e r f e c t i o n , and a l a c k of respect f o r the t e c h n i c a l knowledge base of nurs i n g on the part of s o c i e t y . A d e s c r i p t i o n of the fo r m u l a t i o n of an i n t e r p r o f e s s i o n a l c a r d i o v a s c u l a r h e a l t h team by the process of r o l e n e g o t i a t i o n (McKenna, 1980) serves as a n i i l l u s t r a t i o n of Thornton and Nardi's concept of r o l e m o d i f i c a t i o n . A group of h e a l t h p r o f e s s i o n a l s , i n c l u d i n g an occupational t h e r a p i s t , p h y s i c a l t h e r a p i s t , s o c i a l worker, pharmacologist, n u t r i t i o n i s t , r e g i s t e r e d nurse, and p h y s i c i a n , undertook t h i s challenge i n order to improve s e r v i c e to c a r d i o v a s c u l a r p a t i e n t s . Each person entered the s i t u a t i o n w i t h p a r t i c u l a r expectations of h i m s e l f and of others; r o l e ambiguity, r o l e c o n f l i c t , and power s t r u g g l e s were very much i n evidence during the i n i t i a l stages of group process. The team, through an o f f i c i a l process of r o l e n e g o t i a t i o n , was able to come to a consensus about mutual expectations, and implemented an i n n o v a t i v e , e f f e c t i v e programme. Gendron (1981) proposes an i n t e r e s t i n g s t r a t e g y f o r the s o c i a l i z a t i o n of n u r s i n g students. Her argument r e s t s on the premise that many students enter n u r s i n g with the per-c e p t i o n t h a t c e r t a i n "symbolic a c t s " are r e p r e s e n t a t i v e of the nurse's r o l e . Such ac t s are u s u a l l y t e c h n i c a l procedures such as a d m i n i s t e r i n g i n j e c t i o n s and changing dressings. Because most n u r s i n g programmes delay g i v i n g the students opportunity to perform these f u n c t i o n s , students f e e l d i s i l l u s i o n e d and f r u s t r a t e d w i t h t h e i r educational programme. 33 Gendron b e l i e v e s that g i v i n g students the opportunity to p r a c t i c e tasks w i t h symbolic meaning e a r l i e r would help them " f e e l l i k e a nurse". She goes on to p o i n t out t h a t f a c u l t y could then b u i l d upon student l a y conceptions of the n u r s i n g r o l e and f a c i l i t a t e s o c i a l i z a t i o n to broader n u r s i n g r o l e conceptions. Role C o n f l i c t Benne and Bennis (1959a; 1959^ ) were among the f i r s t to study r o l e c o n f l i c t i n n u r s i n g and i d e n t i f y i t as an impedi-ment to the growth of the i n d i v i d u a l p r o f e s s i o n a l and of the n u r s i n g p r o f e s s i o n . S h o r t l y t h e r e a f t e r , Corwin (i960; 196la, 196lb) developed the Nursing Role Conception S c a l e , a three-part scale which was designed to measure 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 s e r v i c e r o l e conceptions. The instrument c o n s i s t s of 22 h y p o t h e t i c a l s i t u a t i o n s ; the respondent i s r e q u i r e d to respond to each s i t u a t i o n from two d i f f e r e n t p e r s p e c t i v e s - - h i s perception of the i d e a l i n n u r s i n g , and h i s perception of the a c t u a l s i t u a t i o n i n n u r s i n g p r a c t i c e . The d i f f e r e n c e between the two p e r s p e c t i v e s i s the r o l e d e p r i v a t i o n . Studies conducted by Corwin (i960; 196la; 196lb) and Corwin and Taves (1962) i n d i c a t e that graduates from baccalaureate n u r s i n g programmes (a) have higher p r o f e s s i o n a l r o l e conceptions than do diploma graduates, and (b) are more s u s c e p t i b l e to r o l e d e p r i v a t i o n , and thus to r o l e c o n f l i c t . Kramer (1966) used Corwin's instrument to study the 3^ e f f e c t of employing bureaucracies on neophyte nurses. She found that nurses i n d i c a t e d a s i g n i f i c a n t increase i n bu r e a u c r a t i c r o l e conceptions, and a continuous drop i n p r o f e s s i o n a l r o l e conceptions during the f i r s t s i x months of employment (pp. 7 7 - 7 8 ) - There was also an increase i n r o l e d e p r i v a t i o n scores during the f i r s t three months of employment. Her f i n d i n g that subjects w i t h high p r o f e s -s i o n a l and high b u r e a u c r a t i c scores a l s o had the highest r o l e d e p r i v a t i o n scores l e d her to the conclusion that simultaneous a l l e g i a n c e to both c u l t u r e s was as s o c i a t e d w i t h r o l e c o n f l i c t (p. 7 7 )• Subjects who dropped out of n u r s i n g , changed jobs because of d i s s a t i s f a c t i o n , or undertook more formal education, tended to have higher r o l e d e p r i v a t i o n scores than d i d those who remained on the job f o r s i x months (p. 7 7 ) . In a study of f a c t o r s c o n t r i b u t i n g to success i n h o s p i t a l n u r s i n g (Kramer, 1970 ; Kramer & Baker, 1971) Corwin's scale was again used, and r e s u l t e d i n the f o l l o w i n g f i n d i n g s : (a) Nurses r a t e d as h i g h l y s u c c e s s f u l had higher b u r e a u c r a t i c r o l e conceptions than d i d l e s s s u c c e s s f u l nurses, and (b) l e s s s u c c e s s f u l nurses had higher r o l e d e p r i v a t i o n scores, and thus more severe r o l e c o n f l i c t . Kramer and Baker ( 1971 ) a l s o found that nurses who l e f t n u r s i n g tended to have higher p r o f e s s i o n a l values. The term " r e a l i t y shock" was coined by Kramer ( 1974 ) and defined as f o l l o w s : the phenomenon and the s p e c i f i c s h o c k l i k e r e a c t i o n s of new workers when they f i n d themselves i n a work s i t u a t i o n f o r which they have spent s e v e r a l years preparing and f o r which they thought they were going to be prepared, and then suddenly f i n d that they are not. (pp. v i i - v i i i ) 35 R e a l i t y shock stems from the f a c t that many p r o f e s s i o n a l i d e a l s and values taught i n the educational programme are impossible to p r a c t i c e and go unrewarded i n the work s e t t i n g (Kramer, 1974 , p. v i i i ) . An " a n t i c i p a t o r y s o c i a l i z a t i o n program", designed by Kramer as a supplement to the r e g u l a r n u r s i n g programme f o r the purpose of minimizing r e a l i t y shock ( 1 9 7 4 , chap. 3 ) . has r e a l i z e d some success (p. 1 3 4 ) . More r e c e n t l y , Kramer and Schmalenberg (1978) have de-veloped a " b i c u l t u r a l t r a i n i n g program" to a s s i s t new graduates i n the h o s p i t a l s e t t i n g to i n t e g r a t 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 behaviours. New graduates who have par-t i c i p a t e d i n t h i s programme have tended to r e t a i n higher p r o f e s s i o n a l r o l e conceptions (p. 27) and demonstrate more b i c u l t u r a l behaviours (p. 2 9 ) . F o l l o w i n g the p u b l i c a t i o n of Corwin's Nursing Role Conception S c a l e , the problem of r o l e c o n f l i c t i n n u r s i n g was discussed under the more r e f i n e d term, " 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 problem was described as a con-f l i c t between p r o f e s s i o n a l values such as autonomy, whole-task o r i e n t a t i o n , s e l f - e v a l u a t i o n , and c o l l e g i a l r e l a t i o n s h i p s w i t h others; and b u r e a u c r a t i c values such as adherence to r u l e s , e f f i c i e n c y , and h i e r a r c h i c a l r e l a t i o n s h i p s . Many nu r s i n g authors began to document the existence of and describe t h i s problem (Johnson, 1971 ; Malone, 1964; Seward, 1969; Simms, 1977; Watson, 1 9 7 7 ) . The problem of 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 s a pre s s i n g one f o r n u r s i n g education. The r o l e c o n f l i c t experienced by nursing students when confronted by c o n f l i c t i n g 36 expectations of n u r s i n g i n s t r u c t o r s and head nurses i s described- by Smith (19?8), who maintains that the c o n f l i c t d i s t r a c t s the student from l e a r n i n g and i n t e r f e r e s w i t h c a r i n g f o r the p a t i e n t . S t i n s o n (1973a) b e l i e v e s that the much-discussed n u r s i n g s e r v i c e - n u r s i n g education dichotomy i s a smaller p a r t of the l a r g e r problem of 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 suggests that the key to a r e s o l u t i o n l i e s w i t h both p a r t i e s f u l f i l l i n g t h e i r commitment to act i n the best i n t e r e s t s of the p a t i e n t . Other s t r a t e g i e s she suggests (1973^0 are t r y i n g to g a i n a b e t t e r understanding of the other party's p e r s p e c t i v e , making d e c i s i o n s about student l e a r n i n g experiences at the n u r s i n g u n i t l e v e l , encouraging n u r s i n g s t a f f to p a r t i c i p a t e i n teaching students, j o i n t appointments, and co-authoring of a r t i c l e s by n u r s i n g i n s t r u c t o r s and n u r s i n g p r a c t i t i o n e r s . Another dimension of the s e r v i c e - e d u c a t i o n dichotomy i s i l l u s t r a t e d i n s t u d i e s conducted by Krueger (1967) and B r i e f , V a n S e l l , Aldag, and Melone (1979). Both s t u d i e s i n d i c a t e d that there i s a d i s p a r i t y between t h e o l o g i c a l use of nurses i n the work s e t t i n g according to t h e i r c a p a b i l i t i e s (as achieved i n t h e i r educational programmes), and t h e i r a c t u a l on-the-job a c t i v i t i e s . P r o f e s s i o n a l i s m and Nursing A u t h o r i t i e s appear to be i n general agreement about the nature of and c r i t e r i a f o r professionalism.-Greenwood (1966, pp. 10-19) describes f i v e d i s t i n g u i s h i n g a t t r i b u t e s of a 37 p r o f e s s i o n : 1. A systematic body of theory: A c q u i r i n g t h i s body of theory i n v o l v e s lengthy, r i g o r o u s , formal education, u s u a l l y i n a u n i v e r s i t y s e t t i n g . Greenwood in c l u d e s a commitment to research (to expand the body of knowledge), continuous l e a r n i n g , and c r i t i c a l t h i n k i n g as elements of t h i s a t t r i b u t e . 2. P r o f e s s i o n a l a u t h o r i t y : This a t t r i b u t e r e l a t e s to the autonomy a f f o r d e d a p r o f e s s i o n a l because of the p r o f e s s i o n ' s monopoly over the knowledge underlying i t s unique s e r v i c e . 3. Sanction of the community: The powers and p r i v i l e g e s conferred upon the p r o f e s s i o n by s o c i e t y comprise t h i s a t t r i b u t e . Powers inc l u d e c o n t r o l of the p r o f e s s i o n over education and admission to the p r o f e s s i o n . P r i v i l e g e s i n c l u d e c o n f i d e n t i a l i t y and freedom from l a y judgment on pr o f e s s i o n a l matters. P r o f e s s i o n a l s are judged by t h e i r peers. 4. Regulative code of e t h i c s : The purpose of such a code i s to prevent the abuse of powers and p r i v i l e g e s . Standard elements inc l u d e an emotional n e u t r a l i t y to the c l i e n t , a requirement to provide s e r v i c e f o r whomever asks i t , a commitment to maximum c a l i b e r s e r v i c e under a l l circumstances, and p r o v i s i o n f o r i n t e r n a l d i s c i p l i n e procedures ( u s u a l l y under the auspices of a p r o f e s s i o n a l a s s o c i a t i o n ) . 5- A p r o f e s s i o n a l c u l t u r e : The values of the p r o f e s s i o n and standards f o r p r o f e s s i o n a l p r a c t i c e are i n c l u d e d i n t h i s c r i t e r i o n . Also i n c l u d e d i s the concept of an a l t r u i s t i c , s e r v i c e - o r i e n t e d m o t i v a t i o n f o r p r a c t i c e . Moore (1970, pp. 5-l6) and Yarmolinsky (1978, pp. 159-160) 38 define p r o f e s s i o n a l i s m i n e s s e n t i a l l y the same terms. The c r i t e r i o n 6f autonomy i s i d e n t i f i e d by Moore ( 1 9 7 0 , p. 16) as the u l t i m a t e goal f o r an occupational group which a s p i r e s to p r o f e s s i o n a l i z a t i o n . Nursing authors, a l s o i n general agreement about the nature of p r o f e s s i o n a l n u r s i n g , have r e l a t e d c r i t e r i a f o r p r o f e s s i o n a l i s m s p e c i f i c a l l y to the p r a c t i c e of n u r s i n g . Watson ( 1981) i d e n t i f i e s four major p r o f e s s i o n a l values f o r nu r s i n g : a s e r v i c e o r i e n t a t i o n ; r e c o g n i t i o n of the d i g n i t y and worth of each person, expressed as a commitment to act i n the best i n t e r e s t of the p a t i e n t and f a m i l y ; a commitment to education, i n c l u d i n g research and continuous l e a r n i n g ; and autonomy, i n c l u d i n g freedom to use knowledge and s k i l l s i n the s e r v i c e of the p a t i e n t , and a u t h o r i t y to ensure'safe, e f f e c t i v e d e l i v e r y of n u r s i n g care. Davis, Kramer, and Strauss ( 1 9 7 5 , P- v i i ) i d e n t i f y care of the whole p a t i e n t , r a t h e r than segmented care, as the key value of p r o f e s s i o n a l n u r s i n g . S c h l o t f e l d t ' s d i s c u s s i o n (1974) i s i n general agreement wi t h others; however, she a l s o subscribes to the b e l i e f that a p r o f e s s i o n a l has the expecta-t i o n of appropriate remuneration (p. 2 8 ) . Wang and Watson (1977) describe p r o f e s s i o n a l n u r s i n g i n the same terms as authors discussed above. The Canadian Nurses A s s o c i a t i o n (1980) s p e c i f i e s the use of a conceptual model f o r n u r s i n g as the b a s i s f o r the independent part of nu r s i n g p r a c t i c e , and the use of the n u r s i n g process as standards f o r p r o f e s s i o n a l n u r s i n g p r a c t i c e . Adam ( I98O) supports the above standards i n her argument that the use of a conceptual model f o r n u r s i n g 39 w i l l strengthen the t h e o r e t i c a l knowledge "base of the p r o f e s s i o n (p. v i i ) . An....interesting s i d e l i n e here i s that Watson ( 1 9 8 1 , p. 297) questions the wisdom of u s i n g a s i n g l e conceptual model as the b a s i s f o r c u r r i c u l u m con-s t r u c t i o n — a p r a c t i c e which i s becoming widespread i n n u r s i n g education. Conway (1983) i d e n t i f i e s the p r i n c i p a l task f o r the p r o f e s s i o n a l i z a t i o n of n u r s i n g as the develop-ment of i t s knowledge base (p. 3 0 ) . Jacox (1978) i d e n t i f i e s three major c r i t e r i a f o r p r o f e s s i o n a l i s m i n n u r s i n g : (a) a long p e r i o d of s p e c i a l i z e d education, i n c l u d i n g a commitment to research and continuous l e a r n i n g ; (b) a s e r v i c e o r i e n t a t i o n , expressed as a commit-ment to a c t i n g i n the best i n t e r e s t s of the p a t i e n t ; and (c) autonomy, meaning that the p r o f e s s i o n i s s e l f - r e g u l a t i n g , members have c o n t r o l over t h e i r f u n c t i o n s i n the work s e t t i n g , and members are evaluated by t h e i r peers. Autonomy i s iden-t i f i e d as the c r i t e r i o n on which n u r s i n g has made the l e a s t progress ( 1 9 7 8 , p. 1 4 ) . Because Jacox* a n a l y s i s (1978) i s s t r a i g h t f o r w a r d , comprehensive, and co n s i s t e n t w i t h other l i t e r a t u r e , i t was se l e c t e d as the framework f o r a summary of the c h a r a c t e r i s t i c s of p r o f e s s i o n a l n u r s i n g . This summary o u t l i n e s Jacox' three major c r i t e r i a ; i t a l s o elaborates upon and adds to them, u s i n g ideas from the other w r i t i n g s reviewed above. The c r i t e r i a f o r p r o f e s s i o n a l i s m i n n u r s i n g are summarized as f o l l o w s : 1. Commitment to education: This c r i t e r i o n r e f e r s to 40 a lengthy, r i g o r o u s education i n an academic s e t t i n g . I t i n c l u d e s the concepts of research to expand the body of knowledge, continuous l e a r n i n g , and c r i t i c a l t h i n k i n g . 2. S e r v i c e o r i e n t a t i o n : Values r e l a t e d to a c t i n g i n the best i n t e r e s t of the p a t i e n t are i n c l u d e d i n t h i s a t t r i b u t e , i n c l u d i n g a l t r u i s t i c m o t i v a t i o n , h o l i s t i c care, the use of a conceptual model f o r n u r s i n g and the n u r s i n g process, p a t i e n t teaching, p a t i e n t involvement i n n u r s i n g care, c o n f i d e n t i a l i t y , and a b e l i e f i n the worth of the s e r v i c e provided. Values a n t i t h e t i c a l to t h i s c h a r a c t e r i s t i c i n c l u d e a task o r i e n t a t i o n , emphasis on e f f i c i e n c y , emphasis on completing forms and o r d e r i n g s u p p l i e s , and i m p e r s o n a l i t y i n human r e l a t i o n s . 3 . Autonomy: This c r i t e r i o n r e f e r s to values such as a s e l f - r e g u l a t i n g p r o f e s s i o n a l a s s o c i a t i o n , c o n t r o l over education and entry to p r a c t i c e , i n d i v i d u a l c o n t r o l of func-t i o n s i n the work s e t t i n g , a c t i n g as a change agent, use of peer and s e l f - e v a l u a t i o n , c o l l e g i a l r e l a t i o n s h i p s w i t h other h e a l t h p r o f e s s i o n a l s , a s s e r t i v e n e s s , use of sound judgment, c r e a t i v i t y , and a q u e s t i o n i n g approach to e s t a b l i s h e d r o u t i n e . A n t i t h e t i c a l values i n c l u d e compliance, obedience, h i e r a r c h i c a l r e l a t i o n s h i p s , and s t r i c t adherence to r o u t i n e s and procedures. 4. P a r t i c i p a t i o n i n the p r o f e s s i o n a l a s s o c i a t i o n : T h i s a t t r i b u t e i n c l u d e s attendance at meetings, p r o v i d i n g input to the a s s o c i a t i o n , and p a r t i c i p a t i n g i n the work of the a s s o c i a t i o n . 41 5 . A c c o u n t a b i l i t y : This value r e f e r s to accepting r e s p o n s i b i l i t y f o r one's a c t i o n s . 6 . E x p e c t a t i o n of appropriate remuneration: Although secondary to a l t r u i s t i c c o n s i d e r a t i o n s , t h i s a t t r i b u t e i s based on the b e l i e f that s o c i e t y w i l l not value a. pro-f e s s i o n a l ' s c o n t r i b u t i o n i f he himself does not. . The above summary was used to formulate the t a b l e of s p e c i f i c a t i o n s f o r the i n i t i a l item p o o l , which was pre-t e s t e d f o r t h i s study. "The' Measurement of A t t i t u d e s S e l f - r e p o r t a t t i t u d e ' s c a l e s have been assessed by numerous a u t h o r i t i e s (Gorden, 1 9 7 7 , P- 1; Nunnally, 1 9 7 0 , p. 4 2 1 ; 1 9 7 8 , p. 5 9 1 ; P o l i t & Hungler, 1 9 7 8 , p. 350) as the most v a l i d , d i r e c t , and u b i q u i t o u s approach f o r measuring human a t t i t u d e s . Although they are l i m i t e d " to the extent of i n d i v i d u a l s ' i n s i g h t i n t o t h e i r own a t t i t u d e s and t h e i r w i l l i n g n e s s to share them, these l i m i t a t i o n s are not con-s i d e r e d severe enough to d e t r a c t s i g n i f i c a n t l y from the usef u l n e s s of the s c a l e s (Nunnally, 1 9 7 0 , p. 4 2 1 ; 1 9 7 8 , p.. -591) . But a word of warning about the above l i m i t a t i o n s i s i n order. Researchers u s i n g s e l f - r e p o r t measures to c o l l e c t data can only assume t h a t , to the best of t h e i r a b i l i t y , respondents w i l l give honest r e p l i e s ; however, there are numerous reasons to f a l s i f y responses. D i s t o r t e d or f a l s e 42 r e p o r t i n g may be d e l i b e r a t e or subconscious ( P h i l l i p p s , 1971, pp. 2 5 - 2 6 ). One type of d i s t o r t e d r e p o r t i n g i s the response set, defined by Robinson et a l . (1974) as f o l l o w s : "a tendency on the part of i n d i v i d u a l s to respond to a t t i t u d e statements f o r reasons other than the content of the s t a t e -ments" (p. 247 )• Making the scale as i n t e r e s t i n g and pleasant as p o s s i b l e f o r the respondent i s recommended as a b a s i c preventive measure (Robinson et a l . , 1974, p. 247). One type of response set, termed "acquiescence", occurs when the respondent tends to agree with everything. Varying the item wording from p o s i t i v e to negative has been suggested as a technique to combat t h i s phenomenon, but the l i t e r a t u r e i s c o n f l i c t i n g as to. the value of t h i s measure (Robinson et a l . , 1974, pp. 247-248). A p a r t i c u l a r l y troublesome type of response set i s " s o c i a l d e s i r a b i l i t y " , which i n v o l v e s respondents s e l e c t i n g options which they perceive to be more s o c i a l l y acceptable i n order to avo i d f e e l i n g s of personal discomfort or appre-hension ( P h i l l i p s , 1971, PP. 2 5 - 2 6 ; Robinson et a l . , 1974, pp. 248-249). Although i t i s f e l t that t h i s type of b i a s i s impossible to el i m i n a t e e n t i r e l y , guaranteeing respondents anonymity i s recommended as a st r a t e g y f o r minimizing t h i s d i s t o r t i o n (Fox, 1976, p. 2 3 5 ) . Thurstone s c a l e s , L i k e r t s c a l e s , Guttman s c a l e s , and the semantic d i f f e r e n t i a l are the methods of s c a l i n g a t t i t u d e s c u r r e n t l y i n common use (Nunnally, 1978, pp. 602-604; 6 0 7 - 6 0 9 ; P o l i t & Hungler, 1978, pp. 3 6 O - 3 6 9 ) • ^3 Thurstone s c a l e s have "been assessedjby P o l i t and Hungler ( 1 9 7 8 , p. 360) as l e s s u s e f u l than others because of t h e i r complexity and methodological shortcomings. A t y p i c a l study r e q u i r e s the use of 100 judges (Nunnally, 1978 , p. 6 0 3 ) . Guttman s c a l e s are considered by Nunnally ( 1 9 7 8 , p. 602) to be i m p r a c t i c a l because only gross d i s c r i m i n a t i o n s among i n d i v i d u a l s can be derived. P o l i t and Hungler ( 1978) r e p o r t that semantic d i f f e r e n t i a l s are analyzed u s i n g s p e c i f i c , s o p h i s t i c a t e d techniques (p. 3 6 8 ) . L i k e r t s c a l e s appear more p r a c t i c a l than the other types mentioned because they are e a s i e r to construct and analyze than the semantic d i f f e r e n t i a l , and do not share the disadvantages of Thurstone and Guttman sc a l e s i d e n t i f i e d above. L i k e r t s c a l e s , a l s o c a l l e d summative s c a l e s , have been assessed by Nunnally (1970) as possessing the f o l l o w i n g advantages over a l l other methods: They (1) f o l l o w from an appealing model, ( 2 ) are r a t h e r easy to co n s t r u c t , (3 ) u s u a l l y are h i g h l y r e l i a b l e , (4) can be adapted to the measurement of many d i f f e r e n t kinds of a t t i t u d e s , and (5 ) have produced meaningful r e s u l t s i n many st u d i e s to date. (p. 604) For the reasons d e l i n e a t e d above i t was decided to develop a L i k e r t scale to measure p r o f e s s i o n a l r o l e a t t i t u d e s f o r t h i s study. A L i k e r t scale c o n s i s t s of a pool of p o s i t i v e l y and n e g a t i v e l y worded statements (or items) w i t h which respondents are asked to i n d i c a t e v a r y i n g degrees of agreement (Nunnally, 1978 , p. 6 0 5 ) . 44 Summary and I m p l i c a t i o n s f o r the Current Study I t has been e s t a b l i s h e d that a major r e s p o n s i b i l i t y of n u r s i n g education i s to f a c i l i t a t e the s o c i a l i z a t i o n of n u r s i n g students i n t o the a t t i t u d e s and values of the.pro-f e s s i o n a l n u r s i n g r o l e . Values can be taught ( R e i l l y , 19?8b ) , but a knowledge of p r o f e s s i o n a l i s m and the p r o f e s s i o n a l s o c i a l i z a t i o n process i s a fundamental p r e r e q u i s i t e to such teaching. To provide a b a s i s f o r understanding the process of p r o f e s s i o n a l s o c i a l i z a t i o n , w r i t i n g s i n psychology and s o c i o l o g y and the nursing l i t e r a t u r e on p r o f e s s i o n a l r o l e a c q u i s i t i o n were examined. I t was found t h a t , over the past s e v e r a l decades, t h e o r i e s of p r o f e s s i o n a l s o c i a l i z a t i o n have become p r o g r e s s i v e l y more'complex, and have portrayed the s o c i a l i z e e as an i n c r e a s i n g l y a c t i v e agent i n h i s own s o c i a l i z a t i o n . Role c o n f l i c t was found to be an obstacle which can i n t e r f e r e w i t h the process of r o l e a c q u i s i t i o n . Thornton and Nardi's theory on r o l e a c q u i s i t i o n was examined i n d e t a i l because i t i s a comprehensive model which can be r e a d i l y a p p l i e d to the p r o f e s s i o n a l s o c i a l i z a t i o n of n u r s i n g students. Once the appropriate a t t i t u d e s and values have been taught, the e f f e c t i v e n e s s of that teaching can and should be evaluated ( R e i l l y , 1978a). A necessary p r e r e q u i s i t e f o r e v a l u a t i n g a t t i t u d e s and values i s an instrument w i t h which to measure them. The l i t e r a t u r e on the nature of p r o f e s s i o n -a l i s m and p r o f e s s i o n a l n u r s i n g was reviewed to provide the 45 knowledge and understanding necessary for the construction of such an instrument. The decision to construct an instrument necessitates a further decision about what kind of instrument to develop. An examination of the l i t e r a t u r e on the measurement of attitudes resulted i n the conclusion that a L i k e r t scale i s an e f f e c t i v e , p r a c t i c a l , powerful tool f o r attitude measurement. CHAPTER I I I METHODOLOGY Overview An a t t i t u d e s cale based on the L i k e r t technique was developed to measure the p r o f e s s i o n a l r o l e a t t i t u d e s of diploma n u r s i n g students. The instrument was developed according to the methodology suggested i n the l i t e r a t u r e on the c o n s t r u c t i o n of a L i k e r t s c a l e . Procedures f o r const-r u c t i o n of the instrument were a l s o designed i n accordance w i t h the major c r i t e r i a f o r v a l i d i t y . The o r i g i n a l 60 items were c r i t i q u e d by a panel of n u r s i n g i n s t r u c t o r s and r e v i s e d s e v e r a l times p r i o r to a d m i n i s t r a t i o n . The data producing sample c o n s i s t e d of a l l consenting students e n r o l l e d i n fou r diploma n u r s i n g programmes l o c a t e d i n B r i t i s h Columbia. Completed instruments were scored by hand;;, data were analyzed by computer. On the b a s i s of the c o r r e l a t i o n of each item w i t h the t o t a l score, 40 items were s e l e c t e d f o r the f i n a l instrument. R e l i a b i l i t y was assessed f o r i n t e r n a l consistency. F a c t o r a n a l y s i s was attempted f o r the purpose of i d e n t i f i c a -t i o n of item c l u s t e r s which might c o n s t i t u t e appropriate subscales f o r the instrument. 46 47 Development of the O r i g i n a l Item Pool  Nature of the Statements A L i k e r t s c a l e c o n s i s t s of a c o l l e c t i o n of statements (or items) w i t h which respondents are asked to i n d i c a t e v a r y i n g degrees of agreement or approval. L i k e r t emphasizes the importance of c l e a r , concise statements, and recommends frequent use of the word "should" to i n d i c a t e expressions of d e s i r e d behaviour r a t h e r than f a c t ( L i k e r t , 1 9 7 4 , p. 2 3 4 ) . The item pool should be approximately evenly d i v i d e d between p o s i t i v e l y and n e g a t i v e l y worded items ( L i k e r t , 1 9 7 4 , pp. 2 3 4 - 2 3 5 ; Nunnally, 1 9 7 8 , p. 6 0 5 ). Nunnally ( 1 9 7 8 , p. 605) cautions that n e u t r a l statements and extreme s t a t e -ments i n a p o s i t i v e or negative d i r e c t i o n should be avoided because they tend to be l e s s d i s c r i m i n a t i n g than moderately p o s i t i v e and moderately negative statements. The d i s t r i b u -t i o n of p o s i t i v e and negative statements throughout the instrument should be "haphazard" ( L i k e r t , 1 9 7 4 , p. 2 3 5 ) -The o r i g i n a l item pool f o r the study was developed i n accordance w i t h the above recommendations. An equal number of moderately p o s i t i v e and negative items were d i s t r i b u t e d i n a haphazard manner throughought the p o o l . Items were c r i t i q u e d by n u r s i n g educators and r e v i s e d s e v e r a l times to avoid ambiguity. Number of Items The number of items appropriate f o r the i n i t i a l pool 48 of statements i s not s p e c i f i e d i n the l i t e r a t u r e . Most a u t h o r i t i e s suggest that considerably more items should be developed f o r the t e s t i n g stage than are d e s i r e d f o r the f i n a l instrument. Nunnally ( 1 9 7 8 , p. 605) i n d i c a t e s that 40 items are the maximum commonly r e q u i r e d i n an a t t i t u d e s c a l e . Since there i s general agreement i n the l i t e r a t u r e that longer s c a l e s increase r e l i a b i l i t y , i t was decided to generate a pool of 60 items; 20 of these items were l a t e r e l i m i n a t e d . Number of Steps on the Scale The matter of the appropriate number of steps to i n d i c a t e degrees of agreement i n the scale i s c o n t r o v e r s i a l . Nunnally ( I 9 7 8 ) r e p o r t s the f o l l o w i n g : As the number of scale steps i s increased from 2 up through 2 0 , the increase i n r e l i a b i l i t y i s very r a p i d at f i r s t . I t tends to l e v e l o f f at about 7 » and a f t e r about 11 steps there i s l i t t l e g ain i n r e l i a b i l i t y from i n c r e a s i n g the number of steps, (p. 595) L i k e r t h i m s e l f (1974) used a 5-point s c a l e . Another issue regarding the number of steps i s whether to use an odd or even number. An odd number allows f o r an undecided or n e u t r a l response, whereas an even number f o r c e s the respondent to i n d i c a t e some degree i n the d i r e c t i o n of agreement or disagreement. The d e c i s i o n about the appropriate number of steps i s u s u a l l y l e f t to the judgement of the i n v e s t i g a t o r (Nunnally, 1 9 7 8 , p. 5 9 6 ) . On the grounds that respondents might 49 l e g i t i m a t e l y have n e u t r a l f e e l i n g s about some items, i t was f e l t t h a t p r o v i s i o n f o r a n e u t r a l response would a l l o w respondents to express n e u t r a l f e e l i n g s and thereby reduce problems of nonresponse to items. A 7-point s c a l e was used i n order to provide f o r a n e u t r a l response and to maximize the r e l i a b i l i t y of the instrument. V a l i d i t y " V a l i d i t y r e f e r s to the degree to which an instrument measures what i t i s supposed to be measuring" ( P o l i t & Hungler, 1 9 7 8 , p. 4 3 4 ) . Three types of v a l i d i t y are iden-t i f i e d as being of common concern: c r i t e r i o n - r e l a t e d v a l i d i t y , c onstruct v a l i d i t y , and content v a l i d i t y . C r i t e r i o n - r e l a t e d v a l i d i t y i n v o l v e s e s t a b l i s h i n g a r e l a t i o n s h i p between the instrument being developed and some other c r i t e r i o n . The American P s y c h o l o g i c a l A s s o c i a t i o n (APA) suggests t h a t t h i s type of v a l i d i t y i s most important f o r instruments developed f o r p r e d i c t i v e purposes ( 1 9 7 4 , pp. 2 6 - 2 8 ) . Furthermore, an appropriate c r i t e r i o n must be a v a i l a b l e against which to v a l i d a t e the instrument. " A l l too o f t e n , t e s t s are v a l i d a t e d against any a v a i l a b l e c r i t e r i o n w i t h no corresponding i n v e s t i g a t i o n of the c r i t e r i o n i t s e l f " (APA, 1 9 7 4 , p. 27 )• Because the instrument developed f o r t h i s study was mainly f o r d e s c r i p t i v e purposes, and because no c r i t e r i o n known to be v a l i d f o r the concept of p r o f e s s i o n a l a t t i t u d e s was i d e n t i f i e d i n the l i t e r a t u r e , c r i t e r i o n - r e l a t e d 50 v a l i d i t y was n o t c o n s i d e r e d i n the assessment o f the i n s t r u m e n t . C o n s t r u c t v a l i d i t y i s concerned w i t h the adequacy w i t h which the u n d e r l y i n g t h e o r e t i c a l a b s t r a c t concept i s measured. E v i d e n c e o f c o n s t r u c t v a l i d i t y i s n o t f o u n d i n a s i n g l e s t u d y , but r a t h e r a c c r u e s from many s t u d i e s ; a s u c c e s s i o n o f a c c e p t a n c e and r e j e c t i o n o f hypotheses about the n a t u r e o f a c o n s t r u c t l e a d s t o a b e t t e r u n d e r s t a n d i n g o f the a t t r i b u t e b e i n g measured by the i n s t r u m e n t (APA, 1974 , p. 30; N u n n a l l y , 1 9 7 8 , p. 9 9 ) . The attempt a t f a c t o r a n a l y s i s on t h e 40 i t e m s s e l e c t e d f o r the f i n a l i n s t r u m e n t c o u l d be c o n s i d e r e d a b e g i n n i n g assessment o f c o n s t r u c t v a l i d i t y . C o n t e n t v a l i d i t y r e f e r s to the adequacy w i t h w h i c h a domain o f c o n t e n t i s sampled. I f the major i n t e r e s t o f a s t u d y i s " v e r b a l i z e d a t t i t u d e s f o r t h e i r own sake, c o n t e n t  v a l i d i t y ... i s the major i s s u e " ( N u n n a l l y , 1 9 7 8 , p. 5 9 2 ) . Because the s t u d y was d e s c r i p t i v e i n n a t u r e , t h i s type o f v a l i d i t y was o f p r i m a r y c o n c e r n . N u n n a l l y i d e n t i f i e s two components o f c o n t e n t v a l i d i t y - - a r e p r e s e n t a t i v e sample o f i t e m s and " s e n s i b l e methods o f t e s t c o n s t r u c t i o n " ( 1 9 7 8 , p. 9 2 ) . I t i s b e t t e r t o a d d r e s s v a l i d i t y d u r i n g the p r o c e s s o f i n s t r u m e n t c o n s t r u c t i o n r a t h e r than to t e s t a completed i n s t r u m e n t f o r v a l i d i t y ( N u n n a l l y , 1 9 7 8 , p. 9 2 ) . N u n n a l l y ' s two components o f c o n t e n t v a l i d i t y were a t t e n d e d to i n the f o l l o w i n g manner. A T a b l e o f S p e c i f i c a t i o n s (see T a b l e I ) 51 • Table I Table of S p e c i f i c a t i o n s f o r Content Sampling P r o f e s s i o n a l C h a r a c t e r i s t i c Number I terns O r i g i n a l Item Pool of F i n a l Instrument Commitment to education 16 11 S e r v i c e o r i e n t a t i o n 16 10 Autonomy 16 10 P a r t i c i p a t i o n i n p r o f e s s i o n a l a s s o c i a t i o n 4 3 A c c o u n t a b i l i t y 4 3 E x p e c t a t i o n of appropriate remuneration J t _3 60 40 was constructed to ensure a r e p r e s e n t a t i v e sample of items. This t a b l e was based on the l i t e r a t u r e about p r o f e s s i o n a l i s m i n n u r s i n g ; the p r o f e s s i o n a l c h a r a c t e r i s t i c s i d e n t i f i e d i n the t a b l e are explained on pages 3 9 - 4 1 . S i x t y items r e p r e s e n t a t i v e of the i d e n t i f i e d p r o f e s s i o n a l c h a r a c t e r i s t i c s were developed (see Appendix B); they were evenly d i v i d e d between p o s i t i v e l y and n e g a t i v e l y worded statements. The 52 r e l a t i o n s h i p of items to each p r o f e s s i o n a l c h a r a c t e r i s t i c i s i l l u s t r a t e d i n Table I I . The assurance of " s e n s i b l e methods of t e s t c o n s t r u c t i o n " r e s t s mainly on "appeals to reason regarding ... the adequacy w i t h which the content has been cast i n the form of t e s t items" (Nunnally, 1978 , p. 93 )• In order to address t h i s concern, items were c r i t i q u e d by 12 n u r s i n g i n s t r u c t o r s from 2 B r i t i s h Columbia diploma n u r s i n g programmes. R e v i s i o n s were made, the r e v i s e d items were reviewed by 4 of the above 12 n u r s i n g i n s t r u c t o r s , and f u r t h e r minor r e v i s i o n s were undertaken. As a f u r t h e r check on item c l a r i t y , respondents were requested to i n d i c a t e d i r e c t l y on the instrument those items which they found d i f f i c u l t to i n t e r p r e t at the time of data c o l l e c t i o n . S e l e c t i o n of the Sample Nunnally ( 1 9 7 0 , p. 436) suggests a minimum of f i v e times as many subjects as items on a summative r a t i n g s c a l e . Since the o r i g i n a l instrumentfvconsistede of 6 0 i t e m s , a minimum sample s i z e of 300 was r e q u i r e d f o r the study. The p o p u l a t i o n f o r the study c o n s i s t e d of a l l students e n r o l l e d i n 4 diploma n u r s i n g programmes l o c a t e d i n B r i t i s h Columbia (N=537)• A convenience sample of 407 students was obtained from t h i s p o p u l a t i o n by approaching students i n r e g u l a r l y scheduled c l a s s e s i n A p r i l and May, 1983-53 Table I I R e l a t i o n s h i p of Items i n the O r i g i n a l Instrument to P r o f e s s i o n a l C h a r a c t e r i s t i c s I d e n t i f i e d i n the L i t e r a t u r e "Education" "Service" "Autonomy" Items Items Items P o s i t i v e Negative P o s i t i v e Negative P o s i t i v e Negative 1 11 9 3 6 2 5 17 12 20 16 7 14 23 18 30 21 10 19 34 24 35 37 15 29 39 27 40 38 22 41 45 32 48 47 26 54 46 44 55 50 43 59 49 57 56 51 60 " P r o f e s s i o n a l A s s o c i a t i o n " " A c c o u n t a b i l i t y " "Remuneration" Items Items Items P o s i t i v e Negative P o s i t i v e Negative P o s i t i v e Negative 4 28 31 13 8 25 52 42 36 58 53 33 Note. The numbers i n t h i s t a b l e r e f e r to items as they are numbered i n the o r i g i n a l instrument (see Appendix B). The designations " p o s i t i v e " and "negative" i n d i c a t e p o s i t i v e l y and n e g a t i v e l y worded items. 54 P a r t i c i p a t i o n was v o l u n t a r y and anonymous. In an i n t r o d u c t i o n to the research instrument (see Appendix A ) , attached to the f r o n t of the t o o l , students were informed of the f o l l o w i n g : (a) the general nature of the research, (b) that withdrawal from the study was a p o s s i b i l i t y at any time, (c) that r e f u s a l to p a r t i c i p a t e would not p r e j u d i c e grades or standing i n the nursing programme, and (d) that completion of the a t t i t u d e s cale and demographic data qu e s t i o n n a i r e s i g n i f i e d consent to p a r t i c i p a t e i n the study. Procedure f o r Data C o l l e c t i o n O f f i c i a l consent was obtained from the a d m i n i s t r a t i o n and n u r s i n g f a c u l t y at each educational i n s t i t u t i o n f o r conducting the study i n the agency. R e g u l a r l y scheduled c l a s s time was reserved i n each agency. The agency i n s t r u c t o r introduced the i n v e s t i g a t o r , who v e r b a l l y presented i n t r o -ductory i n f o r m a t i o n to the students i n attendance; t h i s i n f o r m a t i o n was e s s e n t i a l l y the same as that i n the w r i t t e n i n t r o d u c t i o n to the research instrument (Appendix A). The word " p r o f e s s i o n a l " was excluded from the in f o r m a t i o n i n order to avoid i n f l u e n c i n g the students' responses. Student p a r t i c i p a t i o n was requested, and opportunity to leave was provided f o r those who d i d not wish to p a r t i c i p a t e ; i t was observed t h a t only one student chose not to p a r t i c i p a t e . The i n v e s t i g a t o r was a v a i l a b l e to respond to questions. The instruments were completed and c o l l e c t e d i n a convenient 55 l o c a t i o n i n the classroom. S t a t i s t i c a l Procedures Data were coded and scored by hand, and then entered i n t o computer f i l e s f o r a n a l y s i s . The SCSS Conversational System (Nie, H u l l , F r a n k l i n , J e n k i n s , Sours, N o r u s i s , & Beadle, 1980) was the s t a t i s t i c a l computer package used f o r data a n a l y s i s . This computer package was s e l e c t e d l a r g e l y because i t was r e a d i l y a v a i l a b l e to the i n v e s t i g a t o r . S c o ring Scores f o r p o s i t i v e l y worded items were assigned using a ?-point s c a l e , w i t h a value of 7 f o r " s t r o n g l y agree" through 1 f o r " s t r o n g l y disagree". N e g a t i v e l y worded items were r e v e r s e l y scored, w i t h a value of 1 f o r " s t r o n g l y agree" through 7 for " s t r o n g l y disagree". , Item E l i m i n a t i o n and R e t e n t i o n A u t h o r i t i e s on the c o n s t r u c t i o n of L i k e r t s c a l e s are i n general agreement that items should be s e l e c t e d f o r r e t e n t i o n i n the f i n a l instrument on the b a s i s of Pearson product-moment c o r r e l a t i o n s of each i n d i v i d u a l item w i t h the t o t a l score (Gorden, 1 9 7 7 . p . 3 9 ; L i k e r t , 1974: Nunnally, 1 9 7 8 , PP- 6 0 5 - 6 0 6 ) . Separate rank-orderings of the c o r r e l a t i o n s should be made f o r both p o s i t i v e and negative statements. Then, 56 working from the top of the rank-orders downward, one would choose an equal number of p o s i t i v e and negative items f o r the f i n a l s c a l e . (Nunnally, 1 9 7 8 , p. 606) The above procedure was f o l l o w e d w i t h one m o d i f i c a t i o n . Rather than s e l e c t i n g items f o r the f i n a l s c a l e s o l e l y on the b a s i s of i t e m - t o t a l score c o r r e l a t i o n s , the n e c e s s i t y of r e t a i n i n g a r e p r e s e n t a t i v e sample of items was considered simultaneously so that v a l i d i t y would not be s a c r i f i c e d to a s i g n i f i c a n t extent. Such a m o d i f i c a t i o n i s supported by Gorden ( 1 9 7 7 , P- 40), who cautions against u s i n g i t e m - t o t a l score c o r r e l a t i o n s as the s i n g l e b a s i s f o r the f i n a l s e l e c t i o n of items; t h i s concern r e f l e c t s h i s o p i n i o n that the major weakness of the L i k e r t approach r e s t s i n the f a c t that the method of t e s t i n g i n t e r n a l consistency "does not c l e a r l y e s t a b l i s h that the items a c t u a l l y belong on a unidimensional continuum" (p. 39 )• Gorden goes on to e x p l a i n tha t : Under c e r t a i n circumstances an item which does c o r r e l a t e h i g h l y w i t h the t o t a l score does not belong on the same dimension w i t h the other items i n the set used to o b t a i n that t o t a l score. Furthermore, items which do not c o r r e l a t e w i t h the t o t a l score may a c t u a l l y belong on the continuum....They may belong to s e v e r a l i n t e r c o r r e l a t i n g s c a l e s , or each may c o n s t i t u t e a one-item scale w i t h a f i v e - p o i n t response. (p. 40) For the reasons explained above, c o r r e l a t i o n c o e f f i c i e n t s were rank-ordered s e p a r a t e l y f o r p o s i t i v e l y and n e g a t i v e l y worded items, and simultaneously f o r the p r o f e s s i o n a l c h a r a c t e r i s t i c s i d e n t i f i e d i n the Table of S p e c i f i c a t i o n s (Table I ) . Items w i t h the highest c o r r e l a t i o n c o e f f i c i e n t s were s e l e c t e d f o r each p r o f e s s i o n a l c h a r a c t e r i s t i c i n the proportions i n d i c a t e d i n Table I . Approximately equal numbers 57 of p o s i t i v e l y and n e g a t i v e l y worded items were s e l e c t e d i n each category, f o r a t o t a l of 40 items. R e l i a b i l i t y R e l i a b i l i t y r e f e r s to the degree of consistency w i t h which an instrument measures the a t t r i b u t e i t claims to measure ( P o l i t & Hungler, 1 9 7 8 , p. 424). C o e f f i c i e n t alpha, sometimes c a l l e d Cronbach's alpha, i s s a i d to be the most u s e f u l formula f o r determining r e l i a b i l i t y (Nunnally, 1 9 7 8 , p. 2 3 0 ) . The formula i s based on the variance of i n d i v i d u a l items i n comparison w i t h the variance of the t o t a l t e s t . Nunnally recommends that c o e f f i c i e n t alpha be computed f o r the items s e l e c t e d on the b a s i s of c o r r e l a -t i o n w i t h the t o t a l score; i f c o e f f i c i e n t alpha i s s u f f i c i e n t l y h igh, these items could be accepted as the f i n a l s c a l e (Nunnally, 1 9 7 8 , p. 6 0 6 ). I t i s suggested that a r e l i a b i l i t y of . 7 0 i s s u f f i c i e n t i n the e a r l y stages of research on measures of a c o n s t r u c t , and t h a t , " f o r b a s i c research, i t can be argued that i n c r e a s i n g r e l i a b i l i t i e s much beyond . 80 i s o f t e n w a s t e f u l of time and funds" (Nunnally, 1 9 7 8 , p. 245). C o e f f i c i e n t alpha was computed (by c a l c u l a t o r ) on the 40 s e l e c t e d items according to the f o l l o w i n g formula: 58 where s XJ_ i s the variance of the part-scores x^ fo r each part i n t u r n and s^x^ i s the variance of the sum of k part scores. (Cronbach, 1 9 7 0 , p. 161) F a c t o r A n a l y s i s F a c t o r a n a l y s i s i s a technique f o r i d e n t i f y i n g c l u s t e r s of r e l a t e d v a r i a b l e s ; the procedure i s r e l a t e d to content and construct v a l i d i t y (Nunnally, 1978 , pp. 1 1 2 - 1 1 3 ) . The r o l e of t h i s technique i n the c o n s t r u c t i o n of L i k e r t s c a l e s i s somewhat c o n t r o v e r s i a l . Nunnally (1978) r e p o r t s t h a t f a c t o r a n a l y s i s of the t y p i c a l item pool y i e l d s r e s u l t s which tend to be "messy" (p. 6 0 7 ); however, he goes on to say that f a c t o r a n a l y s i s of item pools f o r a t t i t u d e measure-ment tends to y i e l d more conclusive r e s u l t s because i n t e r -item c o r r e l a t i o n s tend to be greater (p. 6 0 7 ) . H i s recommendation about the use of f a c t o r a n a l y s i s i n the c o n s t r u c t i o n of a L i k e r t s c a l e i s as f o l l o w s : I f one hypothesizes a number of f a c t o r s r e l a t i n g to a p a r t i c u l a r a t t i t u d e or, l a c k i n g hypotheses, one suspects that an item pool harbors a number of strong f a c t o r s , there i s nothing wrong wit h f a c t o r - a n a l y z i n g the item pool i n i t i a l l y r a t h e r than proceeding d i r e c t l y to the c o n s t r u c t i o n of a homogeneous s c a l e , as was o u t l i n e d p r e v i o u s l y . (Nunnally, 1978 , p. 607) Robinson et a l . (1974) r e p o r t t h a t , where i n t e r i t e m c o r r e l a t i o n s range from approximately . 1 5 to . 4 5 , the r e s u l t s of f a c t o r a n a l y s i s w i l l l i k e l y be u n d e f i n i t i v e (pp. 2 5 2 - 2 5 3 ) . They go on to argue that "on balance, however, one i s f u r t h e r ahead performing such a n a l y s i s than not doing so" (p. 2 5 3 ) • F a c t o r a n a l y s i s on the o r i g i n a l 60 items f o r t h i s study 59 was found to be impossible because of s i z e l i m i t a t i o n s inherent i n the SCSS computer package. However, the procedure was attempted on the 40 items s e l e c t e d f o r the f i n a l instrument, f o r the purpose of determining the extent to which i d e n t i f i e d item c l u s t e r s correspond to the categories i n Table I . S i g n i f i c a n c e L e v e l The l e v e l of s t a t i s t i c a l s i g n i f i c a n c e accepted f o r i t e m - t o t a l score c o r r e l a t i o n s was . 0 5 - T h i s i s the l e v e l g e n e r a l l y accepted f o r b a s i c s c i e n t i f i c research which does not have i m p l i c a t i o n s f o r i n d i v i d u a l human beings (Gay, 1 9 7 6 , p. 247; P o l i t & Hungler, 1978 , p. 5 4 5 ; Robinson et a l . , 1 9 7 4 , p. 246). Demographic Data Demographic data were obtained through the use of a b r i e f questionnaire (see Appendix E ) . They were subjected to u n i v a r i a t e a n a l y s i s f o r the purpose of sample d e s c r i p -t i o n . CHAPTER IV PRESENTATION AND DISCUSSION OF FINDINGS D e s c r i p t i o n of the Sample During A p r i l and May of 1983 the i n v e s t i g a t o r v i s i t e d 4 diploma n u r s i n g programmes (14 nursing c l a s s e s ) i n B r i t i s h Columbia. The number of students a t t e n d i n g each c l a s s v a r i e d from 18 to 53- Data were c o l l e c t e d as described i n Chapter I I I (pp. 5 4 - 5 5 )• Of the 408 instruments returned, 1 was incomplete, l e a v i n g a sample s i z e of 40?. The composition of the sample i n r e l a t i o n to school of nursi n g i s reported i n Table I I I . B r i t i s h Columbia I n s i t u t e of Technology (BCIT) and Vancouver Community College (VCC) are l o c a t e d i n Burnaby and Vancouver, r e s p e c t i v e l y ; both are l a r g e urban centres. Okanagan College i s l o c a t e d i n Kelowna, a smaller i n t e r i o r c i t y , and serves the area of the Okanagan V a l l e y . S e l k i r k College i s l o c a t e d i n C a s t l e g a r , an even smaller i n t e r i o r c i t y , and serves the West Kootenay area. The m a j o r i t y of nu r s i n g students p a r t i c i p a t i n g i n the study were from BCIT and VCC (N=289, or 71$ of the sample). The composition of the sample i n r e l a t i o n to age, sex, and pre-nursing school education i s reported i n Table IV. The 20-24 year age group contains the most students ( .187); mature students (25 years and over) number 172 , or 42 . 3 $ of the sample, which i s composed almost e n t i r e l y of females 60 61 Table I I I Composition of the Sample According to School of Nursing (N=407) School of Nursim? Number of fo of Obtained bchool o i Nursing Subjects Sample B r i t i s h Columbia I n s t i t u t e of Technology 124 3 0 - 5 Okanagan College 77 18.9 S e l k i r k College 41 1 0 . 1 Vancouver Community College 165 40 . 5 407 1 0 0 . 0 ( 9 6 . 1 $ ) . The m a j o r i t y of students ( 2 4 3 , or 5 9 - 7 $ of the sample) had educational q u a l i f i c a t i o n s beyond secondary school graduation on ent e r i n g nursing school. U n i v e r s i t y degrees h e l d by p a r t i c i p a n t s are a l l at the baccalaureate l e v e l and i n c l u d e degrees i n general a r t s , h i s t o r y , psychology, economics, p o l i t i c a l science, E n g l i s h , education, and general sciences. V o c a t i o n a l graduates represent a wide v a r i e t y of t e c h n i c a l and career programmes. A s u b s t a n t i a l number of students (see Table V) were employed by h e a l t h care agencies p r i o r to e n t e r i n g n u r s i n g school. Almost h a l f of these students ( 7 2 , or 48$) were Table IV Composition of the Sample According to Age, Sex, and Pre-Nursing School Education (N=407) Number of $ of Obtained Subjects Sample Age 19 years or under 48 1 1 . 8 2 0 - 2 4 years 187 4 5 . 9 2 5 - 2 9 years 94 2 3 . 1 3 0 - 3 9 years 55 1 3 . 5 4 0 - 4 9 years 20 4 . 9 50 years or over 3 .7 407 1 0 0 . 0 Sex Female 391 9 6 . 1 Male _15_ 3 . 7 4 0 6 a 9 9 . 8 a Pre-Nursing School Education High school graduation or equivalent 164 4 0 . 3 Some univ e r s i t y , but did not graduate 151 3 7 - 1 University degree 21 5 . 2 Graduation from a community college or technical school 58 1 4 . 3 Other 13 3 . 2 407 1 0 0 . 0 These discrepancies r e s u l t from the fac t that one student f a i l e d to indicate his or her sex on the Demographic Data Questionnaire. 63 Table V Composition of the Sample According to Pre-Nursing School Employment i n Health Care Agencies (N=407) Number of % of Obtained Subjects Sample Pre-Nursing School Employment  i n a Health Care Agency Employed Not employed Type of Employment i n  H e a l t h Care Agency Nurse-aide Licensed P r a c t i c a l Nurse Orderly Other 150 257 407 3 6 . 9 63.I 1 0 0 . 0 43 27 2 77 149 a 10 . 6 6 . 6 • 5 18.9 3 6 . 6 a These d i s c r e p a n c i e s r e s u l t from the f a c t that one student f a i l e d to i n d i c a t e type of employment on the Demographic Data Questionnaire. 6k employed i n p a t i e n t care p o s i t i o n s of nurse-aide, l i c e n s e d p r a c t i c a l nurse, and o r d e r l y . The remainder, i n the "other" category, were employed mostly as c l e r i c a l workers of v a r i o u s types, and as housekeeping s t a f f . Item A n a l y s i s The procedures described below were used to assess the value of i n d i v i d u a l items and make d e c i s i o n s regarding which items should be e l i m i n a t e d from the f i n a l instrument. The item numbers used i n t h i s chapter r e f e r to items as they are numbered i n the o r i g i n a l instrument (see Appendix B). I n t e r p r e t a t i o n D i f f i c u l t y The number of students who had d i f f i c u l t y i n t e r p r e t i n g each item i s reported i n Table VI. F i v e items are a s s o c i a t e d w i t h d i f f i c u l t y r a t e s of greater than 2$ (9 students or more). Of these f i v e items, only two (items 10 and 21) were r e t a i n e d i n the f i n a l instrument. These items are considered ambigu-ous and should be rephrased or replaced i n any futu r e r e v i s i o n of the instrument. Variance The variance of each item i n the o r i g i n a l instrument i s reported i n Table V I I . This s t a t i s t i c i s an i n d i c a t i o n of the degree of v a r i a t i o n i n the data from the mean score f o r each 65 Table VI Number of Students Indicating Interpretation D i f f i c u l t y for Items i n the Or i g i n a l Instrument (N-4Q7) Item Number Number of $ of Item Number Number of $ of Students Sample Students Sample 1 0 0 ( 3 D 2 • 5 (2) 6 1 . 5 32 0 0 3 3 • 7 33 4 1 .0 (4) 27 6 . 6 34 7 1 .7 5 2 • 5 (35) 0 0 (6) 1 . .2 36 1 . 2 7 4 1 .0 37 3 • 7 (8) 7 1 .7 38 4 1 .0 (9) 0 0 (39) 3 • 7 10 11 2 . 7 40 6 1-5 (11) 6 1 . 5 (41) 3 • 7 12 8 2 . 0 42 4 1 .0 13 3 . 7 43 4 1 .0 14 4 1 .0 (44) 26 6.4 (15) 6 1 . 5 4,5 2 . 5 (16) 5 1 . 2 46 1 . 2 (17) 20 4.9 (47) 3 .7 18 1 . 2 48 1 .2 19 1 . 2 49 3 • 7 20 6 1 . 5 50 2 . 5 21 22 5-4 51 0 0 22 8 2 . 0 52 2 . 5 23 4 1 .0 53 5 1 . 2 24 5 1 . 2 54 7 1 .7 25 • 0 0 (55) 2 • 5 26 2 • 5 (56) 2 • 5 (27) 4 1 .0 57 1 . 2 28 6 1 . 5 58 2 . 5 (29) 3 • 7 59 1' . 2 30 1 . 2 (60) 1 . 2 Item numbers i n parentheses indicate items which were eliminated from the f i n a l instrument. 66 Table VII Variance of Items i n the O r i g i n a l Instrument-(N=407) Item Number Variance Item Number3" Variance Item Number3- Variance 1 • 765 21 1 . 3 7 4 (41) 3 . 4 0 2 (2) 1 . 4 6 2 22 2 . 3 8 4 42 2 . 1 7 8 3 2 . 5 7 3 23 1 . 6 2 0 43 1 . 9 4 1 (4) 2 . 9 2 1 24 2 . 4 4 9 (44) 1 . 1 3 9 5 3 - 4 7 6 25 2 . 3 1 3 45 2 . 0 3 9 (6) 4 . 1 1 5 26 1 . 9 7 0 46 2 . 8 2 2 7 2 . 8 9 2 (27) 3 . 2 8 0 (47)~ 1 . 5 6 4 ' (8) 2 . 3 0 8 28 1 • 330 48 1 . 5 3 3 (9) . 2 8 2 (29) 1 . 447 49 2 . 0 2 4 10 2 . 6 7 7 30 2 . 4 9 3 50 . 8 0 3 (11) 2 . 8 2 2 ( 3 D • 739 51 . 6 4 9 12 1 . 9 4 0 32 1 .171 52 . 7 0 3 13 1 . 8 3 4 33 1 . 8 1 3 53 4 . 2 2 9 14 1 . 3 4 9 34 2 . 5 7 6 54 • 796 (15) 3 . 1 7 8 (35) 2 . 0 0 6 (55) 3 - 5 4 2 (16) 2 . 5 4 2 36 2 . 1 7 2 (56) 2 . 5 0 3 (17) 2 . 0 7 6 37 1 .017 57 • 530 18 1 . 7 8 4 38 1 . 2 5 6 58 1 . 3 3 8 19 2 . 0 5 9 (39) 3 . 1 1 0 59 1 . 5 6 3 20 1 . 0 9 3 40 2 . 4 1 0 (60) 2 . 6 6 4 Item numbers i n parentheses i n d i c a t e items which were e l i m i n a t e d from the f i n a l instrument . 67 item (Nie et a l . , 1980, p.215 ). E i g h t items have a variance below 1; of these eight items, s i x were r e t a i n e d i n the f i n a l , instrument (items 1, 50, 51, 52, 54, and 57) • Seventeen other items i n the f i n a l instrument have a variance between. 1 and 2. A p o s s i b l e c o n t r i b u t i n g f a c t o r to these low variances could be the wording of items; they may be too extremely p o s i t i v e or negative, or too n e u t r a l . The items w i t h the lowest variances should be r e v i s e d or r e p l a c e d w i t h items y i e l d i n g a higher variance. When u s i n g Cro'nbach's formula f o r c a l c u l a t i n g r e l i a b i l i t y , i n creases i n the variance of i n d i v i d u a l items - r e s u l t ' i n a higher r e l i a b i l i t y " ' c o e f f i c i e n t (Cronbach, 1970, p. l6l) . C o r r e l a t i o n 'of i n d i v i d u a l Items  wi t h the "Total- Score The; Pearson product-moment c o r r e l a t i o n - c o e f f i c i e n t s of i n d i v i d u a l items with the t o t a l score of the o r i g i n a l instrument are reported i n Table V I I I . A l l c o e f f i c i e n t s except f i v e (items 6, 27, 39, "41, and 60) are s i g n i f i c a n t at the .001 l e v e l or higher. C o r r e l a t i o n s f o r items 6 and 39 are s i g n i f i c a n t at the .01 l e v e l . The c o r r e l a t i o n coef-f i c i e n t f o r item 27 i s s i g n i f i c a n t at the .05 l e v e l . A l l items r e t a i n e d i n the f i n a l instrument have c o r r e l a t i o n s w i t h the t o t a l score which are s i g n i f i c a n t at the .001 l e v e l . C o r r e l a t i o n c o e f f i c i e n t s f o r these items range from .174 to .428. 68 Table V I I I C o r r e l a t i o n of I n d i v i d u a l Items w i t h the T o t a l Score of the O r i g i n a l Instrument (N=407) Item Number C o r r e l a t i o n Item C o r r e l a t i o n C o e f f i c i e n t Number C o e f f i c i e n t 1 . 336 . 000 ( 3 D . 1 8 5 .000 (2) .146 . 000 32 . 277 .000 3 . 236 . 000 33 . 228 .000 (4) • 235 . 000 34 . 187 .000 5 . 267 . 000 (35) . 2 0 3 .000 (6) . 1 2 5 . 006 36 . 1 9 3 .000 7 . 2 0 9 . 0 0 0 37 . 3 2 5 .000 (8) . 1 8 3 . 000 38 . 256 .000 (9) . 1 6 3 . 0 0 0 (39) .141 . 002 10 . 321 . 0 0 0 40 . 3 1 2 .000 (11) . 1 7 7 . 000 (41) . 081 . 0 5 3 12 . 2 0 5 . 0 0 0 42 • 356 . 000 13 . 286 . 000 43 . 4 0 5 .000 14 .341 . 000 (44) . 198 .000 (15) .182 . 0 0 0 45 .301 .000 (16) • 195 . 000 46 . 300 .000 (17) . 1 3 6 . 0 0 0 (47) . 166 .000 18 . 237 . 0 0 0 48 . 247 . 000 19 . 1 7 4 . 000 49 .384 . 000 20 . 221 . 000 50 . 3 2 3 .000 21 • 350 . 000 51 . 3 2 2 .000 22 . 3 0 5 . 000 52 . 4 0 3 .000 23 •331 . 0 0 0 53 . 2 1 5 . 000 24 .249 . 000 54 . 397 .000 25 . 3 0 8 . 000 (55) . 162 .001 26 . 270 . 000 (56) .171 .000 (27) .094 . 0 2 9 57 .401 . 000 28 .428 . 000 58 . 3 1 3 .000 (29) . 1 7 0 . 000 59 • 373 . 000 30 . 217 . 000 (60) -.046 . 180 Item numbers i n parentheses i n d i c a t e items which were e l i m i n a t e d from the f i n a l instrument . 69 Standards f o r c o r r e l a t i o n s of items w i t h the t o t a l score are not i n d i c a t e d i n the l i t e r a t u r e ; however, these coef-f i c i e n t s appear to he low. Low c o e f f i c i e n t s f r e q u e n t l y i n d i c a t e t h a t an i n d i v i d u a l item i s measuring something d i f f e r e n t from what the r e s t of the items are measuring ( L i k e r t , 1 9 7 4 , p. 2 3 7 ) . The concept of p r o f e s s i o n a l a t t i t u d e s appears to be broad, and may a c t u a l l y c o n s i s t of a number of subconcepts. When t h i s s i t u a t i o n e x i s t s , the development of a homogeneous group of items i s more d i f f i c u l t . D i v i s i o n of the instrument i n t o a number of subscales might be i n d i c a t e d . Item E l i m i n a t i o n Twenty items (items 2 , 4 , 6 , 8 , 9 , 1 1 , 1 5 , 1 6 , 1 7 , 2 7 , 2 9 , 3 1 , 3 5 , 3 9,41 , 4 4 , 4 7 , 5 5 , 5 6 , and 60) were e l i m i n a t e d from the f i n a l instrument. These items were e l i m i n a t e d on the b a s i s of c o r r e l a t i o n s of i n d i v i d u a l items w i t h the t o t a l score. Rank-orderings of c o e f f i c i e n t s f o r p o s i t i v e l y and n e g a t i v e l y worded items were made under the cate g o r i e s i n the Table of S p e c i f i c a t i o n s (Table I ) . Items were e l i m i n a t e d propor-t i o n a l l y from the bottom of each category. The 40 items s e l e c t e d f o r the f i n a l instrument are renumbered and presented i n Appendix C. The r e l a t i o n s h i p of renumbered items to p r o f e s s i o n a l c h a r a c t e r i s t i c s i n the Table of S p e c i f i c a t i o n s i s reported i n Appendix D (Table X ) . 70 R e l i a b i l i t y C o e f f i c i e n t alpha (or Cronbach's alpha) f o r the 40 sel e c t e d items i s .80; t h i s degree of r e l i a b i l i t y i s considered by Nunnally ( 1 9 7 8 , p. 245) to be acceptable f o r ba s i c research on groups. In f a c t , he suggests that i n c r e a s -i n g r e l i a b i l i t i e s much beyond t h i s l e v e l might be "wasteful of time and funds" (p. 245). Facto r A n a l y s i s I n i t i a l f a c t o r a n a l y s i s of the 40 s e l e c t e d items using the p r i n c i p a l components method e x t r a c t e d 13 f a c t o r s , a l l w i t h eigenvalues g r e a t e r than 1. The determination of the number of f a c t o r s to r e t a i n was made by the Scree-Test (Nie et a l . , 1980, p. 492), which i n d i c a t e d a l e v e l l i n g p o i n t f o l l o w i n g f a c t o r 7 « As i n d i c a t e d by the eigenvalues, the f a c t o r s e x t r a c t e d are r a t h e r weak. Because i n t e r i t e m c o r r e l a t i o n s are low, t h i s r e s u l t was a n t i c i p a t e d . Most i n t e r i t e m c o r r e l a t i o n c o e f f i c i e n t s are between .100 and . 3 0 0 ; many are below .100, and a few are above . '300, w i t h the highest value being .489- Because the r e s u l t s of f a c t o r a n a l y s i s are u n d e f i n i t i v e , only t e n t a t i v e suggestions can be made r e -garding the i n t e r p r e t a t i o n of item c l u s t e r s . Table IX i l l u s t r a t e s item c l u s t e r s as i d e n t i f i e d by f a c t o r a n a l y s i s using the p r i n c i p a l components method of e x t r a c t i o n , and the varimax method of r o t a t i o n w i t h K a i s a r 71 Table IX Item C l u s t e r s I d e n t i f i e d by Fa c t o r A n a l y s i s (N=407) a Factor 3 a F a c t o r 4 F a c t o r 1 F a c t o r 2' 54 42 59 49 52 45 14 34 21 23 50 (19) 1 (5) 57 12 51 (19) neg b 30 38 46 43 b - 7 53 neg? 22 (5) neg 20 F a c t o r 5 F a c t o r 6 F a c t o r 7 26 13 24 10 36 3 25 37 18 33 58 28 32 40 48 Note. The numbers i n t h i s t a b l e represent items as they are numbered i n the o r i g i n a l instrument (see Appendix B). Items are l i s t e d i n descending order of the extent to which they l o a d on the f a c t o r . ""Numbers i n parentheses i n d i c a t e items which l o a d n e g a t i v e l y on one f a c t o r and p o s i t i v e l y on another. The designation "neg" beside an item i n d i c a t e s that the item i s a s s o c i a t e d w i t h the others i n the c l u s t e r i n a negative or opposite manner. 72 n o r m a l i z a t i o n (Nie et a l . , pp. 475-494). F a c t o r s were r e s t r i c t e d to seven i n number. F a c t o r a n a l y s i s i s a technique which i d e n t i f i e s c l u s t e r s of r e l a t e d v a r i a b l e s on the b a s i s of mathematical manipulation of numbers i n a c o r r e l a t i o n m a t r i x . The computer i d e n t i f i e s the c l u s t e r s , but i t i s up to the i n v e s t i g a t o r to i d e n t i f y s u b j e c t i v e l y the conceptual element common to the v a r i a b l e s w i t h i n the c l u s t e r . Often the patterns are u n i n t e r p r e t a b l e (Nie et a l . , 1>980, p. 490); t h i s f a c t as w e l l as the o v e r a l l weakness of the f a c t o r s should be kept i n mind when cons i d e r i n g the f o l l o w i n g attempt at i n t e r p r e t a t i o n . F a c t o r 1 does not appear to be i n t e r p r e t a b l e i n conceptual terms r e l a t e d to p r o f e s s i o n a l a t t i t u d e s . Because t h i s i s the strongest f a c t o r i d e n t i f i e d , the l a c k of i n t e r p r e t a b i l i t y i s d i s a p p o i n t i n g . The f a c t o r contains ten items from f o u r of the s i x categories i n the Table of S p e c i f i c a t i o n s (Table I ) ; these f o u r c a t e g o r i e s are education, autonomy, s e r v i c e , and p r o f e s s i o n a l a s s o c i a t i o n . I t i s i n t e r e s t i n g to note that a l l items i n the scale w i t h a variance below 1 are i n c l u d e d i n t h i s f a c t o r , and 1.940 i s the l a r g e s t item variance i n the c l u s t e r . This r e s u l t suggests that the items i n t h i s f a c t o r might be "motherhood" statements which were responded to i n a s i m i l a r manner by most n u r s i n g students i n the sample. Also of i n t e r e s t i s the f a c t that a l l items i n t h i s c l u s t e r are p o s i t i v e l y worded. 73 Factor 2 contains seven items, s i x of which are from the education category; the f a c t o r could therefore he considered to represent a f a i r l y c l e a r education component. An element of continuing education or p r o f e s s i o n a l develop-ment i s present i n many of these items. A l l items i n t h i s c l u s t e r except item 5 are n e g a t i v e l y worded. Although f a c t o r 3 i n c l u d e s items from the education, autonomy, s e r v i c e , and s a l a r y c a t e g o r i e s , a l l except item 20 can he seen to have an education component. A l l items which make reference to a baccalaureate degree i n nursing are i n c l u d e d i n t h i s f a c t o r ; furthermore, these are the items which l o a d n e g a t i v e l y on the f a c t o r . The only other common element i d e n t i f i e d i s that these items, again w i t h the exception of item 2 0 , r e f e r to concepts which may be r e l a t i v e l y u n f a m i l i a r to most diploma l e v e l n u r s i n g students. F a c t o r 4 i n c l u d e s items from the s e r v i c e , education, and autonomy c a t e g o r i e s . One commonality i d e n t i f i e d i s that i n some manner they a l l address the matter of who should make h e a l t h care d e c i s i o n s . Another common element i s that the items could a l l be seen to address matters of e f f i c i e n c y and r o u t i n e . A l l items i n t h i s c l u s t e r are n e g a t i v e l y worded. Factor 5 i n c l u d e s items from the autonomy, s e r v i c e , s a l a r y , and p r o f e s s i o n a l a s s o c i a t i o n c a t e g o r i e s . A l l of these items i n v o l v e s i t u a t i o n s which r e q u i r e some measure of a s s e r t i v e n e s s to demonstrate p r o f e s s i o n a l a t t i t u d e s . They a l l deal w i t h p r o f e s s i o n a l behaviours which f r e q u e n t l y 74 are unrewarded or even discouraged i n the h o s p i t a l s e t t i n g . "Bucking the system" might be an appropriate l a b e l f o r t h i s c l u s t e r . A l l items are n e g a t i v e l y worded. Fa c t o r 6 c o n s i s t s of items o r i g i n a l l y placed i n the a c c o u n t a b i l i t y , s e r v i c e , and autonomy c a t e g o r i e s . A l l three a c c o u n t a b i l i t y items are in c l u d e d i n t h i s c l u s t e r ; furthermore, the other three items i n the c l u s t e r c o n tain an a c c o u n t a b i l i t y element. D e l i v e r y of the best p o s s i b l e n u r s i n g care to the p a t i e n t i s another element i n t h i s c l u s t e r . This f a c t o r i s evenly d i v i d e d between p o s i t i v e l y and n e g a t i v e l y worded items. F a c t o r 7 c o n s i s t s of three items, a l l from the s e r v i c e category. They appear to address the uniqueness of the p a t i e n t . An element of c o n f l i c t between the p a t i e n t ' s needs and the needs of the h o s p i t a l bureaucracy i s common to these items. Two p o s i t i v e l y worded items and one n e g a t i v e l y worded item comprise t h i s f a c t o r . I n summary, of the o r i g i n a l s i x ca t e g o r i e s i n the Table of S p e c i f i c a t i o n s (Table I ) , only education and a c c o u n t a b i l i t y were confirmed by f a c t o r a n a l y s i s . Although t e n t a t i v e suggestions f o r other c a t e g o r i e s evolved i n the i n t e r p r e t a t i o n of the a n a l y s i s , the f a c t o r s e x t r a c t e d are considered by the i n v e s t i g a t o r to be too weak to j u s t i f y d i v i s i o n of the scale i n t o corresponding subscales. An i n t e r e s t i n g observation i s that p o s i t i v e l y worded items and n e g a t i v e l y worded items f r e q u e n t l y tended to group together. 75 V a l i d i t y The instrument i s considered to possess content v a l i d i t y to the extent t h a t Nunnally's ( 1 9 7 8 , p. 92) major c r i t e r i a of a r e p r e s e n t a t i v e sample of items and s e n s i b l e methods of t e s t c o n s t r u c t i o n were attended to during development of the instrument. Both the o r i g i n a l instrument and the f i n a l instrument are based on a Table of S p e c i f i c a t i o n s derived from the l i t e r a t u r e . Items were c r i t i q u e d and r e v i s e d to address the matters of c l a r i t y and adequacy w i t h which the content was cast i n the form of items. As an a d d i t i o n a l check on c l a r i t y , students were asked to i n d i c a t e items which they found to be ambiguous. An i n i t i a l attempt to demonstrate evidence of construct v a l i d i t y was made through f a c t o r a n a l y s i s ; however, the r e s u l t s of t h i s .procedure were i n c o n c l u s i v e . Summary The data-producing sample f o r the study c o n s i s t e d of 407 diploma n u r s i n g students e n r o l l e d i n 4 B r i t i s h Columbia schools of n u r s i n g . A n a l y s i s of demographic data provided the i n f o r m a t i o n fundamental to the d e s c r i p t i o n of the sample. Students i n the two l a r g e s t nursing schools c o n s t i t u t e d 71$ of the obtained sample. The under - 2 5 age group i n c l u d e d 5 7 - 7 $ of the t o t a l ; 9 6 . 1 $ were females. Students who had ed u c a t i o n a l q u a l i f i c a t i o n s beyond secondary school graduation 76 p r i o r to e n t e r i n g nursing school c o n s t i t u t e d 5 9 - 7 $ . Those students who were employed by a h e a l t h care agency p r i o r to nursing school entry numbered 3 6 . 8 $ . The f i n d i n g s summarized below are the outcomes of the v a r i o u s procedures employed f o r data a n a l y s i s . Item numbers r e f e r to items as they are numbered i n the o r i g i n a l instrument (Appendix B). 1. Items 10 and 21 are a s s o c i a t e d w i t h i n t e r p r e t a -t i o n d i f f i c u l t y r a t e s greater than 2%. These items are considered ambiguous and should be r e v i s e d . 2. Items 1, 5 0 , 5 1 , 52 , 54 , and 57 have a variance of l e s s than 1. These items are considered to d i s c r i m i n a t e i n s u f f i c i e n t l y ; c o r r e c t i o n of t h i s s i t u a t i o n would r e s u l t i n a sca l e w i t h a wider d i s p e r s i o n and a higher r e l i a b i l i t y c o e f f i c i e n t f o r i n t e r n a l consistency. 3 . The c o r r e l a t i o n c o e f f i c i e n t s of i n d i v i d u a l items w i t h the t o t a l score of the o r i g i n a l instrument are g e n e r a l l y low. This r e s u l t suggests that the concept of p r o f e s s i o n a l a t t i t u d e s might c o n s i s t of sev e r a l d i f f e r e n t dimensions or subconcepts, each of which were responded to i n a d i f f e r e n t manner. 4 . The c o e f f i c i e n t alpha (or Cronbach's alpha) i s .80; t h i s f i g u r e represents a f a i r l y high index f o r r e l i a b i l i t y i n terms of i n t e r n a l consistency. 5 . Of the s i x dimensions of p r o f e s s i o n a l i s m e x t r a c t e d from the l i t e r a t u r e , only education and a c c o u n t a b i l i t y were confirmed by f a c t o r a n a l y s i s . The f a c t o r s e x t r a c t e d 77 are too weak to j u s t i f y d i v i s i o n of the instrument into corresponding subscales. 6. Content v a l i d i t y of the instrument can be assumed because of the methods employed f o r instrument construction. CHAPTER V SUMMARY AND CONCLUSIONS, IMPLICATIONS, AND RECOMMENDATIONS Summary and Conclusions The purpose of t h i s study was to develop and t e s t an instrument t h a t would r e l i a b l y assess the p r o f e s s i o n a l r o l e a t t i t u d e s of diploma nursing students, and would be easy to administer. A L i k e r t scale was developed and employed f o r the above purpose. The instrument was designed to address the f o l l o w i n g s i x c h a r a c t e r i s t i c s of p r o f e s s i o n a l n u rsing e x t r a c t e d from the l i t e r a t u r e : commitment to education, s e r v i c e o r i e n t a t i o n , autonomy, p a r t i c i p a t i o n i n the pro-f e s s i o n a l a s s o c i a t i o n , a c c o u n t a b i l i t y , and expectation of appropriate remuneration. The s i x t y items i n the o r i g i n a l item pool were c r i t i q u e d by a panel of nursing i n s t r u c t o r s and r e v i s e d p r i o r to a d m i n i s t r a t i o n . The o r i g i n a l instrument was tested, w i t h a sample of 407 diploma nursing students from 4 schools of nursing i n B r i t i s h Columbia. I t was found that the instrument was easy to administer, and no problems regarding comprehension of the i n s t r u c t i o n s were i d e n t i f i e d . The time -period r e q u i r e d f o r completion of the o r i g i n a l instrument was 30 minutes or l e s s . 78 79 On the b a s i s of i t e m - t o t a l score c o r r e l a t i o n s , 40 items from the o r i g i n a l instrument were s e l e c t e d f o r the f i n a l instrument. The f o l l o w i n g conclusions are deriv e d from the r e s u l t s of data a n a l y s i s . Item numbers r e f e r to items as they were renumbered f o r the f i n a l instrument (see Appendix C). 1. The f i n a l instrument i s considered u n s u i t a b l e f o r use i n i t s present form. Items 5 and 12 are ambiguous, and items 1 , 3 3 » 3 4 , 3 5 > 3 7 » and 38 do not d i s c r i m i n a t e s u f f i c i e n t l y . Many of the other items are b o r d e r l i n e i n terms of d i s -c r i m i n a t i o n . The instrument could be r e v i s e d to c o r r e c t these d e f i c i e n c i e s . 2 . The low c o r r e l a t i o n c o e f f i c i e n t s f o r i n d i v i d u a l items w i t h the t o t a l score suggest that the concept of p r o f e s s i o n a l a t t i t u d e s may be too broad to measure i n one homogeneous s c a l e . With the exception of education and a c c o u n t a b i l i t y , items d i d not tend to c l u s t e r i n accordance w i t h the c h a r a c t e r i s t i c s of p r o f e s s i o n a l n u r s i n g e x t r a c t e d from the l i t e r a t u r e . F actor a n a l y s i s d i d not r e s u l t i n the i d e n t i f i c a t i o n of appropriate subscales f o r the instrument. 3- The r e l i a b i l i t y of the instrument i s at a l e v e l considered s u f f i c i e n t l y high f o r the purpose of b a s i c research on groups. 4 . Content v a l i d i t y of the instrument i s inherent i n the methods employed f o r i t s c o n s t r u c t i o n . 80 I m p l i c a t i o n s f o r Nursing Education Nursing has not yet gained u n i v e r s a l r e c o g n i t i o n and acceptance as a p r o f e s s i o n ; f o r t h i s reason, i t i s c u r r e n t l y embroiled i n a d r i v e f o r p r o f e s s i o n a l i z a t i o n . One of the most important ways f o r t h i s to occur i s through the i n c u l c a t i o n of p r o f e s s i o n a l a t t i t u d e s and a b i l i t i e s i n neophyte nurses e n t e r i n g p r a c t i c e . Nursing educators are accountable f o r the s o c i a l i z a t i o n of n u r s i n g students i n t o the a b i l i t i e s , v alues, and a t t i t u d e s of the p r o f e s s i o n . A t t i t u d e s comprise an important component of any p r o f e s s i o n a l r o l e . I f n u r s i n g educators assume the r e s p o n s i b i l i t y f o r f a c i l i t a t i n g the p r o f e s s i o n a l s o c i a l -i z a t i o n process, they need some means of e v a l u a t i n g t h e i r e f f o r t . Although the instrument developed and t e s t e d i n t h i s study has f l a w s , f u r t h e r refinement could r e s u l t i n an instrument which would s a t i s f y the need f o r a s s e s s i n g the a t t i t u d e component of the p r o f e s s i o n a l s o c i a l i z a t i o n process i n n u r s i n g programmes. The r e v i s e d instrument could be administered to n u r s i n g students at i n t e r v a l s during the n u r s i n g programme, as part of the process of curriculum e v a l u a t i o n . Changes i n group a t t i t u d e s from one i n t e r v a l to the next could be assessed, and diagnoses made wit h respect to the curriculum. Such a process might provide d i r e c t i o n f o r meaningful change i n the curriculum, and f o r e v a l u a t i o n of the e f f e c t i v e n e s s of such change. 81 Recommendations f o r Further Research Proposals f o r f u r t h e r research described "below f a l l i n t o two c a t e g o r i e s : recommendations f o r development of the instrument, and recommendations f o r f u t u r e s t u d i e s u s i n g a r e f i n e d v e r s i o n of the instrument. Recommendations f o r development of the instrument in c l u d e the f o l l o w i n g : 1. The items i d e n t i f i e d on page 79 as being ambiguous and i n s u f f i c i e n t l y d i s c r i m i n a t i n g should be r e v i s e d . 2. The r e v i s e d instrument should be t e s t e d and the r e l i a b i l i t y estimated using c o e f f i c i e n t alpha. 3- Construct v a l i d i t y should be i n v e s t i g a t e d f u r t h e r . Other measures of p r o f e s s i o n a l a t t i t u d e s could be i d e n t i f i e d or developed, and c o r r e l a t i o n of these measures wi t h the r e v i s e d instrument determined. Another attempt at f a c t o r a n a l y s i s should be made to i d e n t i f y appropriate subscales. I f the instrument were s u f f i c i e n t l y r e f i n e d i t could be used f o r the f o l l o w i n g purposes: 1. A l o n g i t u d i n a l study i n v o l v i n g a d m i n i s t r a t i o n of the instrument at i n t e r v a l s during a nursing programme might a s s i s t i n assessing the need f o r change i n aspects of the curriculum r e l a t e d to p r o f e s s i o n a l i s m . 2. The e f f e c t s of d i f f e r e n c e s i n methods of p r o f e s s i o n a l role- s o c i a l i z a t i o n (or of d i f f e r e n t types of l e a r n i n g experiences) on p r o f e s s i o n a l a t t i t u d e s could be s t u d i e d using the instrument. 82 3. The instrument could be used as part of a study comparing the p r o f e s s i o n a l r o l e a t t i t u d e s of nursing students at the baccalaureate. and diploma..levels. 4. The instrument could be administered to students immediately p r i o r to graduation, and again f o l l o w i n g a p e r i o d of employment i n a h o s p i t a l s e t t i n g , i n order to assess the constancy of the a t t i t u d e s measured on gradua-t i o n . 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C r i t e r i a f o r an a t t i t u d e s c a l e . In G.M. Mara n e l l (Ed.), S c a l i n g :  A sourcebook f o r b e h a v i o r a l s c i e n t i s t s . Chicago: A l d i n e P u b l i s h i n g Co., 1974. S a r b i n , T.R., & A l l e n , V.L. Role theory. I n G. Lindzey & E. Aronson (Eds.), The handbook of s o c i a l psychology (2nd ed.). Reading, Massachusetts: Addison-Wesley P u b l i s h i n g Co., 1968. 1 89 Schein, E.H. The f i r s t job dilemma: An a p p r a i s a l of why col l e g e graduates change jobs and what can be done about i t . Psychology Today, March 1 9 6 8 , pp. 27-37. S c h l o t f e l d t , R.M. On the p r o f e s s i o n a l s t a t u s of n u r s i n g . Nursing Forum, 1974, X I I I (1), 16-31. S c h l o t f e l d t , R.M. Nursing i n the f u t u r e . Nursing Outlook, 1981, 2£ ( 5 ) , 295-301. S c o t t , W.R. P r o f e s s i o n a l s i n bureaucracies--areas of c o n f l i c t . In H.M. Vollmer & D.L. M i l l s (Eds.), P r o f e s s i o n a l i z a t i o n . Englewood C l i f f s , New Jersey: P r e n t i c e - H a l l Inc., 1966. Seward, J.F. P r o f e s s i o n a l p r a c t i c e i n a bu r e a u c r a t i c s t r u c t u r e . Nursing Outlook, 1969, 12 (12), 58-61. Sherlock, B.J., & M o r r i s , R.T. The e v o l u t i o n of the pro-f e s s i o n a l : A paradigm. S o c i o l o g i c a l I n q u i r y , I967, 22 (Winter), 27-46. Simms, S. Nursing's dilemma--the b a t t l e f o r r o l e deter-mination. Supervisor Nurse, 1977, 8 (9), 29-31,33-Smith, K.M. Discrep a n c i e s i n the r o l e - s p e c i f i c values of head nurses and n u r s i n g educators. Nursing Digest, 1978, (Winter), 67-74. Sorensen, J.E/, & Sorensen, T.L. The c o n f l i c t of p r o f e s s i o n -a l s 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 d m i n i s t r a t i v e  Science Q u a r t e r l y , 1974, j52» 98-106. S t i n s o n , S.M. P r o f e s s i o n a l s i n bureaucracies: Autonomy vs. i n t e g r a t i o n . Nursing Papers, 1973, 3. (3), 14-17. (a ) S t i n s o n , S.M. S t r a t e g i e s f o r reducing c o n f l i c t s between nur s i n g s e r v i c e and nursing education. Nursing  Papers, 1973, i (3), 31-36. (b) Thornton, R., & Na r d i , P.M. The dynamics of r o l e a c q u i s i -t i o n . American Journal of Sociology, 1975, 80 (4), 870-885. Turner, R.H. R o l e - t a k i n g , r o l e standpoint, and r e f e r e n c e -group behavior. American J o u r n a l of Sociology, 1956, 61 (Sept.), 316-328"! Wang, R.Y., & Watson. J . The p r o f e s s i o n a l nurse: Roles, competencies and c h a r a c t e r i s t i c s . Supervisor Nurse, 1977, 8 (6), 69-71. 90 Ward, M.J., & F e t l e r , M.E. Instruments f o r use i n n u r s i n g  education research. Boulder, Colorado: Western I n t e r s t a t e Commission f o r Higher Education, 1979• Warner, E.T., & Jones, S.L. The s o c i a l i z a t i o n experience i n n u r s i n g : An i n t e r a c t i v e e x p l a n a t i o n . I n t e r n a t i o n a l  J o u r n a l of Nursing S t u d i e s , 1981, 18 (3) , 185-189. Watson, I . S o c i a l i z a t i o n of the n u r s i n g student i n a p r o f e s s i o n a l n u rsing education programme. Nursing  Papers, 1981, J J ( 2 ) , 19-24. Watson, J . Role c o n f l i c t i n n u r s i n g . S u p e r v i s o r Nurse, 1977, 8 (7), 40-41, 45-47, 50. Way, S.L. Role conceptions of baccalaureate n u r s i n g graduates. Unpublished master's t h e s i s , The Univer-s i t y of B r i t i s h Columbia, A p r i l 1981. Wolfe, D.M., & Snoek, J.D. A study of tensions and adjustment under r o l e c o n f l i c t . J o u r n a l of S o c i a l  Issues, 1962, 18 (3) , 102-121. Yarmolinsky, A. What f u t u r e f o r the p r o f e s s i o n a l i n American s o c i e t y ? Daedalus, 1978, 107 (Winter), 159-174. APPENDIX A I n t r o d u c t i o n to the Research Instrument 91 NURSING STUDENT ATTITUDE SURVEY Introduction My name i s J i l l Peregrym. As a graduate student at the University of B r i t i s h Columbia, I am studying the attitudes of nursing students toward certain aspects of nursing. I t i s hoped that the findings of t h i s study w i l l a s s i s t nursing faculty to make constructive decisions about the curriculum of the nursing programme. In order to obtain t h i s information, I am asking for your p a r t i c i p a t i o n , which w i l l consist of com-p l e t i n g the attached attitude scale and b r i e f questionnaire--a task which should require approximately 3° minutes of your time. Since the attitude scale i s in the process of development, you are also being asked to comment on any d i f f i c u l t i e s you encounter i n inte r p r e t i n g the items. Space i s provided on the instrument f o r t h i s purpose. Although there may be no d i r e c t benefits to you yourselves, students who follow you through the programme should derive benefits from improved learning experiences. P a r t i c i p a t i o n in t h i s study i s e n t i r e l y voluntary, and r e f u s a l t o ' p a r t i c i p a t e w i l l not prejudice your'grades or your status in the nursing programme. I f you choose to complete the attached attitude scale and questionnaire, i t w i l l be assumed that your consent to p a r t i c i p a t e i n the study has been given. You may withdraw from the study at any time. Your responses on these forms w i l l be t o t a l l y anonymous. You are asked not to write your name on the instrument, or id e n t i f y yourself i n any other way. Please t r y to be completely honest i n your responses. There are no righ t or wrong answers. Thank you in advance for your p a r t i c i p a t i o n . APPENDIX B O r i g i n a l Instrument 93 NURSING STUDENT ATTITUDE SURVEY Instructions This survey consists of 60 items. Some of the items are general statements; other items describe s i t u a -tions i n which a nurse might f i n d h e r s e l f and include a statement i n d i c a t i n g the action which the nurse should take. You are asked to indicate the extent to which you agree or disagree with each statement by checking one of the columns with the following headings: Strongly Agree indicate Agree indicate S l i g h t l y Agree indicate Neutral indicate an equal S l i g h t l y Disagree indicate Disagree indicate Strongly Disagree indicate s that you agree with the statement with almost no exceptions, s that you agree with the statement with some exceptions, s that you agree with the statement, but with quite a few exceptions, s that you could either agree or disagree with the statement with about number of exceptions in e i t h e r case. s that you disagree with the statement, but with quite a few exceptions, s that you disagree with the statement with some exceptions, s that you disagree with the statement with almost no exceptions. You are also asked to check the f a r ri g h t column, headed "Interpretation D i f f i c u l t y , " i f you have d i f f i c u l t y understanding or interpreting the item. I t would be very much appreciated i f you would b r i e f l y explain the nature of your d i f f i c u l t y on the reverse side of the page. Here i s an example: While alone at the nurses' station a nurse becomes aware that a patient's c a l l l i g h t i s on. The nurse should put aside her paperwork and answer the patient's c a l l l i g h t immediately. >> >> > 3 CD CD >> CD r H H r H r H CU CD r H CD TO - P cd • P u u TO U C 0) CD & <r> u TO TO C TO O CD 0) TO CD +> TO cd cd o cd u u •rt U •H CO CO SH co • P IjD TO r H TO CD r H - H •rH • F - r l OT < < OT < Z OT Q o OT Q v7 Interpretation D i f f i c u l t y Suppose that, almost without exception, you agree that the nurse should answer the c a l l l i g h t immediately. Then check the f i r s t column (Strongly Agree) f o r that question. The absence of a check mark i n the column headed "Interpretation D i f f i c u l t y " indicates that you have no d i f f i c u l t y understanding or i n t e r p r e t i n g the item. Unless s p e c i f i e d otherwise, the word "nurse," or any form of that word, i s used to denote a registered nurse working i n a professional capacity. A l l items r e f e r to hospi t a l settings, unless otherwise indicated. 1. Nurses should read p r o f e s s i o n a l journals and other p r o f e s s i o n a l m a t e r i a l on a regular b a s i s . 2 . ' A nurse disagrees with a physician's order; however, she f e e l s h e s i t a n t about questioning the physician. She should comply with the order as w r i t t e n . . . 3- Mr. P. has been keeping h i s a n x i e t i e s to himself f o r some time. He f i n a l l y "opens up" to the nurse 5 minutes before change of s h i f t . The nurse has planned an e x c i t i n g s o c i a l engagement a f t e r work. She should leave work on time. 4. P a r t i c i p a t i o n i n the pr o f e s s i o n a l a s s o c i a t i o n should be considered a component of a nurse's job performance. 5. I f a l l p r a c t i c i n g nurses held bachelor's degrees i n nursing the status of nursing as a profession would be enhanced. 6. A h o s p i t a l ' s routine procedure i s that p a t i e n t s are trans-ported w i t h i n the h o s p i t a l by wheelchair or s t r e t c h e r . Mrs F. has been up and about f o r some time and i s proud of her progress. She wishes to walk to radi o l o g y f o r her chest X-Ray. The nurse, who agrees that Mrs. F. i s f u l l y capable of t h i s a c t i v i t y , should make an exception i n t h i s case. 7. The physician i s the best a u t h o r i t y on matters r e l a t e d to the h e a l t h of the p u b l i c i n general. 8. A nurse with 5 years experience, who has been unemployed f o r 8 months, i s of f e r e d a p o s i t i o n . The s a l a r y o ffered corresponds to that which should be offered f o r 3 years experience. The d i r e c t o r of nursing explains that t h i s discrepancy i s the r e s u l t of the 8-month i n t e r r u p t i o n i n work experience. The nurse should i n s i s t upon the 5-year s a l a r y , to which she i s e n t i t l e d by contract. 9. P a t i e n t teaching i s an important component of nursing care. S trongly Agree Agree Slightly Agree Neutral 'Slightly Disagree Disagree Strongly Disagree Code I n t e r p r e t a t i o n D i f f i c u l t y VJ-V 10. A new graduate nurse i s d i s l i k e d by many of her co-workers because she frequently suggests improvements to established routines and procedures. She i s c r i t i c i z e d f o r t h i s behaviou: by the head nurse during her f i r s t evaluation. The new nurse should make every e f f o r t to change t h i s behaviour. 11. Two nurses are being considered f o r promotion to head nurse; both have been assessed as excellent nurses. Nurse A gradua-ted from a diploma nursing program' and has 6 years experience Nurse B has a bachelor's degree i n nursing and 3 years experience. The position should be given to Nurse A. 12. Talking with an anxious, ambulatory patient should take p r i o r i t y over his d a i l y bath. 13- A physician orders an unsafe dose of a medication which i s subsequently administered by a nurse. The nurse, who accurately followed the physician's order, bears no r e s p o n s i b i l i t y f o r the error. 1^ . Attendance at inservice education offerings should be con-sidered an important part of a nurse's job performance. 15. An 11-year old boy i s admitted to hospital on night s h i f t with a painful foot injury following an automobile accident. His father i s dead on a r r i v a l . The physician's in s t r u c t i o n s are to withhold a l l information about the father, however, the boy continually asks the nurse about his father's condi-t i o n . Even though the nurse believes i t i s not in the boy's best i n t e r e s t , she should comply with the physician's i n s t r u c t i o n s . 16. Evaluation by a nurse's peers should be included as a component of the nurse's performance appraisal. 17- The general duty nurse does not require a knowledge of basic research p r i n c i p l e s and methods. Strongly Agree Agree •Slightly Agree Neutral Slightly Disagree Disagree Strongly Disagree I n t erpretation D i f f i c u l t y ON 18. Mrs. H. had d i f f i c u l t y sleeping during the night and i s re s t i n g quietly at 1100 hours. Established hospital procedure dictates that patients must be bathed and t h e i r beds made by 1130. The nurse should allow Mrs. H. to sleep, even though her bed looks messy. 19. The minimum educational q u a l i f i c a t i o n which should be required to become a registered nurse i s a bachelor's degree i n nursing. 20. A nurse in a small town hospital i s approached by a v i s i t o r who wishes to see the l i s t of patients. He wants to determine i f any friends whom he might v i s i t are patients. The nurse should comply with the v i s i t o r ' s request. 21. Nurses should a c t i v e l y seek representation on health-re l a t e d government decision-making bodies. '22. Mr. C. i s a new patient on a medical unit. On taking a nursing history the nurse i s informed that part of Mr. C.'s bedtime r i t u a l at home i s a warm bath; he wishes to continue t h i s practice. The nurse should p o l i t e l y explain to Mr. C. that, because fewer nurses are scheduled for night s h i f t , a l l patients must have t h e i r bath in the morning. 23- A general duty nurse does not need a knowledge of basic s c i e n t i f i c p r i n c i p l e s , such as those learned in chemistry, biology, and s o c i a l science courses. 2 k . While completing a report for the supervisor, a nurse i s made aware that Mrs. B. i s very anxious about her surgery, which i s scheduled for the following day. Time does not permit the nurse to complete the.report and talk to the patient. The nurse should set aside the report and talk to Mrs. B. 25. A nurse i s being interviewed for a general duty po s i t i o n . The interview i s coming to a close, and the matter of salary has not been discussed. The nurse should not i n i t i a t e a discussion about salary. 1 Strongly Agree Agree (Slightly ! Agree Neutral 'Slightly Disagree Disagree Strongly Disagree • Interpretation D i f f i c u l t y 26. A new graduate nurse on a medical unit f e e l s that the system in use f o r d i s i n f e c t i n g the thermometers i s inadequate. The nurse should wait u n t i l she has more experience before bringing the matter to the attention of the head nurse. 27. Completing r e q u i s i t i o n s and ordering supplies are tasks which should be assigned to non-nursing personnel. 2 8 . A nurse wishes to run for e l e c t i o n as an executive o f f i c e r of the professional association. The administrator has discouraged t h i s action on the grounds that i t w i l l disrupt hospital s t a f f i n g schedules i f the nurse should win the e l e c t i o n . The nurse should l e t the matter drop. 29. A nurse wishes to pursue a bachelor's degree on a part-time basis. The hospital should allow the nurse to reduce to part-time and be f l e x i b l e with the s h i f t r o t a t i o n . 30. The delivery of nursing care on a functional basis ( i . e . , one nurse to pass medications, one to do treatments, one to bathe patients, etc.) r e s u l t s i n high q u a l i t y nursing care. 31. Nurse Y observes that a colleague has been reporting to work under the influence of alcohol. Several instances of impaired judgement have been documented. Nurse Y i s responsible f o r taking some kind of action. 32. Patient problems are e f f e c t i v e l y resolved by using the nursing process. 33- Nurse D., an experienced, w e l l - q u a l i f i e d nurse, has applied for a senior nursing administrative position i n a large h o s p i t a l . I t i s well known that competition for the p o s i t i o n has been s t i f f . The position has been offered to Nurse D. at a salary s i g n i f i c a n t l y below that which i s appropriate f o r the r e s p o n s i b i l i t i e s of the position. Nurse D. should accept the position at the salary offered. Strongly Agree 1 Agree (Slightly ..Agree Neutral Slightly j Disagree Disagree Strongly Disagree I n t erpretation D i f f i c u l t y OO J k . The nature of a nurse's educational preparation should be regarded as of minimal importance when considering her for promotion. 35- About an hour a f t e r administering a d a i l y medication to Mr. Y. a nurse r e a l i z e s that she gave the medication at the wrong time. No adverse e f f e c t s are observed. I t i s not necessary f o r her to report t h i s occurrence. 36. Mrs. L. i s to be ambulated every 4 hours. The registered nurse delegates t h i s task to a p r a c t i c a l nurse, who forgets-to carry i t out. Some r e s p o n s i b i l i t y f or the omission rests with the registered nurse. 37. A new graduate nurse i s instructed by the team leader to take an action which the nurse believes w i l l jeopardize the wel-fare of a patient. The new graduate should refuse to follow the in s t r u c t i o n s u n t i l the matter i s discussed further. 38. Decisions regarding the curriculum of a college nursing programme should be made by the nursing f a c u l t y rather than the college administration. 39- Nurses should not be expected to attend continuing education a c t i v i t i e s unless they are reimbursed by the hospital for t h e i r expenses. k O . A nurse should maintain an impersonal distance i n her re l a t i o n s h i p with patients. kl. A d i r e c t o r of nursing (or equivalent) position should have a master's degree as the minimal educational requirement. 42. Attendance at meetings of the professional association i s too much to expect of a general duty nurse who must work ro t a t i n g s h i f t s . 43. Approval of basic nursing education programmes should be in the hands of the Mini s t r y of Education rather than the professional association. Strongly Agree Agree Slightly Agree 1 Neutral Slightly Disagree Disagree Strongly Disagree I n t e rpretation D i f f i c u l t y MO MD 44. Without a conceptual model for nursing, the planning of t o t a l patient care would be more d i f f i c u l t . Strongly Agree Agree Slightly •Agree Neutral * Slightly Disagree Disagree Strongly Disagree I n t erpretation D i f f i c u l t y A registered nurse, recently graduated from a basic nursing programme, has no more exams to write. I t i s now reasonable f o r her to consider s e l l i n g her textbooks. 46. Most routine bedside nursing care should be delivered by p r a c t i c a l nurses rather than by registered nurses. 47- Nurses should modify hospital routines and procedures to meet the i n d i v i d u a l needs of thei r ' p a t i e n t s . 48. The development of an i n d i v i d u a l i z e d kardex nursing care plan for every patient i s unnecessary i n the hospital setting. 49. Attendance at continuing education a c t i v i t i e s outside of working hours i s too much to expect of a general duty nurse. 50. Senior nurse-administrators in hospitals should consult with general duty nurses before developing p o l i c i e s which might a f f e c t nursing care a c t i v i t i e s . 51. A physician writes an order for Mrs. K. to be discharged, and then leaves the hospital for his o f f i c e . The nurse has good reason to believe that Mrs. K. i s not ready f o r discharge. The nurse should telephone the physician at his o f f i c e to discuss the matter. 52. P a r t i c i p a t i o n in the professional association i s an e f f e c t i v e way for a nurse to voice input about the directions which should be taken by the nursing profession. 53- A beginning general duty nurse who holds a bachelor's degree i n nursing should receive a higher salary than a beginning general duty nurse with diploma l e v e l preparation-. •-5*. Research conducted by nurses constitutes an important avenue for expanding the body of nursing knowledge. o o A major reason f o r pursuing a career in nursing i s the potential for a f i n a n c i a l l y secure position. Most patient care problems can be resolved by adhering to regular hospital nursing routines and procedures. The delivery of high q u a l i t y nursing care constitutes an important contribution to the health of the patient. Nurse P. observes that a co-worker has been making a habit of recording v i t a l signs which have not, in f a c t , been measured. Nurse P. bears no r e s p o n s i b i l i t y f o r taking action on this matter. Nurses should be encouraged to par t i c i p a t e i n nursing research projects. Basic nursing education programmes should include more classroom presentations delivered by physicians than i s the current practice. Strongly Agree Agree Slightly .Agree Neutral Slightly Disagree Disagree S trongly Disagree I n t e rpretation D i f f i c u l t y APPENDIX C F i n a l Instrument 102 NURSING STUDENT ATTITUDE SURVEY Instructions This survey consists of 40 items. Some of the items are general statements; other items describe s i t u a t i o n s i n which a nurse might f i n d h e r s e l f and include a statement i n d i c a t i n g the action which the nurse should take. You are asked to indicate the extent to which you agree or disagree with each statement by checking one of the columns with the following headings; Strongly Agree  Agree S l i g h t l y Agree  Neutral S l i g h t l y Disagree  Disagree Strongly Disagree indicates that you agree with the statement with almost no exceptions. indicates that you agree with the statement with some exceptions. indicates that you agree with the statement, but with quite a few exceptions. indicates that you could either agree or disagree with the statement with about an equal number of exceptions i n ei t h e r case. indicates that you disagree with the statement, but with quite a few exceptions, indicates that you disagree with the statement with some exceptions, indicates that you disagree with the statement with almost no exceptions. Here i s an example: While alone at the nurses' station a nurse becomes aware that a patient's c a l l l i g h t i s on. The nurse should put aside her paperwork and answer the patient's c a l l l i g h t immediately. >> >> > j CD CD >> CD H r H r H r H a> CD r H CD M - P cd - P fH fH bD U a <B CD si CD fH si bD bO C bo O CD CD hi) a) - p hOcd cd o cd u u U • H U • H CO CO fn co - p bD r H M a> r H ' H • H • P - H t o < : < t o < CO Q Q c o Q Suppose that, almost without exception, you agree that the nurse should answer the c a l l l i g h t immediately. Then check the f i r s t column (Strongly Agree) f o r that question. Unless s p e c i f i e d otherwise, the word "nurse," or any form of that word, i s used to denote a regis t e r e d nurse working i n a professional capacity. A l l items r e f e r to h o s p i t a l s e t t i n g s , unless otherwise indicated. 1. Nurses should read professional journals and other professional material on a regular basis. 2. Mr. P. has been keeping h i s anxieties to himself f o r some time. He f i n a l l y "opens up" to the nurse 5 minutes'before change of s h i f t . The nurse has; planned an ex c i t i n g s o c i a l engagement a f t e r work. She should leave work on time. 7 3. I f a l l p r a c t i c i n g nurses held bachelor's degrees in nursing, the status of nursing as a profession would be enhanced. 4 . The physician i s the best authority on matters re l a t e d to the health of the public i n general. 5- A new graduate nurse i s d i s l i k e d by many of her co-workers because she frequently suggests improvements to established routines and procedures. She i s c r i t i c i z e d for t h i s behaviour by the head nurse during her f i r s t evaluation. The new nurse should make every e f f o r t to change t h i s behaviour. 6. Talking with an anxious, ambulatory patient should take p r i o r i t y over h i s d a i l y bath. 7. A physician orders an unsafe dose of a medication which i s subsequently administered by a nurse. The nurse, who accurately followed the physician's order, bears no r e s p o n s i b i l i t y f o r the error. 8. Attendance at inservice education offerings should be considered an important part of a nurse's job performance. 9. Mrs. H. had d i f f i c u l t y sleeping during the night and i s r e s t i n g q u i e t l y at 1100 hours. Established hospital procedure dictates that patients must be bathed and t h e i r beds made by 1130. The nurse should allow Mrs. H. to sleep, even though her bed looks messy. 10. The minimum educational q u a l i f i c a t i o n which should be required to become a registered nurse i s a bachelor's degree in nursing. Strongly Agree Agree Slightly Agree | Neutral Slightly | Disagree Disagree Strongly Disagree • o 11. A nurse in a small town hospital i s approached by a v i s i t o r who wishes to see the l i s t of patients. He wants to determine i f any friends whom he might v i s i t are patients. The nurse should comply with the v i s i t o r ' s request. 12. Nurses should a c t i v e l y seek representation on health-related government decision-making bodies. 13- Mr. C. i s a new patient on a medical unit. On taking a nursing h i s t o r y the nurse i s informed that part of Mr. G.'s bedtime r i t u a l at home i s a warm bath; he wishes to continue t h i s practice. The nurse should p o l i t e l y explain to Mr. C. that, because fewer nurses are scheduled f o r night s h i f t , a l l patients must have t h e i r bath in the morning. 14. A general duty nurse does not need a knowledge of basic s c i e n t i f i c p r i n c i p l e such as those learned i n chemistry, biology, and s o c i a l science courses. 15- While completing a report for the supervisor, a nurse i s made aware that Mrs. B. i s very anxious about her surgery, which i s scheduled f o r the following day. Time does not permit the nurse to complete the report and tal k to the patient. The nurse should set aside the report and t a l k to Mrs. B. 16. A nurse i s being interviewed for a general duty position. The interview i s coming to a close, and the matter of salary has not been discussed. The nurse should not i n i t i a t e a discussion about salary. 1?. A new graduate nurse on a medical unit f e e l s that the system i n use f o r d i s i n f e c t i n g the thermometers i s inadequate. The nurse should wait u n t i l she has more experience before bringing the matter to the attention of the head nurse. 18. A nurse wishes to run f o r e l e c t i o n as an executive o f f i c e r of the professional association. The administrator has discouraged t h i s action on the grounds that i t w i l l disrupt hospital s t a f f i n g schedules i f the nurse should win the el e c t i o n . The nurse should l e t the matter drop. 19. The delivery of nursing care on a functional basis ( i . e . , one nurse to pass medications, one to do treatments, one to bathe patients, etc.) r e s u l t s in high q u a l i t y nursing care. Strongly Agree Agree Slightly Agree Neutral Slightly ' Disagree Disagree Strongly Disagree o 20. Patient problems are e f f e c t i v e l y resolved by using the nursing process. 21. Nurse D. , an experienced, w e l l - q u a l i f i e d nurse, has applied f o r a senior nursing administrative position in a large h o s p i t a l . I t i s well known that competition f o r the position has been s t i f f . The position has been offered to Nurse D. at a salary s i g n i f i c a n t l y below that which i s appropriate f o r the r e s p o n s i b i l i t i e s of the p o s i t i o n . Nurse D. should accept the p o s i t i o n at the salary offered. 22. The nature of a nurse's educational preparation should be regarded as of minimal importance when considering her for promotion'. 23- Mrs. L. i s to be ambulated every 4 hours. The registered nurse delegates t h i s task to a p r a c t i c a l nurse, who forgets to carry i t out. Some r e s p o n s i b i l i t y for the omission rests with the registered nurse. 24. A new graduate nurse i s instructed by the team leader to take an action which the nurse believes w i l l jeopardize the welfare of a patient. The new graduate should refuse to follow the i n s t r u c t i o n s u n t i l the matter i s discussed further. 25. Decisions regarding the curriculum of a college nursing programme should be made by the nursing f a c u l t y rather than the college administration. 26. A nurse should maintain an impersonal distance in her r e l a t i o n s h i p with patients. 27. Attendance at meetings of the professional association i s too much to expect of a general duty nurse who must work rotating s h i f t s . 28. Approval of basic nursing education programmes should be i n the hands of the M i n i s t r y of Education rather than the professional association. 29. A registered nurse, recently graduated from a basic nursing programme, has no more exams to write. I t i s now reasonable for her to consider s e l l i n g her textbooks. 30. Most routine bedside nursing care should be delivered by p r a c t i c a l nurses rather than by registered nurses. Strongly Agree Agree Slightly Agree Neutral Slightly Disagree Disagree Strongly Disagree Strongly Agree Agree | Slightly Agree Neutral Slightly Disagree Disagree Strongly [Disagree 31. The development of an i n d i v i d u a l i z e d kardex nursing care plan f o r every patient i s innecessary i n the h o s p i t a l s e t t i n g . 32. Attendance at continuing education a c t i v i t i e s outside of working hours i s too much to expect of a general duty nurse. 33- Senior nurse-administrators i n ho s p i t a l s should consult with general duty nurses before developing p o l i c i e s which might a f f e c t nursing care a c t i v i t i e s . 34. A physician writes an order f o r Mrs. K. to be discharged, and then leaves the h o s p i t a l f o r his o f f i c e . The nurse has good reason to be l i e v e that Mrs. K. i s not ready f o r discharge. The nurse should telephone the physician at h i s o f f i c e to discuss the matter. 35. P a r t i c i p a t i o n i n the professional association i s an e f f e c t i v e way f o r a nurse to voice input about the d i r e c t i o n s which should be taken by the nursing profession. 36. A beginning general duty nurse who holds a bachelor's degree i n nursing should receive a higher salary than a beginning general duty nurse with diploma preparation. 3?. Research conducted by nurses constitutes an important avenue f o r expanding the body of nursing knowledge. 38. The d e l i v e r y of high q u a l i t y nursing care constitutes an important contribution to the health of the patient. 39. Nurse P. observes that a co-worker has been making a habit of recording v i t a l signs which have not, in f a c t , been measured. Nurse P. bears no r e s p o n s i b i l i t y f o r taking action on t h i s matter. 40. Nurses should be encouraged to p a r t i c i p a t e i n nursing research p r o j e c t s . o APPENDIX D Table X R e l a t i o n s h i p of Items i n the F i n a l Instrument to P r o f e s s i o n a l C h a r a c t e r i s t i c s I d e n t i f i e d i n the L i t e r a t u r e 108 109 Table X R e l a t i o n s h i p of Items i n the F i n a l Instrument to P r o f e s s i o n a l C h a r a c t e r i s t i c s I d e n t i f i e d i n the L i t e r a t u r e "Education" Items "Service" Items "Autonomy" Items P o s i t i v e 3 " Negative 3" P o s i t i v e Negative P o s i t i v e Negative 1 14 6 2 12 4 3 22 9 11 24 5 8 29 15 19 25' 13 lo 30 20 26 33 17 37 32 38 31 34 28 40 " P r o f e s s i o n a l A s s o c i a t i o n " Items " A c c o u n t a b i l i t y " Items "Remuneration" Items P o s i t i v e Negative P o s i t i v e Negative P o s i t i v e Negative 35 18 23 7 36 16 27 39 21 Note. The numbers i n t h i s t a b l e r e f e r to items as they are numbered i n the f i n a l instrument (see Appendix C). The designations " p o s i t i v e " and "negative" i n d i c a t e p o s i t i v e l y and n e g a t i v e l y worded items. APPENDIX E Demographic Data Questionnaire 110 DEMOGRAPHIC DATA QUESTIONNAIRE Code In which educational i n s t i t u t i o n are you currently registered as a nursing student? B r i t i s h Columbia Institute of Technology Okanagan College Selkirk College Vancouver Community College In which semester (or term) of the nursing programme are you currently registered? Age Sex 1st semester 2nd semester 3rd semester 19 years or under 20-24 years 25-29 years female 4th semester 5th semester 6th semester 30-39 years 40-49 years 50 years or over| male What i s the highest l e v e l of education which you attained p r i o r to entering the nursing programme? high school graduation or equivalent some u n i v e r s i t y education, but did not graduate u n i v e r s i t y degree(s) (please specify degree) graduation from a community college or t e c h n i c a l school (please ^specify type of programme) other (please specify) Were you employed by a health care i n s t i t u t i o n p r i o r to entering the nursing programme? yes I f you answered "yes" to question 6, please indicate type of employment. nurse-aide lice n s e d p r a c t i c a l nurse orderly other (please specify) 

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