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Perceptions of nursing as a profession of students graduating from college-based nursing diploma programs Ouellet, Marie Louiselle Lise 1985

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PERCEPTIONS OF NURSING AS A PROFESSION OF STUDENTS GRADUATING FROM COLLEGE-BASED NURSING DIPLOMA PROGRAMS By MARIE LOUISELLE LISE OUELLET B.S.N., The Universite' de Moncton, 1976 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING i n 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 A p r i l 1985 © Marie L o u i s e l l e Lise Ouellet, 1985 I n p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f t h e r e q u i r e m e n t s f o r an advanced degree a t the U n i v e r s i t y o f B r i t i s h C o l u m b i a , I agree t h a t t h e L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and s t u d y . I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y purposes may be g r a n t e d by t h e head o f my department o r by h i s o r h e r r e p r e s e n t a t i v e s . I t i s u n d e r s t o o d t h a t c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l n o t be a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . Department o f l\J'U [•Z/'tltfJ  The U n i v e r s i t y o f B r i t i s h Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 DE-6 (3/81) ABSTRACT This study examined the perceptions of nursing as a profession of students graduating from college-based nursing diploma programs. To answer the research question, the Concept of Nursing Scale designed and tested by Valiga (1982) was administered to 101 students in British Columbia Colleges approximately four weeks prior to graduation. Demographic data were also obtained. The responses were coded and scored by hand and the data entered into computer f i l e s . The s t a t i s t i c a l package used for analysis consisted of the SCSS Conversational System (Nie, et a l . , 1980). The concepts reflected in the Valiga Concept of Nursing Scale consist of: (a) boundaries of the profession, (b) recipient of the profession's service, (c) goals of the profession, (d) relationship of the profession to others, (e) independence of the practitioner, (f) responsibility of the practitioner, (g) scholarly component of the profession, (h) autonomy of the practitioner, (i) commitment of the practitioner, and (j) activities of the profession. Scores were high in the areas of definition, client, goals, and scholarship. These results indicated that: (a) the students surveyed had a clear definition of the scope of the profession, (b) they were able to identify the recipient of the profession's service and the goal of the profession, and (c) they recognized a scholarly component to the profession. The scores in the areas of independence and commitment were marginally lower than in the four areas mentioned above. These findings implied that the students graduating from college-based nursing diploma i i programs perceived nursing as functioning independently and that commitment was viewed as a c h a r a c t e r i s t i c of the nursing profession. F i n a l l y , the scores i n the areas of autonomy, ^r e s p o n s i b i l i t y , r e l a t i o n s h i p s , and a c t i v i t i e s were low. These r e s u l t s indicated that the students surveyed perceived nursing as having minimal control over i t s practice and did not view the members of the profession as being responsible and accountable f o r t h e i r own actions. In addition, these students did not have a clear understanding of the nature of nursing's r e l a t i o n s h i p with other members of the health care team and were uncertain as to the a c t i v i t i e s of the nurse. i i i TABLE OF CONTENTS ABSTRACT i i LIST OF TABLES v i i ACKNOWLEDGEMENT v i i i CHAPTER I INTRODUCTION Rationale for the Study 1 Statement of the Problem 3 Purpose of the Study 3 Significance of the Problem 4 D e f i n i t i o n of Terms 4 Assumptions 5 Limitations of the Study 6 Summary 6 II CONCEPTUAL FRAMEWORK 7 Overview 7 S o c i a l i z a t i o n 8 Professional S o c i a l i z a t i o n 10 Models of S o c i a l i z a t i o n 11 Professionalism 18 Professionalism i n Nursing 21 Summary 31 i v III LITERATURE REVIEW 33 Overview 33 Studies Related to the S o c i a l i z a t i o n of Nursing Students 33 Summary 42 IV METHODOLOGY 44 Overview 44 Research Design 44 Instruments 45 Sample 47 Procedure for Data C o l l e c t i o n 47 Analysis of Data 49 Summary 50 V ANALYSIS AND DISCUSSION OF FINDINGS 51 Overview 51 Analysis of Demographic Data 51 Scoring of Valiga Concept of Nursing Scale 54 Relationship of Findings to to the Professional Model 60 Relationship of Findings to the Model of S o c i a l i z a t i o n 61 Summary 64 v VI SUMMARY, CONCLUSIONS, IMPLICATIONS AND RECOMMENDATIONS Overview 65 Summary and Conclusions 65 Implications 67 Nursing Education 67 Nursing Practice 69 Recommendations for Further Research 69 Summary 70 REFERENCES 71 APPENDICES A Valiga Concept of Nursing Scale 76 B Demographic Data Sheet 80 C Introduction to the Research Instrument (College Y) 82 D Reminder Note 84 E Introduction to the Research Instrument (College X) 86 F Introduction to the Research Instrument (College Z) 88 G Table X 90 v i LIST OF TABLES TABLE I The Professional Model 22 II Relationship of Items to the Categories I d e n t i f i e d by Valiga 46 III Composition of the Sample per Program 52 IV Demographic Data 53 V Frequency D i s t r i b u t i o n of Responses by Category 56 VI Frequency D i s t r i b u t i o n of Values by Category 57 VII Percentage D i s t r i b u t i o n of Strong Scores by Category 59 VIII Relationship of the Phases of the S o c i a l i z a t i o n Model to the Response Alternatives of the Vali g a Concept of Nursing Scale 62 IX Percentage D i s t r i b u t i o n of Responses by Category for Each Phase of the S o c i a l i z a t i o n Model 64 X Percentage D i s t r i b u t i o n of Responses of Individual Items for Each Phase of the S o c i a l i z a t i o n Model 91 v i i ACKNOWLEDGEMENT I extend my sincere appreciation to the members of my thesis committee, Dr. Margaret Campbell, chairman, and Ms. Rose Murakami for thei r guidance, t h e i r advice, t h e i r challenges, and t h e i r support. I benefitted greatly from t h e i r contributions. I also wish to thank the p r i n c i p a l s and the nursing f a c u l t y of the schools used i n t h i s study for t h e i r assistance i n surveying t h e i r students. Thanks also go to the students who so w i l l i n g l y p a r t i c i p a t e d i n thi s study. G r a t e f u l l y acknowledged i s the assistance received from Mrs. J i l l Peregrym and Dr. Richard H a l l e t t of S e l k i r k College for sharing t h e i r computer knowledge. I also recognize the very r e a l support of S e l k i r k College i n allowing me a leave of absence to pursue my studies and to my working colleagues for a l l t h e i r support and advice. F i n a l l y , sincere thanks go to my husband, James Cromwell, and friends for t h e i r encouragement and continuous support. v i i i 1 CHAPTER 1 Introduction Rationale for the Study The goal of t h i s study i s to determine students' views about nursing as a profession upon completion of a college-based nursing diploma program. The process by which students learn the culture of a profession, thereby acquiring appropriate perceptions of the professional r o l e , has been c a l l e d professional s o c i a l i z a t i o n (Crocker & Brodie, 1974, p. 233). Professional s o c i a l i z a t i o n i s assumed to be a dynamic, on-going process, most of which i s accomplished by formal educational programs. Watson (1981) claims that "the a c q u i s i t i o n and i n t e r n a l i z a t i o n of professional values occur within educational programs" (p. 19). S i m i l a r l y , Simpson, Back, Ingles, Kerckhoff, and McKinney (1979, p. 3) and Cohen (1981, p. 14) a t t e s t to the fact that professional schools are charged with the s o c i a l i z a t i o n of t h e i r students. Jacox (1978) believes that nursing f a c u l t y are required to encourage i n t h e i r students the development of professional attitudes and the a c q u i s i t i o n of professional values (pp. 17-19). Thus, i t i s through the professiona l s o c i a l i z a t i o n process that the students' views about nursing as a profession are changed from those generally held by the lay public to those of the professional nurse. Nurses who engage i n the practice of nursing are expected to demonstrate professional behaviors consistent with the values and standards of the nursing profession. Valiga (1982) contends that professional 2 behaviors expected of nurses consist of the a b i l i t y : (a) to assume r e s p o n s i b i l i t y , (b) to be s e l f - d i r e c t e d , (c) to be self-governed, (d) to be i n t r a c e p t i v e , (e) to analyze and synthesize data, and ( f ) to define the nursing r o l e and a r t i c u l a t e i t c l e a r l y to c l i e n t s / p a t i e n t s and professionals (p. 72). These behaviors r e f l e c t the expectations of the professional nurse held by the nursing profession (CNA, 1980a; ICN, 1973; RNABC, 1977). It i s the researcher's supposition that the behaviors observed i n graduates of nursing programs are not always consistent with those i d e n t i f i e d by the profession. This phenomenon i s well-documented i n the l i t e r a t u r e . Obedience, according to Jacox (1978), i s s t i l l seen as a desirable t r a i t i n those who are interested In becoming nurses (p. 12). Subordination i s also viewed by some health professionals as e s s e n t i a l to a harmonious nurse-doctor r e l a t i o n s h i p (Kalish & K a l i s h , 1977, p. 5). Obedience and subordination are i n d i r e c t c o n f l i c t with autonomy and s e l f - d i r e c t i o n . In some health agencies, nurses' actions are governed by prescribed routine, p o l i c i e s , and doctors' orders rather than by the exercise of problem-solving and professional judgement (Jacox, 1978, p. 12). When faced with describing the scope of nursing practice and the services which nursing can o f f e r , nurses experience d i f f i c u l t y i n a r t i c u l a t i n g the mission of nursing (Erickson, Tomlin, & Swain, 1984, p. 23). Few nurses engage i n professional a c t i v i t i e s such as maintaining contact with and becoming involved i n the a f f a i r s of t h e i r professional as s o c i a t i o n ("Workshop considers," 1981). The views held by nurses about nursing as a profession determine the 3 behaviors that they demonstrate i n t h e i r p r a c t i c e . Because perception i s a determinant of behavior and because eighty-six percent of the membership of the Registered Nurses' Association of B r i t i s h Columbia are graduates of diploma programs (Kazanjian, 1982, p. 34), i t becomes important to demonstrate through research the perceptions of nursing as a profession acquired by diploma nursing students at the completion of t h e i r educational program. This study i s an attempt to address that need. Statement of the Problem Professional s o c i a l i z a t i o n occurs mostly during the formal educational program. I t i s through t h i s process that students learn to display behaviors consistent with professional behaviors as i d e n t i f i e d by the profession. However, i t has been observed that graduates of nursing diploma programs do not c o n s i s t e n t l y demonstrate professional behaviors. This observation suggests that these graduates may not have acquired perceptions of nursing as a profession that permit them to demonstrate the expected professional behaviors. Therefore, t h i s study addresses the following question: What are the perceptions of nursing as a profession of students graduating from nursing diploma programs? Purpose of the Study The purpose of t h i s study i s to determine the perceptions of nursing as a profession of students graduating from nursing diploma programs. The s p e c i f i c objectives are to: (a) i d e n t i f y the students' responses to each statement included i n the Valiga Concept of Nursing Scale, (b) examine the strength of responses between each category, (c) i d e n t i f y areas of congruence or discrepancy between students' responses and the views held by the nursing profession, and (d) e s t a b l i s h whether the process of s o c i a l i z a t i o n has equipped the students with the appropriate perceptions of the professional r o l e . S ignificance of the Problem Fundamental to nursing i s the b e l i e f that i t i s emerging as a bona f i d e profession. The stated p o s i t i o n of the Canadian Nurses Association (1980a, p. 1) and the Registered Nurses Association of B r i t i s h Columbia (1977, p. 4) i s that nursing i s a profession and that nurses assume professional roles as either p r a c t i t i o n e r s , educators, researchers, or administrators. The examination of perceptions of nursing as a profession held by students graduating from diploma programs as measured by an emp i r i c a l l y developed instrument w i l l i d e n t i f y congruence or discrepancy between the perceptions of a group of graduating students and the expectations of the profession. At the same time, i t w i l l y i e l d to the profession basic information about some of the c h a r a c t e r i s t i c s of some graduates of diploma programs entering the profession. It w i l l provide guidance to nurse educators i n making curriculum decisions about the teaching and evaluation of professional values and a t t i t u d e s . D e f i n i t i o n of Terms The terms used i n t h i s study are defined as follows: NURSING DIPLOMA PROGRAM: College-based nursing program varying i n length from 20 to 26 months leading to nurse r e g i s t r a t i o n and thus entry into the profession. 5 PERCEPTIONS OF NURSING AS A PROFESSION: The view of nursing and the r o l e of the nurse which encompasses the following concepts: (a) boundaries of the profession, (b) r e c i p i e n t s of the profession's service, (c) goals of the profession, (d) r e l a t i o n s h i p of the profession to others, (e) autonomy of the p r a c t i t i o n e r , ( f ) r e s p o n s i b i l i t y of the p r a c t i t i o n e r , (g) s c h o l a r l y component of the profession, (h) commitment to the profession, ( i ) independence of the p r a c t i t i o n e r s , and ( j ) a c t i v i t i e s of the d i s c i p l i n e ' s p r a c t i t i o n e r s (Valiga, 1982, pp. 126-127). PROFESSION: An occupational group characterized by the following: (a) a s p e c i a l i z e d body of knowledge and involvement i n research and other scholarly a c t i v i t i e s to further develop the theory base; (b) a period of s p e c i a l i z e d education; (c) a professional body whose purposes are to e s t a b l i s h standards of practice and education, to promote professional and educational advancement of i t s members, to control admission to the profession, and to delineate the boundaries of the profession; (d) a service o r i e n t a t i o n which includes a strong commitment to acting i n the best i n t e r e s t of the c l i e n t s and a strong commitment to expanding the s p e c i a l i z e d knowledge of the profession; and (e) autonomy (Jacox, 1978, pp. 10, 17; Moore, 1970, pp. 7-17). PROFESSIONAL SOCIALIZATION: The process by which students learn the culture of a profession, thus acquiring appropriate perceptions of the professional r o l e (Adapted from Crocker & Brodie, 1974, p. 233.). Assumptions The following assumptions are relevant to t h i s study: (a) nursing i s a profession, (b) diploma nursing programs are based on the premise that 6 nursing i s a profession and thus the a c q u i s i t i o n of perceptions of nursing as a profession i s an i n t e g r a l part of the nursing curriculum, and (c) the instrument, the Valiga Concept of Nursing Scale, measures the variable "perceptions of nursing as a profession." Limitations of the Study The sample i s a convenience sample drawn from the population of students graduating from college-based nursing diploma programs during the months of June, July, and August 1984. Therefore, findings cannot be generalized beyond that population. Summary The process of s o c i a l i z a t i o n which occurs during a period of formal education equips the s o c i a l i z e e s with the necessary s k i l l s , a t t i t u d e s , perceptions, and ways of thinking which w i l l permit them to display behaviors acceptable to the professional group to which they belong. Thus, at the completion of nursing diploma programs, graduates should demonstrate professional behaviors which r e f l e c t the values of the nursing profession. However, i t has been observed that professional behaviors are not c o n s i s t e n t l y used by these graduates. As perceptions are determinant of behaviors, i t i s proposed that the perceptions of nursing as a profession of students graduating from diploma programs be examined. This research i s based on the assumptions that nursing i s a profession and that professionalism i s a curriculum component of diploma nursing programs. It i s suggested that the findings not be generalized beyond the population being studied due to the r e l a t i v e l y small number of sampling units a v a i l a b l e for t h i s study. 7 CHAPTER 2 Conceptual Framework Overview In t h i s study, the notion "perceptions of nursing as a profession" i s considered an i n d i c a t o r of the construct professional s o c i a l i z a t i o n . Therefore, a review of the l i t e r a t u r e on s o c i a l i z a t i o n i s germane. The research question addresses nursing as a profession; therefore, i t i s necessary to review the concept of professionalism as a background for the study of the a c q u i s i t i o n of perceptions of nursing as a profession of students graduating from college-based diploma programs. Both s o c i a l i z a t i o n and professionalism provide the conceptual framework for understanding the process of the development and the practice of the professional r o l e . Presented i n two major sections, t h i s review f i r s t explores s o c i a l i z a t i o n for the purpose of formulating a framework relevant to the research question. Because the study of s o c i a l i z a t i o n has emerged from d i f f e r e n t d i s c i p l i n e s , no single theory or d e f i n i t i o n of s o c i a l i z a t i o n appears to be adequate for the t h e o r e t i c a l structure of t h i s study. Therefore, i t i s necessary to draw on e x i s t i n g theories and models and develop a framework consistent with the research question addressed i n this study. The second section discusses professionalism within the context of the research question. Elements of professionalism are extracted from the 8 l i t e r a t u r e f or the purpose of developing a professional model which w i l l serve as a framework for the discussion of professionalism i n nursing. S o c i a l i z a t i o n Generally, s o c i a l i z a t i o n has been studied i n terms of the development of the i n d i v i d u a l as a s o c i a l being and a p a r t i c i p a n t i n society. T r a d i t i o n a l l y , psychologists and anthropologists have focused on the process of childhood s o c i a l i z a t i o n and s p e c i f i c a l l y on how the c h i l d becomes a functioning member of the society. E l k i n (1960) i n his work on the process of c h i l d s o c i a l i z a t i o n approaches s o c i a l i z a t i o n from the perspective of the i n d i v i d u a l . He describes i t as "the process by which someone learns the ways of a given society or s o c i a l group well enough so that he can function within i t " (p. 3). Clausen (1968) views childhood s o c i a l i z a t i o n as "the s o c i a l o r i e n t a t i o n of the c h i l d and his enculturation, f i r s t within the small s o c i a l world of family and neighborhood and then i n r e l a t i o n to the larger society and culture" (p. 4). Inkeles (1968) provides a summary of the current views of childhood s o c i a l i z a t i o n i n which he describes the process as involving the a c q u i s i t i o n of attitudes and values, ways of thinking, motives and f e e l i n g s , and personal and s o c i a l a t t r i b u t e s which w i l l characterize the i n d i v i d u a l i n his/her next stage of development (p. 76). It i s to be noted that there are two basic elements i n these d e f i n i t i o n s of s o c i a l i z a t i o n as outlined above. One focus i s on the process of a c q u i s i t i o n , the input aspect, and refers to what i s "done" to the c h i l d (Inkeles, 1968, p. 77). This e n t a i l s a continuous i n t e r a c t i o n between the c h i l d and those who attempt to influence him/her as well as 9 developmental change as learning involves change. The other element emphasizes the r e s u l t s of the s o c i a l i z a t i o n process, the output aspect, i n the form of an i n d i v i d u a l who has learned the several roles and s k i l l s , the language and norms, and the ideas and b e l i e f s that make i t possible for him/her to get along i n and contribute to a group or society of which he/she i s a member (Clausen, 1968, p. 6; Inkeles, 1968, p. 77). The process of s o c i a l i z a t i o n i s not l i m i t e d to the c h i l d and has been viewed by many s o c i a l s c i e n t i s t s , e s p e c i a l l y s o c i o l o g i s t s , as an ongoing process continuing throughout adulthood, indeed a l i f e l o n g process (Brim, 1968, p. 84; E l k i n , 1978, p. 35; Mortimer & Simmons, 1978, p. 421). The growing i n t e r e s t i n l i f e stages and l i f e span development (Erickson, 1982; Baltes & Warner, 1973), i n the m i d - l i f e c r i s e s (Levinson et a l . , 1978), and aging (Birren, 1964; Lewis, 1982) point toward a growing emphasis on adult s o c i a l i z a t i o n . It i s clear that the only s i g n i f i c a n t experiences for an i n d i v i d u a l are not r e s t r i c t e d to childhood. The occupational demands and the statuses and roles that become known to adults only a f t e r they have reached adulthood are part of the s o c i a l i z a t i o n process which i s experienced as an adult (Brim, 1968, p. 184; E l k i n , 1978, p. 10; Mortimer & Simmons, 1978, p. 422). While Mortimer and Simmons (1978) view adult s o c i a l i z a t i o n as occurring a f t e r the completion of general education whether secondary school or college, Brim (1968) describes i t as "the process by which one learns to perform his various roles adequately" (p. 186). Brim and Wheeler (1966) i d e n t i f y r o l e a c q u i s i t i o n as an extremely important, i f not the most important, component of adult s o c i a l i z a t i o n which represents a s h i f t from 10 an emphasis on values and motives stressed i n childhood s o c i a l i z a t i o n to an emphasis on overt behavior. Rosow (1965) views adult s o c i a l i z a t i o n as the process of i n c u l c a t i n g new values and behaviors appropriate to adult positions and group memberships (p. 35). Two ce n t r a l themes can be found i n discussions of adult s o c i a l i z a t i o n . The f i r s t concerns the basic elements i d e n t i f i e d i n childhood s o c i a l i z a t i o n - the input and output aspects - which are also found i n adult s o c i a l i z a t i o n . The second relates to the c h a r a c t e r i s t i c s of adult s o c i a l i z a t i o n . These are: (a) the content of what i s learned i n adult s o c i a l i z a t i o n involves more overt behaviors and s p e c i f i c norms and behaviors than i n childhood s o c i a l i z a t i o n (Brim & Wheeler, 1966, p. 5), (b) the content learned involves the synthesis of previously learned material (Clausen, 1968, p. 2-17), (c) the process may involve the unlearning of old norms and values, (d) adults may i n some instances i n i t i a t e s p e c i f i c s o c i a l i z a t i o n experiences (Brim, 1968, p. 189), (e) adults may o f f e r resistance to change i n the new contexts for they are not so e a s i l y malleable as are c h i l d r e n , and ( f ) much s o c i a l i z a t i o n occurs a f t e r the s o c i a l i z e e has assumed f u l l incumbency of the adult role (Mortimer & Simmons, 1978, pp. 423-24). Prof e s s i o n a l s o c i a l i z a t i o n Jacox (1978) describes professional s o c i a l i z a t i o n as "the i n t e r n a l i z a t i o n of the values and norms of a professional group into one's own behavior and self-conception" (p. 10). According to Moore (1970), the process involves "the a c q u i s i t i o n of knowledge, s k i l l s , and sense of occupational i d e n t i t y , and the i n t e r n a l i z a t i o n of occupational norms t y p i c a l of the f u l l y q u a l i f i e d p r a c t i t i o n e r " (p. 71). Similar views have been expressed by Watson (1981) and Crocker and Brodie (1974). By d e f i n i t i o n , as i n childhood s o c i a l i z a t i o n , the process e n t a i l s learning by the i n d i v i d u a l . It also assumes by implication an i n t e r a c t i o n between the learner and the teacher. F i n a l l y , these d e f i n i t i o n s suggest that the product of professional s o c i a l i z a t i o n must be a person who has both the technical competencies and the i n t e r n a l i z e d values, a t t i t u d e s , and b e l i e f s demanded by the profession and expected by the public at large. Thus, professional s o c i a l i z a t i o n has elements i n common with adult s o c i a l i z a t i o n . The objectives of professional s o c i a l i z a t i o n have been i d e n t i f i e d by Watson (1982) as being to "inculcate the novice or person being s o c i a l i z e d with both roles values and consequent behaviors" (p. 28). Cohen (1981) describes four goals of the s o c i a l i z a t i o n process. They are to: (a) learn the technology of the profession - the f a c t s , s k i l l s and theory; (b) learn to i n t e r n a l i z e the professional culture; (c) f i n d a personally and p r o f e s s i o n a l l y acceptable version of the r o l e ; and (d) integrate t h i s professional role into a l l other l i f e r o l e s , (p. 15) Given that the ultimate goal of professional s o c i a l i z a t i o n i s to equip i n d i v i d u a l s with necessary knowledge, s k i l l s , and di s p o s i t i o n s to enable them to use appropriately behaviors r e f l e c t i v e of the values and norms of the professional group to which they belong, i t would be appropriate to examine the process whereby t h i s transformation takes place. Models of s o c i a l i z a t i o n Various authors have offered models of s o c i a l i z a t i o n which i d e n t i f y the stages an i n d i v i d u a l must go through to learn the culture of a given group. Common to these models i s an attempt to explain what i s learned i n each phase, how i t i s learned, and what the expected outcomes are. Simpson's (1967) pattern of s o c i a l i z a t i o n into professions involves a sequential process consisting of three task-oriented, d i s t i n c t phases (pp. 47-50). The f i r s t stage, t r a n s i t i o n to task o r i e n t a t i o n , consists of transforming "the person's lay conceptions about the occupation into t e c hnical orientations of the i n s i d e r " (p. 48). The second stage involves the attachment of s i g n i f i c a n t others i n the work m i l i e u while the t h i r d phase i s hypothesized to be the i n t e r n a l i z a t i o n of professional values. Although Simpson's (1967) theory encompasses phase-specific learning of c u l t u r a l content of the role and some s e l f - i d e n t i f i c a t i o n with i t , i t portrays the i n d i v i d u a l as rather passive, not exerting a substantial influence on the course of the process and does not take into account personal d i f f e r e n c e s . Furthermore, she views the process as rather predictable. However, Simpson's model strongly suggests the presence of r o l e models as c r u c i a l for the learning of desired professional behaviors and i l l u s t r a t e s the important role that "hospital nurses" play i n the s o c i a l i z a t i o n process of nursing students. As students develop an attachment to s i g n i f i c a n t others (nurses) within the work s e t t i n g , they attempt to seek acceptance as professional colleagues (p. 51). This process implies the use of behaviors on the part of the student that are acceptable to s i g n i f i c a n t others. Students w i l l i n t e r n a l i z e the values and norms espoused by the nursing profession only to the extent to which these have been adopted by the s i g n i f i c a n t others. Kelman's (1967) theory of s o c i a l influence helps explain the a c q u i s i t i o n of the values and norms of a professional group. He postulated three processes that play an important role i n the s o c i a l i z a t i o n process: 13 compliance, i d e n t i f i c a t i o n , and i n t e r n a l i z a t i o n (p. 455). Although i d e n t i f i a b l y d i f f e r e n t , these processes are not mutually exclusive nor do they "generally occur i n pure form i n r e a l l i f e " (p. 459). The f i r s t process, compliance, occurs when an i n d i v i d u a l accepts influence from an agent be i t a group or a person i n an attempt to obtain a favorable response from that influencing agent. The induced behavior i s not adopted on the basis of conviction but rather as a way of getting a reward such as s o c i a l approval or a promotion. Kelman's (1967) second process, i d e n t i f i c a t i o n , occurs when an i n d i v i d u a l adopts the behavior of an influ e n c i n g agent because he wishes to e s t a b l i s h a s a t i s f y i n g , s e l f - d e f i n i n g r e l a t i o n s h i p with another person or a group. During t h i s phase, the i n d i v i d u a l self-concept i s not at stake for the new values and behaviors are not integrated within the i n d i v i d u a l ' s value system. F i n a l l y , i n t e r n a l i z a t i o n takes place "when an i n d i v i d u a l accepts influence because he believes i n the content of the induced behavior" (p. 457). The behaviors adopted are integrated with the in d i v i d u a l ' s value system. Kelman's (1967) theory views the s o c i a l i z e e as taking a more active role i n the process than Simpson's (1967). However, he gives i n s u f f i c i e n t consideration to i n d i v i d u a l v a r i a b i l i t y . As with Simpson's (1967) model, Kelman's (1967) i s useful i n explaining the external factors that a f f e c t the s o c i a l i z a t i o n process e s p e c i a l l y as i t relates to the influence of the s o c i a l i z a t i o n agents on the s o c i a l i z e e . Of the three phases, i n t e r n a l i z a t i o n i s the most important because i t implies that the s o c i a l i z e e s (students) have accepted the influence because they believe i n 14 i t and are thus w i l l i n g to demonstrate professional behaviors to which they have been oriented. Cohen (1981) proposes a four stage developmental model of professional s o c i a l i z a t i o n that i s based on Piaget's work on cognitive development (pp. 16-18). The f i r s t stage, complete r e l i a n c e on and acceptance of authority, i s spent p r i m a r i l y on l i s t e n i n g to and accepting material presented by i n s t r u c t o r s . Stage two consists of cognitive r e b e l l i o n . Students begin to question the information presented to them. In addition to learning the a b i l i t y to question, students gain a sense from f a c u l t y of what can be changed and what must remain unchanged i n terms of c e r t a i n ways of doing things, c e r t a i n manners, and c e r t a i n materials. During t h i s phase, students search for ways to make the professional values and norms more acceptable to them. The t h i r d phase marks the developing capacity for evaluative thinking and the incorporation of others' ideas into one's own thoughts and judgements. During t h i s phase, students work out a compromise between the value systems of the profession and t h e i r own values and expectations. The l a s t phase, in t e g r a t i o n of autonomy and mutuality, consists of the i n t e g r a t i o n of the professional role with other l i f e roles or other aspects of the self-concept. According to Cohen (1981), these stages b u i l d on each other. Normally, students move through the stages i n a sequence although there are times when t h i s does not occur. However, one f e e l s comfortable i n the professional r o l e when each stage i s experienced i n sequence (p. 16). Unlike Simpson's (1967) and Kelman's (1967) models, Cohen's (1981) focuses on the cognitive processes and the i n t e r n a l changes that i n d i v i d u a l s 15 experience i n the d i f f e r e n t stages as they acquire the values and norms of the group. In t h i s instance, the s o c i a l i z e e i s viewed as playing an active part i n the s o c i a l i z a t i o n process. From a role perspective, Thornton and Nardi's (1975) theory of role s o c i a l i z a t i o n comprises four stages: a n t i c i p a t o r y , formal, informal, and personal (pp. 870-880). Role i s defined 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. 870). Therefore, each stage i s influenced by the v a r i e t y of sources, content, and forms of expectations present, by the degree of consensus on the expectations, and the i n d i v i d u a l ' s reaction to them. The a n t i c i p a t o r y stage consists of the period which precedes the enactment of the r o l e . The informal stage involves "encounters with u n o f f i c i a l or informal expectations and ways of doing things" (p. 878). F i n a l l y , the personal stage involves the modification of role expectations to f i t the i n d i v i d u a l ' s personality. Thornton and Nardi's (1975) theory views the s o c i a l i z e e as taking an active part i n the process and considers i n d i v i d u a l v a r i a b i l i t y as a factor i n f l u e n c i n g the process. Emphasis i s placed on complex i n t e r a c t i o n a l l earning. Unlike the previous models, t h i s model suggests that the process of s o c i a l i z a t i o n occurs during the an t i c i p a t o r y stage of r o l e a c q u i s i t i o n (p. 875); the remaining stages are viewed as occurring a f t e r incumbency i n a s o c i a l p o s i t i o n (p. 876). For the purpose of this study, the elements i d e n t i f i e d i n the above models w i l l be combined as appropriate and the following model of professional s o c i a l i z a t i o n w i l l be posited as a framework for t h i s study. This model involves a sequential process of three phases, o r i e n t a t i o n , 16 reaction, and a s s i m i l a t i o n . Each phase i s characterized by the "expected behavior(s)" which i n d i v i d u a l s recognize as important and involves i n t e r a c t i o n between the i n d i v i d u a l and the expected behavior(s). Orientation i s a phase during which concepts, p r i n c i p l e s , s k i l l s , norms - the technology of the f i e l d and the values and standards of the profession - are learned while practice i s postponed u n t i l mastery of c e r t a i n basic s k i l l s i s achieved. During t h i s phase, students accept the material presented to them and conform to the demands placed on them as they do not have the knowledge nor the experience to question content and at the same time they wish to gain the approval of f a c u l t y for the opinions expressed and the behaviors displayed. The second phase, reaction, consists of a period of turmoil. During t h i s phase, students experiment with the new material p a r t i c u l a r l y as i t relates to the concepts embodied i n the notion of perceptions of nursing as a profession, by questioning the material, r e j e c t i n g c e r t a i n manners and ways of doing things, weighing the importance of the material, t r y i n g on new behaviors, and t e s t i n g the l i m i t s . This i s done i n an attempt to meet the expectations of f a c u l t y and to search for ways of coming to terms with the views of the profession. A s s i m i l a t i o n p a r a l l e l s Kelman's (1967) concept of i n t e r n a l i z a t i o n and Simpson's (1967) t h i r d phase of i n t e r n a l i z a t i o n of professional values. This phase consists of the int e g r a t i o n of the newly acquired perceptions of nursing as a profession within the student value system and the adoption of behaviors prescribed by the profession. The following assumptions are i m p l i c i t i n t h i s model: (a) The three 17 stages are not mutually exclusive although they are i d e n t i f i a b l y d i f f e r e n t steps; (b) the stages b u i l d on each other; (c) the timing and rate of progress through the stages vary with d i f f e r e n t i n d i v i d u a l s ; (d) students do not always progress through the stages i n order; however, the l a s t stage, a s s i m i l a t i o n , w i l l take place only i f stage I I , reaction, has been resolved; (e) the model does not imply that the ent i r e s o c i a l i z a t i o n process i s complete at the end of the educational program; i t can be hypothesized that students may reach the t h i r d stage i n r e l a t i o n to some aspects of the culture of the profession while they may be at stage I or II i n r e l a t i o n to other aspects; ( f ) the s o c i a l i z e e i s a c t i v e l y involved i n the shaping of situa t i o n s i n which the a c q u i s i t i o n of professional norms and values occurs; (g) behavioral models are required i n order to learn the desired professional behaviors; and (h) f a c u l t y members and s t a f f nurses influence the s o c i a l i z a t i o n process and thus t h e i r perceptions of nursing as a profession have a d i r e c t impact on the students' development and a c q u i s i t i o n of own perceptions of nursing. The model of professional s o c i a l i z a t i o n to be used i n t h i s study serves to explain the process whereby an i n d i v i d u a l acquires the s k i l l s , a t t i t u d e s , perceptions, and ways of thinking that w i l l permit him/her to display behaviors acceptable to the profession. A l l professional groups have developed expectations of the behaviors of t h e i r members and many propositions have been advanced i n an attempt to d i s t i n g u i s h professional a c t i v i t i e s from a c t i v i t i e s of an occupational nature. The l i t e r a t u r e on professionalism i d e n t i f i e s elements characterizing professions and t h e i r expectations of professional behaviors. 18 Professionalism Selected writings on professionalism are reviewed for the purpose of developing a professional model to serve as a framework for the s e l e c t i o n of the research instrument and for the discussion of the f i n d i n g s . S o c i o l o g i s t s and others have devoted many hours to the d e f i n i t i o n s and characterizations of professions. Some have i d e n t i f i e d d i s c r e t e elements that must be present to j u s t i f y the attainment of professional status by an occupation (Carr-Saunders, 1966; Flexner, 1915; Goode, 1969). Others have conceptualized a continuum or scale model of p r o f e s s i o n a l i z a t i o n along which an occupation may be placed and moved (Greenwood, 1966; Moore, 1970; Pavalko, 1971). Flexner (1915) i d e n t i f i e d s i x c r i t e r i a that a work group must possess to be recognized as a profession. These include: (a) i n t e l l e c t u a l operations, (b) a c t i v i t i e s based on a substantial body of knowledge transmissible to students, (c) a practice component involving the a p p l i c a t i o n of knowledge, (d) a teaching component for the dissemination of knowledge and s k i l l s , (e) a strong i n t e r n a l organized group completely engaged i n t h e i r work, and ( f ) altruism (p. 581). Flexner's (1915) c r i t e r i a are i d e a l i s t i c and perhaps u n r e a l i s t i c as few members of any work groups could f u l f i l l exactly every c r i t e r i o n (Bernhard & Walsh, 1981, p. 2). In 1928, Carr-Saunders (1966) discussed the development of what he c a l l e d professionalism. He defined a profession i n terms of: (a) an occupation based upon s p e c i a l i z e d i n t e l l e c t u a l study and t r a i n i n g , (b) the a p p l i c a t i o n of fee or salary, and (c) the use of a code of e t h i c s governing professional p r a c t i c e . These c r i t e r i a can be more e a s i l y met by various work groups than Flexner's (1915). Goode (1969) has reduced the basic c h a r a c t e r i s t i c s of a profession to two c e n t r a l generating q u a l i t i e s : a basic body of abstract knowledge and the i d e a l of service (p. 277). A l l the other c h a r a c t e r i s t i c s are derived from these basics. In his study of the elements of p r o f e s s i o n a l i z a t i o n , Greenwood (1966) maintains that a l l professions seem to possess: (a) a systematic body of theory, (b) professional authority, (c) sanction of the community, (d) regulative code of e t h i c s , and (e) a professional culture sustained by a professional association (p. 10). However, he finds that there are no clear-cut d i s t i n c t i o n s between professions and non-professions. Rather, he suggests that we "think of the occupations i n a society as d i s t r i b u t i n g themselves along a continuum" (p. 10). The concept of an occupation-profession continuum model i s a useful one e s p e c i a l l y for the emerging professions as t h e i r p o s i t i o n on the continuum can be r e a d i l y measured and progress can be e a s i l y monitored. Moore's (1979) conceptualization of professionalism i s s i m i l a r to Greenwood's (1966) i n that he proposes that "professionalism should be regarded as a scale rather than a c l u s t e r of a t t r i b u t e s , and thus that a t t r i b u t e s commonly noted have d i f f e r i n g values" (p. 5). The c h a r a c t e r i s t i c s he describes are not of equal value and the order i n which they are presented represents t h e i r increasing l e v e l of importance and complexity i n achieving professionalism. They are: (a) professionals are employed f u l l time i n an occupation which comprises the p r i n c i p a l source of t h e i r income, (b) professionals are committed to t h e i r occupation, (c) professionals are i d e n t i f i e d with t h e i r peers i n formalized organization, (d) professionals possess useful knowledge and s k i l l s acquired through a long period of s p e c i a l i z e d education and t r a i n i n g , (e) professionals are distinguished by a service o r i e n t a t i o n and are expected to perceive the needs of t h e i r c l i e n t s that are relevant to t h e i r competence and to attend competently to those needs, and ( f ) professionals enjoy autonomy (Moore, 1970, pp. 7-17). From a s i m i l a r perspective, Pavalko (1971) describes eight c h a r a c t e r i s t i c s that can be considered c r u c i a l i n d i f f e r e n t i a t i n g occupations from professions (pp. 18-20). It i s the degree to which each c h a r a c t e r i s t i c i s possessed by a p a r t i c u l a r group that determines the group's p o s i t i o n on the continuum. Six of these a t t r i b u t e s have already been discussed. The other two, relevance to basic values and motivation, add a new dimension to the concept of professionalism, and therefore, deserve some at t e n t i o n . Pavalko (1971) views the r e l a t i o n s h i p of an occupation to the c e n t r a l values of society as a d i f f e r e n t i a t o r of occupations from professions (p. 18). Professions tend to j u s t i f y t h e i r existence by i d e n t i f y i n g themselves with abstract values (eg. l i f e , l i b e r t y , health) on which there i s widespread consensus. Professionals attempt to maximize the r e a l i z a t i o n of such values i n t h e i r r e l a t i o n s h i p s with c l i e n t s . Motivation "involves the juxtaposition of service and s e l f - i n t e r e s t as motivational bases for work" (Pavalko, 1971, p. 20). The issue i s not what motivates i n d i v i d u a l s to work but rather the extent to which the work 21 groups are governed by the desire to best serve t h e i r c l i e n t s rather than by s e l f - i n t e r e s t and the desire for monetary gain. In essence, t h i s a t t r i b u t e i s c l o s e l y related to the i d e a l of service i d e n t i f i e d by Goode (1969) and altruism i d e n t i f i e d by Flexner (1915). There are f i v e basic elements upon which there appears to be consensus among the scholars c i t e d above as c o n s t i t u t i n g the 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 profession. These are included i n the following model characterizing professions that i s posited as a framework to be used i n th i s study (see Table I ) . This framework elaborates upon and adds to these a t t r i b u t e s using ideas from the works reviewed above. In t h i s framework the element of autonomy i s cen t r a l to a l l other elements and thus to the profession. Professionalism i n nursing The professional status of nursing has been and continues to be an area of discussion within the nursing profession and among outside observers. The nursing l i t e r a t u r e , however, points toward the acceptance of professional status for nurses. This l i t e r a t u r e w i l l be discussed within the context of the Professional Model i l l u s t r a t e d i n Table I (see page 22) for the purpose of exploring the area of professionalism i n nursing, of c l a r i f y i n g some of the ideas which have been expressed, and of i d e n t i f y i n g concepts relevant to the examination of professionalism i n nurses. The f i r s t element i d e n t i f i e d i n the Professional Model consists of a systematic body of knowledge on which practice i s based. The a c q u i s i t i o n of such knowledge involves i n t e l l e c t u a l a c t i v i t i e s as well as p r a c t i c a l 22 Table I The P r o f e s s i o n a l Model Body of knowledge -acquired through formal education i n an academic and practice s e t t i n g -generated through the a p p l i c a t i o n of the s c i e n t i f i c method to the s e r v i c e - r e l a t e d problems of the profession Ethics - e s s e n t i a l s are described i n terms of c l i e n t - p r o f e s s i o n a l and colleague-colleague r e l a t i o n s -influenced by society and the profession C l i e n t - p r o f e s s i o n a l r e l a t i o n s h i p -based on service o r i e n t a t i o n and commitment -consistent with basic s o c i e t a l values and enhances the attainment of such values -sustained by a professional association - r e f l e c t s the common i d e n t i t y and destiny of the group Autonomy A" -represents legitimate control '7\ \ over professional behaviours / / '- 7 which i s established through > consensus by the members i n the group -based on the mastery of a knowledge f i e l d . ^ < - — v / -maintained through r e l a t i o n s \ \£, with society and the group >V Culture -characterized by a high degree -includes profes s i o n a l standards of colleagueship and commitment of conduct -sets standards of practice experiences. This knowledge base i s not e n t i r e l y derived from s c i e n t i f i c research; however, to provide a sound basis for professional p r a c t i c e , i t i s necessary to generate knowledge through the a p p l i c a t i o n of the s c i e n t i f i c method to the in v e s t i g a t i o n of c l i n i c a l problems. Nursing has made s i g n i f i c a n t advances i n generating and u t i l i z i n g a body of knowledge which i s on the i n t e l l e c t u a l l e v e l of higher learning (Ahad, 1981, p. 58; McCloskey, 1981, p. 41; S c h l o t f e l d t , 1981, p. 296). A s h i f t toward a c t i v e l y engaging i n serious development of nursing knowledge can be traced. Authors such as Dickoff, James, and Wiedenbach (1968), E l l i s (1968), Hardy (1974), and Johnson (1974) have made a case for theory construction and development i n nursing. Stages of development of s c i e n t i f i c theory have been delineated and c r i t e r i a f o r evaluating theories developed. Some nurse theo r i s t s have proposed formulations and have attempted to va l i d a t e them ( G i l l & Atwood, 1981; Hesook, 1983; Rogers, 1970). Books on the nature of nursing theory and i t s a p p l i c a t i o n to nursing have appeared and are increasing i n number (Chinn & Jacobs, 1983; King, 1981; Stevens, 1979). Three features of t h e o r e t i c a l writings i n nursing which r e f l e c t advancement i n theory development have been i d e n t i f i e d by Chinn and Jacobs (1983). The f i r s t one consists of change and progression of ideas which can be noted i n the works of theor i s t s such as King (1981) and Roy (1981). The evolution of ideas r e f l e c t s the continuing development and refinement of t h e o r e t i c a l knowledge. The second feature involves t r a i t s common to many theories. According to Chinn and Jacobs (1983), "the a b i l i t y to see trends or common t r a i t s demonstrates the c r y s t a l l i z a t i o n of cen t r a l 24 concepts or images for nursing science" (p. 182). F i n a l l y , the t h i r d feature i s the growing evidence that nursing p r a c t i c e , education, and research are guided by current nursing theory. For example, conceptual models for nursing provide d i r e c t i o n to a l l three areas of nursing (Adam, 1980; Fawcett, 1980). For nursing p r a c t i c e , these models provide d i r e c t i o n for what nursing does and how i t does i t . More s p e c i f i c a l l y , conceptual models define and describe the c l i e n t . They specify a goal of action, a state or condition, to be achieved within the c l i e n t , and i d e n t i f y the aspect of the c l i e n t toward which p r a c t i t i o n e r s d i r e c t t h e i r a t t e n t i o n . F i n a l l y , models make e x p l i c i t nursing's unique mission, delineate nursing r e s p o n s i b i l i t i e s , and s t i p u l a t e how and when the p r a c t i t i o n e r should intervene. A number of a r t i c l e s describe the process by which conceptual models have directed nursing p r a c t i c e . Nordal and Sata (1980) i l l u s t r a t e how Peplau's conceptual model can be applied to primary nursing (pp. 60-73). Another example i s the influence of Roy's model on the care of the dying c l i e n t (Starr, 1980, pp. 189-192). Conceptual models can also d i r e c t the process of curriculum bu i l d i n g and r e v i s i o n . Lebold and Davis (1980) describe the o p e r a t i o n a l i z a t i o n of Newman's model as the basis for a conceptual framework for a baccalaureate program i n nursing (pp. 150-158). F i n a l l y , research can be guided by conceptual models. Roy's (1980) model which i d e n t i f i e s the c l i e n t ' s problems i n terms of inadequate coping a c t i v i t y i n the face of environmental s t i m u l i d i r e c t s the nurse to investigate c l i e n t s ' reactions to manipulation of s t i m u l i by the nurse. The amount of research to i d e n t i f y the knowledge base of nursing has increased s u b s t a n t i a l l y i n the l a s t few decades. Brown, Tanner, and Padrick (1984) i n t h e i r examination of research publications conclude that research i n the 1980's has become more t h e o r e t i c a l l y oriented and more sophisticated i n i t s method and that the focus has s h i f t e d to c l i n i c a l problems (p. 31). While t h i s i s encouraging, gaps and l i m i t a t i o n s were also i d e n t i f i e d . A s i g n i f i c a n t l i m i t a t i o n i s the non-cumulative nature of research (p. 32). Fawcett (1983) claims that nursing " i s only beginning to recognize the need for studies that b u i l d on one another from the d e s c r i p t i v e stage to that of c l i n i c a l evaluation" (p. 178). Orientation to the t h e o r e t i c a l body of knowledge pertaining to a profession can be achieved best through formal education i n an academic s e t t i n g . Nursing has long recognized the need for a lengthy, rigorous education i n an academic s e t t i n g for the preparation of a p r a c t i t i o n e r who can demonstrate the a b i l i t y to think c r i t i c a l l y , to use the s c i e n t i f i c method of enquiry, and to engage i n l i f e long learning. The move of nursing diploma schools from h o s p i t a l settings into educational i n s t i t u t i o n s exemplifies t h i s . However, i t i s now the general consensus that the length of such programs i s i n s u f f i c i e n t to prepare a p r o f e s s i o n a l . The Canadian Nurses Association (1982) has taken the p o s i t i o n that by the year 2000, a baccalaureate degree i n nursing w i l l be the minimum preparation l e v e l for a nurse. S c h l o t f e l d t (1981) proposes that a doctoral l e v e l (ND) be a requirement for entry into the practice of nursing as i s the case with medical doctors and dentists (pp. 300-301). A second element of the Professional Model involves the r e l a t i o n s h i p established between the c l i e n t and the p r o f e s s i o n a l . A professional deals with s p e c i f i c c l i e n t s whose welfare i s affected by the competence and q u a l i t y of the service performed (Moore, 1970, p. 3). Thus the c l i e n t - p r o f e s s i o n a l r e l a t i o n s h i p i s based on service o r i e n t a t i o n and commitment. Professionals consider t h e i r c l i e n t ' s concerns within the context of e x i s t i n g basic s o c i a l values, preserve the c o n f i d e n t i a l i t y of t h e i r c l i e n t s , and remain current with the developments i n t h e i r f i e l d . Moreover, the professional i s committed to act i n the best i n t e r e s t of his c l i e n t s . Nursing i s characterized by a strong service o r i e n t a t i o n , personal commitment, and s e l f - s a c r i f i c e (Stuart, 1981, p. 21). Nursing's commitment to the d i g n i t y of the c l i e n t as a person i s expressed i n a l l areas of nursing p r a c t i c e (Stuart, 1981, p. 22). Further, nurses' willingness to assume the function and r e s p o n s i b i l i t i e s of patient advocate r e f l e c t s nursing's involvement i n acting i n the best i n t e r e s t s of the c l i e n t s . Nurses' involvement i n furthering t h e i r education must not be understated. Diploma graduates are i n c r e a s i n g l y returning for baccalaureate and advanced preparation (McCloskey, 1981, p. 41; "UVIC nursing", 1984, p. 31). In the United States, graduate nursing programs at both the master's and doctoral l e v e l s are growing s t e a d i l y ( S c h l o t f e l d t , 1981, p. 296) and many of the states have i n s t i t u t e d mandatory continuing education. A survey conducted for the Registered Nurses' Association of B r i t i s h Columbia revealed that a high demand for continuing education programs existed throughout i t s membership ("Workshop considers," 1981). Fundamental to the c l i e n t professional r e l a t i o n s h i p i s the a b i l i t y of the professional to a r t i c u l a t e c l e a r l y the nature and scope of the services offered to the c l i e n t and to society. It i s imperative that the professional knows who the c l i e n t i s , what state or condition i s to be achieved, and when and how to a s s i s t the c l i e n t i n achieving such a condition. This dimension underlying the c l i e n t - p r o f e s s i o n a l r e l a t i o n s h i p cannot be overemphasized. Conceptual models allow nurses to c l a r i f y the focus, scope, and j u r i s d i c t i o n of t h e i r practice to t h e i r c l i e n t s and society. Furthermore, they enable nurses to define and i n t e r p r e t t h e i r practice to co-workers and t h e i r p o s i t i o n v i s - a - v i s other health care workers. Only when the above conditions e x i s t w i l l the c l i e n t be well served. Autonomy constitutes the t h i r d element of the Professional Model and i s viewed as being c e n t r a l to a l l the other elements. Autonomy refe r s to the profession's a b i l i t y to have control over i t s p r a c t i c e . This means control over work behaviors i n the work s e t t i n g , control over education and entry to p r a c t i c e , and regulation of i t s own a s s o c i a t i o n . According to Pavalko (1971), professionals are concerned with specifying and guarding the boundaries of t h e i r f i e l d of practice and c o n t r o l l i n g matters r e l a t i n g to the a c t i v i t i e s of t h e i r members. U n t i l the development of conceptual models, nursing's mission was i l l - d e f i n e d . Most d e f i n i t i o n s of nursing f a i l e d to i d e n t i f y the unique focus of nursing. Conceptual models now provide a focus for nursing which allows nurses to escape from the p o s i t i o n of p r a c t i c i n g from the perspective of another profession (Fawcett, 1980, p. 312) or assuming the focus of other professions. Defining the parameters of nursing, thus nursing's unique o r i e n t a t i o n , can only r e s u l t i n more independence for i t s p r a c t i t i o n e r (Adam, 1980, p. 2). This i n turn w i l l contribute toward the attainment of f u l l autonomy. Although nursing has delineated i t s scope of functions, the exercise of c o n t r o l over the practice of nursing can be d i f f i c u l t to achieve i n some practice s e t t i n g s . In such settings, decisions are frequently more influenced by authority structures than by authority derived from expert knowledge of the professional nurse and the exercise of professional judgement (Stuart, 1981, p. 22; Jacox, 1978, pp. 14-15). However, recent changes such as the introduction of primary care and the implementation of standards of nursing practice and peer review occurring i n ho s p i t a l s enable nurses to exercise more con t r o l over t h e i r own work s i t u a t i o n (Stuart, 1981, p. 22). The nursing profession exercises a high l e v e l of autonomy i n the areas of basic nursing education, entry to p r a c t i c e , and professional conduct of i t s members. For example, i n B r i t i s h Columbia, nursing has the l e g i s l a t e d authority through the Nurses (Registered) Act (1979) to control the admission to the profession through a r e g i s t r a t i o n process, to approve schools of nursing, and to maintain acceptable l e v e l s of conduct and competence through a d i s c i p l i n e procedure. For a profession to enjoy f u l l autonomy, i t must gain the respect and trust of the general p u b l i c . Unless society i s persuaded that the profession can and w i l l c o n t r o l the work of i t s members i n the i n t e r e s t of c l i e n t s , (Goode, 1969, p. 292), that the profession possesses s p e c i a l i z e d knowledge, (Jacox, 1978, p. 15), and that the service provided i s of value, 29 autonomy w i l l be d i f f i c u l t to e s t a b l i s h . From the foregoing l i t e r a t u r e , i t i s clear that nursing possesses s p e c i a l i z e d knowledge and exercises control over i t s members. With respect to the t h i r d condition, Adam (1980) claims that nursing provides a service considered important by most s o c i e t i e s (p. i x ) . Moreover Adam (1980) argues that only nurses can provide such a se r v i c e . She claims that nurses have an independent s o c i a l mission to accomplish. Stuart (1981) contends that nursing i s held i n high regard by the public (p. 22). Notwithstanding these assertions, nursing needs to further change the public's image to one which w i l l f u l l y recognize nursing's unique and independent se r v i c e . E t h i c s comprises the fourth element of the Professional Model. A desire on the part of the members of the profession to see a proper standard of professional conduct led to the development of a code of et h i c s . The fundamental elements of e t h i c a l codes are described i n terms of c l i e n t - p r o f e s s i o n a l and colleague-colleague r e l a t i o n s h i p s (Goode, 1966, p. 16). The ethic s governing the c l i e n t - p r o f e s s i o n a l r e l a t i o n s h i p demand that the professional assumes an "emotional n e u t r a l i t y " (p. 16), provides service to whomever requests i t , and gives high c a l i b r e s e r v i c e . Toward his colleague, the professional demonstrates a behavior that i s co-operative, e g a l i t a r i a n , and supportive. The International Council of Nurses (ICN), American Nurses Association (ANA), Canadian Nurses Association (CNA) and p r o v i n c i a l nursing associations have adopted codes of ethics which serve as a frame of reference f o r professional conduct and for judgements of e t h i c a l issues i n complex nursing s i t u a t i o n s . These e t h i c a l codes are being revised continuously and improved to r e f l e c t the changes occurring at the s o c i e t a l l e v e l as well as those taking place within the nursing profession. The ICN Code for Nurses (1973) i s based on the following assumptions: a) the need for nursing i s universal; b) nursing i s an i n d i v i d u a l , family, and community-oriented health service; and c) the fundamental r e s p o n s i b i l i t y of nursing consists of promoting health, of preventing i l l n e s s , of r e s t o r i n g health, and of a l l e v i a t i n g s u f f e r i n g (p. 1). The ICN Code for Nurses i d e n t i f i e s f i v e areas i n which the professional nurse has d i r e c t r e s p o n s i b i l i t y . These are: a) nurses and people, b) nurses and p r a c t i c e , c) nurses and society, d) nurses and co-workers, and e) nurses and the professions. The ICN Code for Nurses stresses commitment, r e s p o n s i b i l i t y , a c c o u n t a b i l i t y , respect, and d i g n i t y . The other codes of ethics encompass s i m i l a r standards of conduct. The l a s t element to be discussed r e l a t e s to the culture of a profession, that i s the " s o c i a l configuration" unique to the profession which encompasses i t s values, norms, and symbols (Greenwood, 1966, p. 17). The culture of a profession i s sustained by a professional a s s o c i a t i o n whose members are bound by a sense of common i d e n t i t y and destiny. Colleagueship and commitment p r e v a i l among i t s members. The Canadian Nurses Association founded i n 1908 i s the recognized national nursing organization (CNA, 1980b). Its objectives are to promote health and to seek conditions conducive to the best possible patient care. To achieve i t s objectives, CNA i s concerned with: (a) q u a l i t y and quantity of nursing a v a i l a b l e to the health team; (b) standards of preparation and performance of professional nurses; (c) s o c i a l and economic welfare of nurses; (d) advancement of knowledge, techniques and competence within the profession; (e) promotion of 31 understanding, unity, and good professional c i t i z e n s h i p among i t s members; (f) representing and speaking for the organized nursing profession, both n a t i o n a l l y and i n t e r n a t i o n a l l y , (p. 1) At the p r o v i n c i a l l e v e l , the Registered Nurses' Association of B r i t i s h Columbia (RNABC) determines the course of nursing by bringing together the a b i l i t i e s of i t s members to achieve i t s main objectives. In addition to f u l f i l l i n g i t s statutory r e s p o n s i b i l i t i e s , the RNABC constitutes a major force for e s t a b l i s h i n g standards of nursing, promoting the advancement of knowledge, delineating and explaining nursing's mission and i t s r e l a t i o n s h i p to other health care providers, and i n f l u e n c i n g health p o l i c y matters (RNABC, 1982). These a c t i v i t i e s are consistent with those of CNA thus exemplifying the common goals shared by both associations. It i s possible to extract common themes from t h i s discussion on professionalism. These consist of: (a) the scope of the profession, i t s goal and i t s r e l a t i o n s h i p to both the c l i e n t and other health care p r a c t i t i o n e r s ; (b) the advancement of a body of knowledge; (c) r e s p o n s i b i l i t y , a c c o u n t a b i l i t y , and commitment to the c l i e n t and to the profession; and (d) independence and autonomy of the p r o f e s s i o n a l . These themes represent the major ideas expressed by members of the nursing profession and thus constitute the core of professionalism i n nursing. Therefore, these aspects of professionalism guide the measurement of professionalism i n nurses and should be r e f l e c t e d i n any instrument used for such purpose. Summary Writings i n psychology and sociology and the nursing 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 were examined to provide the basis for understanding the process of professional s o c i a l i z a t i o n and for developing a model of professional s o c i a l i z a t i o n consistent with the research question. The l i t e r a t u r e on professionalism i n general and professionalism i n nursing was reviewed to e s t a b l i s h a d e f i n i t i o n of professionalism appropriate to the objectives of the study. 33 CHAPTER 3 L i t e r a t u r e Review Overview In order to r e l a t e t h e o r e t i c a l writings of professional s o c i a l i z a t i o n and professionalism s p e c i f i c a l l y to nursing, the nursing 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 i s reviewed. Numerous studies have been conducted which deal with the development of students i n nursing programs and t h e i r perceptions of nursing as a profession. Many of the research studies concerning the views of students toward nursing as a profession have been developed within the context of the s o c i a l i z a t i o n process. Therefore, studies relevant to the research question w i l l be reviewed both i n terms of professional s o c i a l i z a t i o n and perceptions of nursing as a profession. Studies Related to the S o c i a l i z a t i o n of Nursing Students and Their Perceptions about Nursing as a Profession In 1959, Simpson et a l . (1979) i n i t i a t e d a l o n g i t u d i n a l study at Duke University which focused on the a c q u i s i t i o n of professional values and norms of nursing students. Their study viewed s o c i a l i z a t i o n as consisting of d i f f e r e n t dimensions, namely: (a) imparting of occupational knowledge, (b) development of occupational o r i e n t a t i o n s , and (c) relatedness to the professional r o l e (p. 29). Three panel classes and f i v e a d d i t i o n a l cohorts were studied for varying periods of time. Data c o l l e c t i o n was accomplished through the administration of questionnaires, the use of anecdotes and 34 interviews. Two dimensions of t h e i r study, occupational orientations and personal relatedness, are p a r t i c u l a r l y relevant. Data ind i c a t e that the d i r e c t i o n of the development of the orientations to the role of the nurse s h i f t e d away from the i n i t i a l values and goals of the school and from the o r i g i n a l expectations of the students toward conformity with the bureaucratic pattern of nursing, a pattern opposed and de-emphasized by the school (pp. 123-124). Students' orientations toward c o l l e g i a l i s m and toward administration and supervision were more favorable upon graduation than upon admission into the school (p. 132). The development of personal relatedness was examined from the perspectives of status i d e n t i f i c a t i o n , occupational commitment, and a t t r a c t i o n to the nursing profession. Using the following modified version of Huntington's (1957) measure, "Do you think of yourself as a nurse?", Simpson et a l . found that status i d e n t i f i c a t i o n developed r a p i d l y from the beginning of the freshman year through the sophomore year (p. 140). The pattern of development of commitment resembles that of the development of status i d e n t i f i c a t i o n . About 40% of the freshmen entered nursing with a high l e v e l of commitment and about 66% graduated with a high commitment to nursing. A t t r a c t i o n to nursing declined s l i g h t l y from the beginning to the end of the program (p. 146). Upon graduation, students i d e n t i f i e d themselves as nurses and were highly committed to nursing but not highly attracted to i t . Findings on the development of orientations to the r o l e of the nurse do not conform to the assumptions i m p l i c i t i n t r a d i t i o n a l models of 35 s o c i a l i z a t i o n discussed herein i n that these models s t i p u l a t e that the s o c i a l i z e e adopts the values and attitudes held by the s o c i a l i z i n g agent. The other phenomena observed are consistent with the models of s o c i a l i z a t i o n with the exception of the decline i n the a t t r a c t i o n to nursing. In another l o n g i t u d i n a l study, Davis and Olesen (1964) examined the concept of professional s o c i a l i z a t i o n , p a r t i c u l a r l y the students' outlook regarding nursing (pp. 8-15). They postulated that as students progress through the program, they would change t h e i r t r a d i t i o n a l and lay images of nursing to p r o f e s s i o n a l l y more advanced images and that over time there would be a tendency to move from bureaucratic images towards i n d i v i d u a l i s t i c and innovative images of nursing. The instrument, a dual focused c h e c k l i s t on images of nursing, was administered to seventy baccalaureate nursing students at entry into the University of C a l i f o r n i a School of Nursing i n San Francisco and upon completion of the f i r s t year of the curriculum. It was found that a f t e r one year i n the program, students gravitated towards and attached importance to i n d i v i d u a l i s t i c , innovative views of nursing, but at the same time no appreciable change was noted i n the importance attached to lay images (Davis & Olesen, 1964, p. 15). C h a r a c t e r i s t i c s ascribed to nursing a f t e r completing the f i r s t year of the program were o r i g i n a l i t y , innovation, imagination, and i n s i g h t . Concomitantly, bureaucratic images of nursing such as c l e a r l y defined tasks, close supervision and d i r e c t i o n , and clear-cut l i n e s of authority were weakened. In t e r e s t i n g l y , the b e l i e f s of advanced professional images such as s o l i d i n t e l l e c t u a l content or high respect of the occupation which are consistent with the Professional Model l o s t credence with students to some degree. Furthermore, there was no s i g n i f i c a n t increase i n consensus among students either with respect to t h e i r characterizations of nursing or the personal importance attached to such characterizations and there was no evidence that students did not achieve greater consonance between t h e i r images of nursing and personal values (p. 15). These l a s t two findings do not lend support to the assumption that students experience a reduction i n the dissonance they may have perceived between t h e i r needs and values and the demands of the profession as they are exposed to the culture of t h e i r profession i m p l i c i t i n the models developed by Cohen (1980) and Thornton and Nardi (1975), and the model of professional s o c i a l i z a t i o n developed above. F i n a l l y , i t was concluded that f a c u l t y appeared to exercise some influence on the development of professional values. The pattern of development as revealed i n th i s study i s s t r i k i n g l y d i f f e r e n t from the one established i n Simpson's (1979) research i n which the students moved away from both the ideals of the school and t h e i r own i d e a l i s t i c o r i e n t a t i o n to adopt a bureaucratic model. In addition, findings on the development of favorable orientations toward professionalism i n Simpson's (1979) study d i f f e r from those i n t h i s study which established that the l e v e l of endorsement of professional values such as high respect of the occupation declined s l i g h t l y from entry to graduation. Olesen and Davis (1966) followed up the students surveyed i n t h e i r previous study. The same questionnaire was administered each succeeding 37 June a f t e r the f i r s t year i n the program u n t i l graduation. During the subsequent years of the program, students did not s i g n i f i c a n t l y a l t e r t h e i r perceptions of nursing nor did they increase consensus among themselves or consonance within themselves. However, students i n c r e a s i n g l y rejected a bureaucratic role conception as they advanced through the program but a portion of the students maintained c e r t a i n lay images of nursing (pp. 156-158). In addition to the above findings, Olesen and Davis' observations show that the s o c i a l i z a t i o n process i s fraught with inner c o n f l i c t s , ambivalence, compromise, and d i f f e r e n t expectations thus lending support to Cohen's (1981) proposition that a period of cognitive r e b e l l i o n i s an i n t e g r a l part of the s o c i a l i z a t i o n process and to the "reaction" phase of the model of professional s o c i a l i z a t i o n developed herein. This implies that the s o c i a l i z e e i s not a passive r e c i p i e n t of the s o c i a l i z a t i o n process. Olesen and Whittaker (1968) claim that students are a c t i v e l y involved i n the process of s o c i a l i z a t i o n and can i n fact shape the r o l e and take an active part i n t h e i r own formation (p. 7). In a r e p l i c a t i o n of Davis and Olesen's (1964) study, Brown, Swift, and Oberman (1974, pp. 53-59) found that students at the University of Oregon School of Nursing did not d i f f e r s i g n i f i c a n t l y from those i n Davis and Olesen's (1964) study. However, the students i n the Oregon study achieved a greater consensus of what they considered important i n nursing but did not show greater achievement i n consensus of what they believed characterized nursing. It i s i n t e r e s t i n g to note that over a period of a decade few changes i n students' values and conceptions of nursing occurred i n l i g h t of the attempts made toward the p r o f e s s i o n a l i z a t i o n of nursing during the l a t e s i x t i e s and early seventies. In a study of baccalaureate nursing students at Seton H a l l University, C o l l i n s and J o e l found that two hundred and t h i r t y respondents comprising sophomore, junior, and senior students and the previous year's graduates held a highly technical o r i e n t a t i o n to nursing (pp. 456-459). C o l l i n s and Joel's (1971) de s c r i p t i o n of a technical nurse consisted of a person who " i s seen as a nurturer and comforter concerned with the accurate performance and the carrying out of the physician's order" (p. 457). In contrast, the professional nurse was viewed as someone characterized by a "desire f o r independent actio n , an eagerness to experiment, to innovate, to question, and to assume r e s p o n s i b i l i t y for one's own behavior" (p. 457). These findings are inconsistent with the r e s u l t s of the studies conducted by Davis and Olesen (1964), Olesen and Davis (1966), and Brown, Swift and Oberman (1974) who established that as students advanced through the program, they i n c r e a s i n g l y depicted nursing i n terms of advanced professional images r e f l e c t i v e of the Professional Model. In addition, C o l l i n s and Jo e l (1971) found that many of the respondents appeared to lack the basic commitment so v i t a l to a profession (p. 459). From another perspective, Crocker and Brodie (1974) measured the congruence between student nurses' perceptions and fa c u l t y ' s views of the professional nursing r o l e (pp. 233-235). On a professional o r i e n t a t i o n scale, four hundred and ninety-four students i n baccalaureate nursing programs and ninety-four i n s t r u c t o r s rated the importance of behaviors common to p r a c t i s i n g nurses. The re s u l t s revealed that the students' perception of the nurse's role s h i f t e d s i g n i f i c a n t l y toward professional views as t h e i r class rank increased " i n d i c a t i n g that students adopt f a c u l t y ' s professional views i n d i r e c t r e l a t i o n to length of t r a i n i n g " (Crocker & Brodie, 1972, p. 233). These r e s u l t s support Davis and Olesen's (1964) contention that f a c u l t y exercise a considerable influence on the students' increasing endorsement of professional values emphasized by f a c u l t y i n t h e i r contacts with students and serve to i l l u s t r a t e the c r u c i a l role played by f a c u l t y i n guiding the student toward i d e n t i f i c a t i o n with the profession. Watson (1982) compared the professional attitudes of students i n d i f f e r e n t types of programs and found that generic baccalaureate graduates held stronger attitudes toward professionalism than did diploma and associate degree graduates (p. 198) thus concluding that the type of educational program i s associated with the development of professional o a t t i t u d e s . Like Crocker and Brodie's (1972), Watson's (1982) research shows that concepts and attitudes of the novice i n time become more l i k e those of a p r o f e s s i o n a l . In a c r o s s - s e c t i o n a l study of nursing students i n an R.N. diploma program, S t o l l e r (1978) focused on the conceptions of nursing of an entering c l a s s of diploma students and those of the graduating class (pp. 2-14). She postulated that the students' attitudes toward the nursing role at the beginning of the program would gravitate toward the school's dominant norms as the process of s o c i a l i z a t i o n progressed. Differences were noted between the f i r s t and t h i r d year students i n the following areas: (a) awareness of the registered nurse i n determining patient care, (b) commitment to the nursing profession, and (c) salience of the nursing role (p. 13). In f a c t , freshman students' image of the nursing role was unclear, ambiguous, and contradictory. They reported that although s c i e n t i f i c knowledge and technical s k i l l s are the most important aspect of nursing education, being a good nurse takes the same q u a l i t i e s as being a good wife and a mother. Moreover, they did not view nursing as making an important contribution to the health care team, expressed a reluctance to disagree with or voice t h e i r views to a superior, and indicated a willingness to leave nursing for a more l u c r a t i v e occupation. Yet, they saw nursing as the most s a l i e n t aspect of t h e i r future l i v e s . Senior students reported that they would not leave nursing for better f i n a n c i a l opportunities, recognized nursing's contribution to care planning, expressed a willingness to voice disagreements, and to c r i t i c i z e or ignore the d i r e c t i v e s of a superior. The behaviors i d e n t i f e d by the senior students point toward an increased awareness of the nurse's a b i l i t y to contribute to patient care, an increased l e v e l of commitment, and a developing sense of autonomy. S t o l l e r ' s (1978) findings are consistent with those of Davis and Olesen (1966) and Brown, Swift and Oberman (1974). In spite of the l i m i t a t i o n s of the cross s e c t i o n a l approach, the data indicate that the behaviors i d e n t i f i e d by the graduating class are r e f l e c t i v e of the Professional Model. Valiga (1982), i n a l o n g i t u d i n a l study, examined the r e l a t i o n s h i p between cognitive development and the perceptions of nursing as a profession of students i n baccalaureate programs. Valiga addressed the 41 concept of "nursing as a profession" i n terms of i t s component parts which she derived from the l i t e r a t u r e on professionalism and c h a r a c t e r i s t i c s of professions and i d e n t i f i e d as encompassing the following: (a) boundaries of the d i s c i p l i n e , (b) r e c i p i e n t of the d i s c i p l i n e ' s s ervice, (c) goals of the d i s c i p l i n e , (d) r e l a t i o n s h i p of the d i s c i p l i n e to others, (e) independence and r e s p o n s i b i l i t y of the d i s c i p l i n e s ' p r a c t i t i o n e r s , ( f ) scholarly component of the d i s c i p l i n e , (g) autonomy of the d i s c i p l i n e ' s p r a c t i t i o n e r s , (h) commitment of the d i s c i p l i n e ' s p r a c t i t i o n e r s , ( i ) a c t i v i t i e s of the d i s c i p l i n e ' s p r a c t i t i o n e r s , (pp. 126-127) Four l e v e l s of nursing students (freshman, sophomore, junior, and senior) were surveyed both at the beginning and at the end of the academic year. An increase i n "views about nursing" scores over the academic year was recorded (p. 199). Also, senior students scored highest and freshman students scored lowest on the instrument measuring perceptions of nursing at both the beginning and at the end of the year. In a recent p u b l i c a t i o n , Dalme (1983) explored the process of professional s o c i a l i z a t i o n from the perspective of the influence of reference groups on the development of professional i d e n t i t y . A Likert-type instrument developed to measure students' perceptions of the influence of peers, f a c u l t y , and s t a f f nurses on i d e n t i t y development was administered to a group of students i n t h e i r f i r s t year of c l i n i c a l nursing and to another group i n t h e i r second year. It was found that f a c u l t y members and s t a f f nurses become more and more s i g n i f i c a n t referents of behavior as the student progresses i n the nursing program and that the rel a t i o n s h i p s established with both groups help the students to i n t e r n a l i z e the norms and values of the profession (p. 143). Data also suggest that peers exercise considerable influence on the transmission of values (p. 143). Dalme's r e s u l t s support Kelman's (1967) proposition that s o c i a l influence plays an important role i n the s o c i a l i z a t i o n process and Simpson's (1967) t h e o r e t i c a l formulation that the second stage of the s o c i a l i z a t i o n process i s characterized by an attachment of s i g n i f i c a n t others i n the work m i l i e u . These findings are also i n accord with the assumption underlying the framework developed for the purposes of t h i s study that f a c u l t y members are s i g n i f i c a n t role models for molding c e r t a i n professional values of students. Role-orientation change among registered nurses i n an upper-division l e v e l baccalaureate program was explored by Whelan (1984). Using a cro s s - s e c t i o n a l design, he administered the modified Corwin Role Orientation Inventory scale to entering and e x i t i n g students within the same u n i v e r s i t y program. The r e s u l t s show that e x i t i n g students are less bureaucratic, more professional, and more service oriented than t h e i r entering counterparts. Although the i n t e r p r e t a t i o n i s l i m i t e d by the cro s s - s e c t i o n a l approach applied i n t h i s study, the findings as well as those of Jones (1976), S t o l l e r (1978), Watson (1982), and V a l i g a (1982) lead the writer to conclude that educational experiences influence the students' perceptions as they progress through the program thus enhancing the p r o f e s s i o n a l i z a t i o n process. Summary Research discussed i n t h i s section shows that students enter a nursing program with a wide range of perceptions about the nursing r o l e but these perceptions begin to coalesce around the professional norms as students are exposed to selected educational experiences. It has been suggested that 43 i n d i v i d u a l students, as well as peer group, are s i g n i f i c a n t forces i n shaping the professional person. Faculty and s t a f f nurses also play a s i g n i f i c a n t role i n the molding of c e r t a i n professional values of students. In general, as the process of s o c i a l i z a t i o n progresses, students gain a greater sense of i d e n t i f i c a t i o n with the nursing profession although there i s some evidence to the contrary. It has been established by some authors that upon completion of a nursing program, students have been s o c i a l i z e d into the culture of the nursing profession and, therefore, have acquired the perceptions of nursing that enable them to demonstrate professional behaviors consistent with the Professional Model. However, research findings i n t h i s area are inconclusive and further research i s indicated. 44 CHAPTER 4 Methodology Overview This study examined the perceptions of nursing as a profession of students graduating from college-based nursing diploma programs i n B r i t i s h Columbia. In order to answer the research question, a questionnaire, designed and tested by Valiga, was administered to a sample of students graduating from college nursing programs. Demographic data were also obtained. The data were compiled and analyzed using a s t a t i s t i c a l computer package. This chapter discusses the type of research approach used i n th i s study, the instruments used to c o l l e c t the data, the s e l e c t i o n of the sample, the data c o l l e c t i o n method, and the s t a t i s t i c a l tests applied to the data. Research Design A d e s c r i p t i v e survey design was used to i d e n t i f y views about nursing as a profession held by graduates of diploma programs. P o l i t and Hungler (1983) claim that such a research design i s appropriate when "the investi g a t o r gathers data from a portion of a population f o r the purpose of examining the c h a r a c t e r i s t i c s , opinions, or intentions of that population" (p. 189). 45 Instruments The V a l i g a Concept of Nursing Scale (Valiga, 1982) was the instrument selected for the measurement of the perceptions of nursing as a profession (see Appendix A). This scale i s composed of form A and form B. Each form contains twenty-five items i n which the following concepts are r e f l e c t e d : (a) boundaries of the profession, (b) r e c i p i e n t s of the profession's service, (c) goals of the profession, (d) r e l a t i o n s h i p of the profession to others, (e) autonomy of the p r a c t i t i o n e r , ( f ) r e s p o n s i b i l i t y of the p r a c t i t i o n e r , (g) scholarly component of the profession, (h) commitment to the profession, ( i ) independence of the p r a c t i t i o n e r s , and ( j ) a c t i v i t i e s of the d i s c i p l i n e ' s p r a c t i t i o n e r s (Valiga, 1982, pp. 126-127). Because forms A and B were intended o r i g i n a l l y to measure the concepts l i s t e d above i n a l o n g i t u d i n a l study and because extensive overlap e x i s t s between the forms, i t was deemed appropriate to administer only form A. The concepts r e f l e c t e d i n the instrument form the basis for the categorization of the items. The r e l a t i o n s h i p of items to each category as i d e n t i f i e d by Valiga (1982) i s presented i n Table I I . In the instrument each item i s followed by a Likert-type f i v e point r a t i n g scale (strongly agree to strongly disagree). To help break 'response pattern', a phenomenon often associated with questionnaires i n the a f f e c t i v e area, items were worded so that approximately 50% of the items were p o s i t i v e l y worded and 50% negatively worded. P o s i t i v e l y worded items were given a value of 5 for strongly agree through 1 for strongly disagree. The negatively worded items were reversely scored with a value of 1 for strongly agree through 5 for strongly disagree. 46 Table II Relationship of Items to the Categories I d e n t i f i e d by V a l i g a Category Item Number D e f i n i t i o n 1, 11, 15, 20, 22 C l i e n t 19 Goals 9, 16, 21 Relationships 2, 12, 23 Autonomy 5 R e s p o n s i b i l i t y 6, 18 Scholarship 4, 17, 24 Commitment 7, 8 Independence 3, 10 A c t i v i t i e s 13, 14 , 25 The content v a l i d i t y of the instrument had been established through a panel review, (Valiga, 1982, p. 125) and construct v a l i d i t y had been demonstrated through known-groups technique (p. 126). There i s no evidence that c r i t e r i o n - r e l a t e d v a l i d i t y was established i n the p i l o t test c a r r i e d out by V a l i g a . The American Psychology Association (1974) suggests that 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 s most important for tests developed for p r e d i c t i v e purposes (p. 27). Because the instrument was used for d e s c r i p t i v e purposes, c r i t e r i o n - r e l a t e d v a l i d i t y was not viewed as a major concern for t h i s study. The r e l i a b i l i t y of the instrument was established on an o r i g i n a l scale of e i g h t y - f i v e items. The alpha was computed to be .86 and the s p l i t half Spearman-Brown formula produced a c o r r e l a t i o n of .77 (Valiga, 1982, p. 139). The r e l i a b i l i t y of each item was determined by c o r r e l a t i n g each item with the t o t a l score (p. 140). Since the items on the f i n a l instrument were selected on the basis of r e l i a b i l i t y c o - e f f i c i e n t s and discriminating power (p. 140), one can be assured that the r e l i a b i l i t y of the t o o l i s acceptable. A b r i e f questionnaire e l i c i t i n g demographic data was attached to the Valiga Concept of Nursing Scale (see Appendix B). Such data included age, sex, work experience, and educational background p r i o r to entering the nursing program. The purpose of c o l l e c t i n g t h i s information was to provide the i n v e s t i g a t o r with a d e s c r i p t i o n of the sample. Sample The population for t h i s study consisted of 204 nursing students i n the 1984 summer graduating classes from three colleges i n B r i t i s h Columbia: namely, College X, College Y,and College Z. Of the 150 questionnaires d i s t r i b u t e d , 101 were completed and returned and the subjects who responded comprised the convenience sample for t h i s study. Procedure f o r Data C o l l e c t i o n After o f f i c i a l consent was obtained from the administration of each educational i n s t i t u t i o n to conduct the study i n t h e i r agency, the inves t i g a t o r approached the chairperson of each school of nursing to arrange for an acceptable method of administering the questionnaires to the 48 students. Because each school had a d i f f e r e n t curriculum organization i t was not possible for the investigator to administer personally the questionnaires to the students at each i n s t i t u t i o n . The differences i n the scheduling of learning a c t i v i t i e s of the schools also made i t impossible to adhere to a consistent format for data c o l l e c t i o n . These differences i n data c o l l e c t i o n were not seen as a f f e c t i n g the students' responses to the questionnaire. The c o l l e c t i o n of data was accomplished as described below. In May, three months p r i o r to the graduation of the students at College Y, the i n v e s t i g a t o r , i n a mutually arranged meeting, met with the graduating students to explain b r i e f l y the purpose of the study and the procedure to be followed, to request student p a r t i c i p a t i o n , and f i n a l l y to obtain the names and mailing addresses of those students who wished to p a r t i c i p a t e i n the study. Of the 90 students i n the graduating c l a s s , approximately 40 attended the meeting. Approximately four weeks p r i o r to graduation, questionnaires were mailed to those who had provided t h e i r name. An introductory note explaining the nature and purpose of the study and s o l i c i t i n g the cooperation of the subjects was attached to each questionnaire (see Appendix C). Included with the above was a stamped addressed envelope for instrument return. An account was kept to monitor d a i l y returns. Approximately three weeks following the i n i t i a l mailing, when the return rate had declined considerably, a follow-up reminder (see Appendix D) urging nonrespondents to complete and return the questionnaire was sent with a second copy of the questionnaire and a stamped addressed envelope. By the t h i r d week of August, i t was assumed that a l l of the questionnaires that were to be returned had a r r i v e d thus e s t a b l i s h i n g the cut o f f date. Responses were received from 28 of the 36 students who had provided t h e i r name, a return rate of 77.8%. Data c o l l e c t i o n at College X d i f f e r e d i n approach from that at College Y. The i n v e s t i g a t o r mailed the questionnaires to the preceptorship coordinator who d i s t r i b u t e d them among the preceptorship i n s t r u c t o r s . In turn, the preceptorship i n s t r u c t o r s d i s t r i b u t e d the questionnaires to and c o l l e c t e d them from the students who were then doing c l i n i c a l work i n various health agencies. An introductory note s i m i l a r to the one sent to the students at College Y was appended to the questionnaire (see Appendix E) . Of the 85 questionnaires mailed, 47 were completed and returned, which represents a return rate of 55.3% of the t o t a l mailed questionnaires. The approach used to c o l l e c t data at College Z resembled that used at College X. The investigator took the questionnaires to the coordinator of the f i n a l term who administered the instrument together with an introductory note to the graduating students, (see Appendix F for introductory note). This was done i n a classroom s e t t i n g , p r i o r to the beginning of a r e g u l a r l y scheduled c l a s s . Of the 29 graduating students, 26 responded to the questionnaire thus giving a return rate of 89.7%. This completed the c o l l e c t i o n of data. The responses were coded and scored by hand and entered into computer f i l e s by the i n v e s t i g a t o r for a n a l y s i s . Analysis of Data The SCSS Conversational System (Nie et a l . , 1980) was the s t a t i s t i c a l computer package used for data a n a l y s i s . This computer package was 50 selected because of i t s a v a i l a b i l i t y and appropriateness. Questionnaires with missing data i n both the Valiga Concept of Nursing Scale and demographic sheet were not eliminated because the SCSS Conversational System provides for the exclusion of missing values i n s t a t i s t i c a l a n a l y s i s . The t o t a l number of usable questionnaires was 101. Demographic data were obtained to provide a d e s c r i p t i o n of the sample. Simple frequency counts and several cross-tabulations were made. Because of missing data, the number of subjects v a r i e d . For example, the number of subjects counted under "sex" was 99 while for "age" the number of subjects was 101. Data obtained through the a p p l i c a t i o n of the Valiga Concept of Nursing Scale were subjected to univariate analysis to: (a) i d e n t i f y responses to each statement included i n the scale, (b) examine the strength of responses between each category, (c) i d e n t i f y areas of congruence or discrepancy between students' responses and the views expressed by the nursing profession and (d) e s t a b l i s h whether the process of professional s o c i a l i z a t i o n has equipped the s o c i a l i z e e with the appropriate perceptions of the professional r o l e . Summary This chapter has presented the methodology of the study. The sample s e l e c t i o n , instruments used, and procedure followed were explained as they were applied to the research question. A b r i e f discussion of the method of data analysis was also included. 51 CHAPTER 5 Analysis and Discussion of Findings Overview Data analysis and discussion of the findings are the major f o c i of th i s chapter. Presented i n four sections, t h i s chapter f i r s t addresses the analysis of demographic data. The second section summarizes the scoring of the Valiga Concept of Nursing Scale. A discussion of the findings as they r e l a t e to the Professional Model comprises section three. Section four includes a discussion of the findings within the context of the model of s o c i a l i z a t i o n developed for t h i s study. Analysis of Demographic Data The sample was composed of students graduating from three college-based nursing diploma programs. These w i l l be referred to as Colleges X,Y, and Z. Both College Y and College Z serve a large urban area. College X serves both an urban and a r u r a l area. The largest group of the students who pa r t i c i p a t e d i n th i s study were from College X (46.5% of the sample). Table III represents a composition of the sample for each nursing diploma program surveyed. The demographic c h a r a c t e r i s t i c s of the sample are presented i n Table IV. Although the sample consisted of 101 respondents, f a i l u r e to complete a l l of the items resulted i n missing data thus causing a d i f f e r e n t t o t a l to appear for some of the variables l i s t e d below. 52 Table III Composition of the Sample per Program Nursing diploma program Number of respondents Percentage of the sample X 47 46.53 Y 28 27.73 Z 26 25.74 Total ToT 100 The d i s t r i b u t i o n of the students i n the d i f f e r e n t age groups was uneven: the 21-25 year age group contained the most students (37.6%) while mature students, the 30-49 year age group, comprised 34.6% of the sample. Ninety-six percent of respondents were female. Half of the respondents were single (50.5%) and one t h i r d i d e n t i f i e d themselves as married (36.6%). A number of students (22) were employed i n occupations d i r e c t l y related to nursing p r i o r to entering the nursing program. Nineteen were licensed p r a c t i c a l nurses and 3, registered p s y c h i a t r i c nurses. In addition, 9 of the respondents had been employed i n the health f i e l d i n occupations such as laboratory technician, f i r s t aid attendant, and dental a s s i s t a n t . The respondents comprising the "other" category were employed i n a v a r i e t y of positions ranging from c l e r i c a l work of various types to managerial p o s i t i o n s . Eighty-one percent of the respondents had educational preparation beyond that of high school l e v e l on entering the diploma nursing programs. TABLE IV 53 Demographic Data Variable Sample Number Percentage 1. Age 17-20 21-25 26-29 30-39 40-49 50+ 2. Sex Female Male 3. M a r i t a l status Single Married Divorced Separated Widowed 4. Occupation p r i o r to e n r o l l i n g i n nursing program Student Licensed p r a c t i c a l nurse Long term care a i d Registered p s y c h i a t r i c nurse Other 5. Post high school education p r i o r to e n r o l l i n g i n nursing program None Some post high school education Graduation from a t e c h n i c a l program Graduation from a u n i v e r s i t y program Other n = 101 6 38 22 28 7 0 n = 99 97 2 n = 99 51 37 6 5 0 . n = 100 30 19 10 3 38 n =101 19 46 23 5 6 5.9 37.6 21.8 27.7 6.9 0.0 97.9 2.0 51.5 37.4 6.1 5.0 0.0 30.0 19.0 10.0 3.0 38.6 18.8 45.5 24.7 4.9 5.9 Many had pursued technical studies but had not completed them. Graduates from technical programs represented 24.7% of the sample. University degrees held by 4.9% of the respondents were at the baccalaureate l e v e l and included degrees i n a r t s , home economics, science and r e l i g i o n . Based on the 101 questionnaires, the demographic data provided information which described the sample. The sample consisted mostly of single females i n the younger age categories who had had some educational preparation beyond secondary school diploma. Scoring of Val i g a Concept of Nursing Scale In completing the Valiga Concept of Nursing Scale, those surveyed responded to 25 statements on a L i k e r t s cale. Score values were assigned as indicated i n the previous chapter: p o s i t i v e l y worded items were given a value of 5 for strongly agree through 1 for strongly disagree and negatively worded items were assigned a value of 5 for strongly disagree through 1 for strongly agree. The inve s t i g a t o r considered no responses and those which were not c l e a r l y marked as missing data which were coded as 9. Missing data variables were excluded i n data analysis of i n d i v i d u a l items and were corrected f o r the remainder of data a n a l y s i s . Fourteen responses were coded as missing. These could be att r i b u t e d to 10 respondents, 2 of whom contributed 4 and 1 contributed 3 of the 14 missing responses. Item analysis indicated that there were four missing responses for item 5, two for items 15, 11, and 2, and the remaining missing responses were scattered generally among the other items. The patterns of missing responses can perhaps be at t r i b u t e d to d i f f i c u l t i e s experienced with the wording of the 55 items. Individual comments, such as "can read t h i s statement two ways", "What are you getting at?" "I don't think that I understand t h i s statement" support this a s s e r t i o n . As part of the construction of the Valiga Concept of Nursing Scale, Val i g a (1982) had established the r e l i a b i l i t y of her instrument. The alpha was estimated to be .86 and the s p l i t h a l f Spearman-Brown formula produced a c o r r e l a t i o n of .77 (Valiga, 1982, p. 139). In any study, however, responses r e f l e c t time, population differences, and environmental context. These factors may impact on the r e l i a b i l i t y of an instrument. Consequently, the investigator found i t necessary to e s t a b l i s h the r e l i a b i l i t y of the instrument with t h i s population. Various methods e x i s t to determine the r e l i a b i l i t y of an instrument. The c o e f f i c i e n t alpha was selected as the method to compute the r e l i a b i l i t y index as i t i s the "single most useful index of r e l i a b i l i t y a v a i l a b l e " ( P o l i t & Hungler, 1983, p. 391). The computation resulted i n a c o e f f i c i e n t alpha of .53. The s p l i t half Spearman-Brown formula was applied and produced a c o r r e l a t i o n of .50. P o l i t and Hungler (1983) recommend as an acceptable l e v e l a c o e f f i c i e n t of .70 or above (p. 388). The low r e l i a b i l i t y c o e f f i c i e n t may be att r i b u t e d to the r e l a t i v e l y small sample size (101). Responses to each item were examined i n an attempt to i d e n t i f y the views held about nursing as a profession. The response d i s t r i b u t i o n for each item i s reported i n Table V. Table VI consists of the frequency d i s t r i b u t i o n of values. The mode for most items i s four with the exception of items 16, 19, 21 which have a TABLE V Frequency D i s t r i b u t i o n of Responses by Category Response d i s t r i b u t i o n Category Item number S.A. A. U. D. S.D. D e f i n i t i o n 1 2 13 24 49 12 11 9 28 12 43 9 15 0 10 6 60 23 20 47 54 0 0 0 22 29 55 15 2 0 C l i e n t 19 0 2 3 33 62 Goals 1A 49 19 18 i 16 56 43 2 0 0 21 56 37 5 3 0 Relationships 2 10 56 11 21 1 12 1 4 6 67 2 2 23 3 13 25 48 12 Autonomy 5 5 20 31 35 6 R e s p o n s i b i l i t y 6 15 44 25 15 2 18 26 62 2 1 0 Scholarship 4 27 61 7 6 0 17 21 47 22 10 1 24 24 59 16 1 0 Commitment 7 16 49 25 10 1 8 17 56 11 17 0 Independence 3 2 17 7 4 21 10 3 18 .21 41 18 A c t i v i t i e s 13 13 31 6 44 7 14 12 17 8 53 10 25 5 37 11 38 10 Note: Items 4, 6, 7, 8, 9, 16, 17, 18, 20, 21, 22, and 24 are p o s i t i v e l y worded items. TABLE VI Frequency D i s t r i b u t i o n of Values by Category Value d i s t r i b u t i o n Category Item number n 1 2 3 4 5. Mode D e f i n i t i o n 1 100 2 13 24 49 12 4 11 99 9 28 12 43 9 4 15 99 0 10 6 60 23 4 20 101 0 0 0 54 47 4 22 101 0 2 15 55 29 .4 C l i e n t 19 100 0 2 3 33 62 5 Goals 9 101 1 18 19 49 ; 14 4 16 101 0 0 2 43 56 5 21 101 0 2 5 37 56 5 Relationships 2 99 10 56 11 21 1 2 12 100 1 4 6 67 22 4 23 101 3 13 25 48 12 4 Autonomy 5 97 5 20 31 35 6 4 R e s p o n s i b i l i t y 6 101 2 15 25 44 15 4 18 101 0 1 2 62 36 4 Scholarship 4 101 0 6 7 61 27 4 17 101 1 10 22 47 21 4 24 100 0 1 16 59 24 4 Commitment 7 101 1 10 25 49 16 4 8 101 0 17 11 56 17 4 Independence 3 101 2 17 7 54 21 4 10 101 3 18 21 41 18 4 A c t i v i t i e s 13 101 13 31 6 44 7 4 14 100 12 17 8 53 10 4 25 101 5 37 11 38 10 4 mode of f i v e and item 2 which has a mode of two. The mode of four indicates that the sample group selected the response a l t e r n a t i v e s , agree or disagree, most frequently as responses to the items. The range for most items i s large, being four for approximately two thirds of the items. Eight items have a range of three, one has a range of two, and one a range of one. Except for a few items, the range suggests a d i v e r s i t y of opinions amongst the respondents; however, i t does not r e f l e c t the heterogeneity of the scores. Within the context of t h i s study, when views expressed by the respondents are consistent with those of the profession, these responses are interpreted as strong responses. Respondents who scored 4 or 5 on the instruments were considered to be holding views of nursing coincident with those i d e n t i f i e d by the profession. Table VII i l l u s t r a t e s the percentage of respondents whose views corresponded with those of the profession. The data i n Table VII show that a divergence of opinion e x i s t s between the respondents and the profession. The areas i n which a substantial discrepancy e x i s t s are autonomy, r e s p o n s i b i l i t y , r e l a t i o n s h i p s , and a c t i v i t i e s . However, agreement Is high i n the categories of d e f i n i t i o n , c l i e n t , goals, and scholarship and marginally less i n the categories of commitment and independence thus r e f l e c t i n g a s i g n i f i c a n t number of respondents whose perceptions p a r a l l e l e d those of the profession. These findings suggest that students graduating from a nursing diploma program can i d e n t i f y the unique focus of nursing and know who the r e c i p i e n t of the profession's service ( c l i e n t ) i s , what state or condition i s to be achieved (goal) i n the c l i e n t , but do not know how to a s s i s t the c l i e n t i n 59 Table VII Percentage D i s t r i b u t i o n of Strong Scores by Category Category Percentage D e f i n i t i o n 75 .0 C l i e n t 95 .0 Goals 84 .0 Relationships 55 .0 Autonomy 42 .3 R e s p o n s i b i l i t y 58 .5 Scholarship 80 .0 Commitment 67 .0 Independence 66 .0 A c t i v i t i e s 55 .0 achieving such a condition. These findings also imply that these graduating students do not view the profession as having control over i t s p r a c t i c e , that they do not view the members of the profession as being responsible and accountable for t h e i r own actions, and that the nature of t h e i r r e l a t i o n s h i p s with other members of the health team i s ambiguous. On the other hand, these graduating students hold the b e l i e f that there i s a sc h o l a r l y component to nursing, thereby acknowledging the existence of a body of knowledge derived from s c i e n t i f i c research and the a p p l i c a t i o n of such knowledge to the practice of nursing. Two thirds of the responses i d e n t i f i e d i n the categories of independence and commitment indic a t e that many of the respondents believe that nursing can function independently and 60 that commitment i s a c h a r a c t e r i s t i c of nursing. Relationship of Findings to the Professional Model When the findings of th i s study are examined within the context of the Professional Model developed for t h i s research (see p. 23), i t becomes evident that the respondents' conceptualization of the profession of nursing does not incorporate a l l of the elements of the Professional Model. These elements have been i d e n t i f i e d as: (a) body of knowledge, (b) c l i e n t - p r o f e s s i o n a l r e l a t i o n s h i p , (c) autonomy, (d) e t h i c s , and (e) cul t u r e . There was general consensus on i d e n t i f y i n g a body of knowledge as an es s e n t i a l element of the nursing profession. Although most respondents recognized the c l i e n t - p r o f e s s i o n a l r e l a t i o n s h i p as a component of th e i r profession, the scope and services offered to the c l i e n t and to society remain unclear to many of them. Commitment was i d e n t i f i e d as a desirable q u a l i t y i n nurses. Autonomy, the exercise of control over one's p r a c t i c e , received a low score thus r e f l e c t i n g the b e l i e f that autonomy i s not perceived as a c h a r a c t e r i s t i c of the nursing profession. This i s i n juxtaposition with the proposition i n the Professional Model that autonomy i s cen t r a l to the other elements and to the profession. This dichotomy has serious implications for nursing p r a c t i c e . The category of r e s p o n s i b i l i t y measured the respondent's perceptions of standards of professional conduct. It i s clear from the scores obtained that ethics was viewed by a few only as a c h a r a c t e r i s t i c of the profession of nursing. 61 Relationship of Findings to the Model of S o c i a l i z a t i o n It has been proposed that the a c q u i s i t i o n of knowledge, s k i l l s , norms, and values necessary to function e f f e c t i v e l y within a professional group takes place during the educational process and has been c a l l e d professional s o c i a l i z a t i o n . To e s t a b l i s h whether the students surveyed have acquired the necessary background to enable them to demonstrate professional behavior, the students' responses were examined within the context of the model of s o c i a l i z a t i o n developed for t h i s study (see pp. 16 and 17). This model of s o c i a l i z a t i o n involves a sequential process of three phases: o r i e n t a t i o n , reaction, and a s s i m i l a t i o n . The f i r s t phase, o r i e n t a t i o n , i s a phase during which the technology of the f i e l d , values, and standards are presented to the s o c i a l i z e e who accepts them and conforms to the demands placed on him. Reaction, the second phase, consists of a period of turmoil r e s u l t i n g from the s o c i a l i z e e ' s attempts at experimenting with the new material. F i n a l l y , a s s i m i l a t i o n comprises the period during which the int e g r a t i o n of newly acquired perceptions of nursing as a profession and the adoption of behaviors prescribed by the profession occur. The Valiga Concept of Nursing Scale (1982) i s an appropriate t o o l to assess where i n the process of s o c i a l i z a t i o n s o c i a l i z e e s f i n d themselves at the completion of th e i r educational program. A Likert-type instrument makes i t possible to l i n k the responses to the phases of the s o c i a l i z a t i o n model because i t allows f i v e response a l t e r n a t i v e s , strongly agree, agree, undecided, disagree, and strongly disagree. Table VIII shows the r e l a t i o n s h i p that can be established between the phases of the model of 62 Table VIII Relationship of Phases of the S o c i a l i z a t i o n Model to the  Response Al t e r n a t i v e s of the Va l i g a Concept of Nursing Scale Phase Response al t e r n a t i v e s Orientation Agree for p o s i t i v e l y worded items Disagree for negatively worded items Reaction Undecided Agree and strongly agree for negatively worded items Disagree and strongly disagree for p o s i t i v e l y worded items A s s i m i l a t i o n Agree and strongly agree for p o s i t i v e l y worded items Disagree and strongly disagree for negatively worded items s o c i a l i z a t i o n and the response a l t e r n a t i v e s included i n the Valiga Concept of Nursing Scale (1982). Although the model of s o c i a l i z a t i o n possesses three i d e n t i f i a b l y d i f f e r e n t phases, these phases are not mutually exclusive. Therefore, t h i s makes i t d i f f i c u l t to e s t a b l i s h a clear d i v i s i o n between each phase. This becomes p a r t i c u l a r l y perplexing when the responses denote agreement with the views expressed by the profession as indicated by agree for p o s i t i v e l y worded items and disagree for negatively worded items. This could be interpreted i n two d i f f e r e n t ways: the respondents may have done so i n an attempt to conform with the demands placed on them i n which case these respondents would be i n the o r i e n t a t i o n phase or they may have so chosen because they have indeed i n t e r n a l i z e d the new value or standard. The l a t t e r would indi c a t e that those respondents have reached the a s s i m i l a t i o n phase. However, i t can be assumed that those who strongly agreed with the profession's views (strongly agree for p o s i t i v e l y worded items and strongly disagree for negatively worded items) have integrated the newly acquired perceptions of nursing as a profession and thus have progressed su c c e s s f u l l y through a l l of the stages of the process of s o c i a l i z a t i o n . The percentage d i s t r i b u t i o n of responses by category i n r e l a t i o n to each phase of the s o c i a l i z a t i o n model i s presented i n Table IX. The percentage d i s t r i b u t i o n of responses for i n d i v i d u a l items i s included i n Appendix G. The findings i n Table IX suggest that few of the respondents w i l l demonstrate a l l of the behaviors expected of the professional nurse as only a small percentage of the sample have reached the phase of a s s i m i l a t i o n . It i s important to note that the responses indicate that many of the respondents were s t i l l i n the reaction phase. These findings support two of the assumptions which were i d e n t i f i e d as being i m p l i c i t i n the model of s o c i a l i z a t i o n . These are: 1. The en t i r e s o c i a l i z a t i o n process i s not necessarily complete at the end of the educational program. Data indicate that respondents are i n the various stages of the s o c i a l i z a t i o n process and that while some have reached the stage of a s s i m i l a t i o n i n some areas, they are at stage I and II i n r e l a t i o n to other areas. 2. The timing and rate of progress through the stages vary with d i f f e r e n t i n d i v i d u a l s . The data c l e a r l y show that the number of respondents i n any one stage d i f f e r s considerably. Table IX Percentage D i s t r i b u t i o n of Responses by Category f or Each Phase of the S o c i a l i z a t i o n Model Phase Category Orientation/Assimilation Reaction A s s i m i l a t i o n D e f i n i t i o n 52.0 24.2 23.8 C l i e n t 33.0 5.0 62.0 Goals 42.5 15.9 41.6 Relationships 45.2 43.2 11.6 Autonomy 36.5 57.8 6.2 Re s p o n s i b i l i t y 52.5 22.3 25.2 Scholarship 55.3 20.8 23.8 Commitment 51.9 31.7 16.3 Independence 47.0 28.7 19.3 A c t i v i t i e s 44.7 46.3 8.9 Summary This chapter has presented the analysis of the demographic data and the scoring of the Valiga Concept of Nursing Scale. A discussion of the findings within the context of the Professional Model and the model of s o c i a l i z a t i o n developed for t h i s study was included. 65 CHAPTER 6 Summary, Conclusions, Implications and Recommendations Overview This chapter presents a summary of the study, conclusions to be drawn from the findings, implications of the findings for nursing education and nursing p r a c t i c e , and recommendations for further research. Summary and Conclusions The purpose of this study was to determine the perceptions of nursing as a profession of students graduating from college-based nursing diploma programs. To answer the research question, the Valiga Concept of Nursing Scale (1982) and a demographic data sheet were administered to 101 students approximately one month p r i o r to graduation from three nursing diploma programs i n B r i t i s h Columbia. The questionnaires were then coded by hand and the data entered into computer f i l e s for a n a l y s i s . The SCSS Conversational System (Nie, et a l . , 1980) was the s t a t i s t i c a l computer package used to analyze the data. Nursing t h e o r i s t s and the nursing profession perceive nursing and the role of the nurse as encompassing the following concepts: (a) boundaries of the profession, (b) r e c i p i e n t of the profession's service, (c) goals of the profession, (d) r e l a t i o n s h i p of the profession to others, (e) independence of the p r a c t i t i o n e r , ( f ) r e s p o n s i b i l i t y of the p r a c t i t i o n e r , (g) scholarly component of the profession, (h) autonomy of the p r a c t i t i o n e r , ( i ) 66 commitment of the p r a c t i t i o n e r , and ( j ) a c t i v i t i e s of the profession. The findings are presented within t h i s context. Scores i n the categories of d e f i n i t i o n , c l i e n t , goals, and scholarship were high thereby suggesting that the students surveyed were able to i d e n t i f y the focus of nursing and to define the r e c i p i e n t of the profession's service ( c l i e n t ) , and could i d e n t i f y the goals to be achieved i n the c l i e n t . In addition, these findings indicated that these students viewed scholarship as an e s s e n t i a l component of a profession. On the other hand, the scores i n the areas of autonomy, r e s p o n s i b i l i t y , r e l a t i o n s h i p s , and a c t i v i t i e s were low. These findings implied that: (a) the students surveyed perceived the nursing profession as having minimal control over i t s p r a c t i c e , (b) r e s p o n s i b i l i t y and acco u n t a b i l i t y were not viewed as being an i n t e g r a l part of nurses' behaviors, (c) ambiguity prevailed i n the area of r e l a t i o n s h i p with other members of the health team, and (d) the scope of practice was unclear to many of these students. F i n a l l y , the scores on independence and commitment suggested that students graduating from diploma programs perceived nursing as functioning independently and that commitment was viewed as a c h a r a c t e r i s t i c of the nursing profession. It can be concluded that at the completion of t h e i r educational program, the students surveyed had not a l l acquired the perceptions of nursing as a profession that w i l l enable them to demonstrate professional behaviors consistent with those expected by the profession. In addition, i t can also be i n f e r r e d that many of these students had not experienced a l l 67 of the stages of the s o c i a l i z a t i o n process as defined i n the s o c i a l i z a t i o n model developed for t h i s study. Therefore, these students had not acquired a l l of the values and norms necessary to enable them to demonstrate expected professional behaviors. The above conclusions are based on the responses of a r e l a t i v e l y small convenience sample of 101 students graduating from diploma programs. The in v e s t i g a t o r does not claim that the sample i s representative of a l l nursing students i n college-based diploma programs and therefore cannot conclude the findings are generalizable to graduates of other college-based nursing schools. Moreover the conclusions of t h i s study rest upon the use of an instrument, the Valiga Concept of Nursing Scale, that had a low r e l i a b i l i t y c o e f f i c i e n t with the population studied. It i s to be noted that the investigator selected the instrument on the basis of the acceptable r e l i a b i l i t y c o e f f i c i e n t established by V a l i g a . The differences i n the r e l i a b i l i t y c o e f f i c i e n t may be a t t r i b u t e d to: (a) time, (b) population differences, (c) environmental context, and (d) the r e l a t i v e l y small sample s i z e . Implications Nursing education Professional s o c i a l i z a t i o n i s the process whereby the a c q u i s i t i o n of knowledge, s k i l l s , values, and norms necessary to function e f f e c t i v e l y within a group occurs. It has been established that most of t h i s process takes place i n the formal educational preparation of a p r o f e s s i o n a l . Thus a major goal of educators should be to i n s t i l l students with views of t h e i r 68 professional r o l e s . Consistent with the model of s o c i a l i z a t i o n developed for t h i s study, the findings revealed that not a l l students graduating from diploma programs have acquired the perceptions of nursing as a profession that w i l l enable them to demonstrate the expected professional behaviors. Nurse educators, however, should be concerned about the way i n which programs enable students to become s o c i a l i z e d into the profession. Two questions should be examined. The f i r s t i s whether "professionalism" i s addressed both conceptually and behaviorally i n nursing c u r r i c u l a . Unless the teaching and evaluating of values, standards, and attitudes are incorporated into the curriculum of schools of nursing, i t w i l l be d i f f i c u l t for the nurse educator to be successful i n her mission to i n s t i l l i n the students professional values. In addition, students' perceptions could be explored at d i f f e r e n t times during the program to assess t h e i r progress i n the development of perceptions that are 'professional' and changes i n c u r r i c u l a r a c t i v i t i e s could be made where appropriate. The second relates to the influence exerted by f a c u l t y and s t a f f nurses upon the development of perceptions of nursing as a profession i n students. As f a c u l t y strongly influence the students' perceptions of t h e i r profession, i t i s desirable to ensure that students associate with f a c u l t y and s t a f f nurses who demonstrate excellence i n the p r a c t i c e s e t t i n g and who can serve as appropriate r o l e models. 69 Nursing pr a c t i c e Graduates of nursing diploma programs are expected to assume the professional role i n the work s e t t i n g . The findings of t h i s study show that not a l l of the students graduating from diploma programs w i l l be able to meet those expectations. Thus, i t becomes important that, i n the work s e t t i n g , the s o c i a l i z a t i o n process be supported to a s s i s t the new graduates to complete the 'p r o f e s s i o n a l i z a t i o n ' process. This means the presence of appropriate role models and the development of educational programs that w i l l contribute to and 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. Recommendations for Further Research Proposals for further research can be divided into two categories: recommendations for future studies i n the area of perceptions of nursing as a profession and recommendations for further refinement of the Valiga Concept of Nursing Scale. In the f i r s t category, recommendations for future studies are as follows: 1. A study of a larger sample of students graduating from diploma programs would be appropriate. This would then y i e l d findings that could be generalized to students graduating from other diploma programs. 2. The development of students' perceptions of nursing as a profession could be assessed at d i f f e r e n t times during the program through the a p p l i c a t i o n of an instrument designed for that purpose. This might a s s i s t i n evaluating the d i f f e r e n t methods used i n the s o c i a l i z a t i o n of students and i n determining the need for curriculum changes i n the area of p r o f e s s i o n a l i z a t i o n . 70 3. It might be useful to study the r e l a t i o n s h i p between the graduating students' perceptions of nursing as a profession upon graduation and a few years a f t e r graduating. Such a study would e s t a b l i s h whether the graduates continue to develop perceptions of nursing that enable them to use c o n s i s t e n t l y expected professional behaviors. 4. It would also be useful to study the r e l a t i o n s h i p between nursing students' and fa c u l t y ' s perceptions of the professional r o l e . This would a s s i s t i n i d e n t i f y i n g areas of congruency and discrepancy between the two groups and i n es t a b l i s h i n g whether students adopt the values and norms espoused by nursing f a c u l t y . For si m i l a r reasons, a study that would compare the views of the students graduating from diploma programs with those of the nurse p r a c t i t i o n e r s and the nurse educators could also be undertaken. Recommendations for further development of the Valiga Concept of Nursing Scale (1980) include: (a) a r e v i s i o n of the wording of the items which were unclear to the respondents, (b) the development of items for the categories which had fewer than three items, (c) e s t a b l i s h i n g the r e l i a b i l i t y of the revised instrument, and (d) determining the dis t i n c t n e s s of the various concept c l u s t e r s (eg. d e f i n i t i o n , goal, autonomy) by means of a factor analysis technique. Summary A summary of this study and the conclusions were presented i n th i s chapter. In addition, the implications for nursing education, nursing p r a c t i c e , and the nursing profession were b r i e f l y discussed. F i n a l l y recommendations f or future research were made. 71 REFERENCES Adam, E. (1980). To be a nurse. Toronto: W.B. Saunders. Ahad, A.A. (1981). Evolution of nursing science: Implications f or nursing worldwide. Image, 13 (2), 56-59. 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A baccalaureate nursing curriculum based on the Newman Health Systems Model. In J.P. Riehl & C.Roy (Eds.), Conceptual models for nursing practice (2nd ed.) (pp. 151-158). New York: Appleton-Century-Crofts. Levinson, D.J., Darrow, C.N., K l e i n , E.B., Levinson, M.H., McKee, B., & Knopf, A.A. (1978). The seasons of a man's l i f e . New York: Knopf. Lewis, A.R. (1982). Later l i f e (2nd ed.). New York: Holt, Rinehart & Winston. McCloskey, J.C. (1981). The p r o f e s s i o n a l i z a t i o n of nursing: United States and England. International Nursing Review, 28 (2), 40-47. 74 Moore, E.W. (1970). The professions: Roles and r u l e s . New York: Russell Sage Foundation. Mortimer, J.T., & Simmons, R.G. (1978). Adult S o c i a l i z a t i o n . Annual  Review of Sociology, 4_, 421-454. Nie, N.H., H u l l , CD., F r a n k l i n , M.N., Jenkins, J.G., Sours, K.J., Norusis, M.J., & Beadle, V. (1980). SCSS: A user's guide to the SCSS  conversational system. New York: McGraw H i l l . Nordal, D., & Sata, A. (1980). Peplau's Model applied to primary nursing i n c l i n i c a l p r a c t i c e . In J.P. Riehl & C. Roy (Eds.), Conceptual models for  nursing pr a c t i c e (2nd ed.) (pp. 60-74). New York: Appleton-Century-Cro f t s . Nurses (Registered) Act. 1979, Revised Statutes of B.C. Chap. 302 (1981). Olesen, V.L., & Davis, F. (1966). Baccalaureate students' images of nursing: A follow-up report. Nursing Research, 15 (2), 151-158. Olesen, V.L. & Whittaker, E.W. (1968). The s i l e n t dialogue. San Francisco: Jossey-Bass. Pavalko, R.M. (1971). Sociology of occupations and professions. Itasca, I I . : F.E. Peacock. P o l i t , D., & Hungler, B. (1983). Nursing research: P r i n c i p l e s and methods (2nd ed.). Philadelphia: J.B. L i p p i n c o t t . Registered Nurses' Association of B r i t i s h Columbia. (1982). Philosophy,  goals, objectives. Vancouver: Author. Registered Nurses' Association of B r i t i s h Columbia. (1977). P o s i t i o n paper  on nursing. Vancouver: Author. Rogers, M.E. (1970). An introduction to the t h e o r e t i c a l basis f or nursing. Philadelphia: F.A. Davis. Rosow, J . (1975). Forms and functions of adult s o c i a l i z a t i o n . S o c i a l  Forces, 44 (1), 35-45. Roy, Sr. C , & Roberts, S. (1981). Theory construction i n nursing: An  adaptation model. Englewood C l i f f s , New Jersey: Prentice H a l l . S c h l o t f e l d t , R.M. (1967). Nursing i n the future. Nursing Outlook, 29 (5), 295-301. Simpson, J.H. (1967). Patterns of s o c i a l i z a t i o n into professions: The case of student nurses. S o c i o l o g i c a l Inquiry, 37, 47-55. 75 Simpson, J.H., Back, K.W., I n g l i s , T., Kerckhoff, A.C, & McKinney, J.C. (1972). From student to nurse: A l o n g i t u d i n a l study of s o c i a l i z a t i o n . Cambridge: Cambridge University Press. Starr, S.L. (1980). Adaptation applied to the dying c l i e n t . In J.P. Riehl & C. Roy (Eds.), Conceptual models for nursing practice (2nd ed.) (pp. 189-192). New York: Appleton-Century-Crofts. Stevens, B.J. (1979). Nursing theory: Analysis, a p p l i c a t i o n , evaluation. Boston: L i t t l e Brown. S t o l l e r , E.P. (1978). Preconceptions of the nursing r o l e : A case study of an entering c l a s s . Journal of Nursing Education, 17 (6), 2-14. Stuart, G.W. (1981). How professionalized i s nursing? Image, 13 (1), 18-23. Thornton, R., & Nardi, P.M. (1975). The dynamics of r o l e a c q u i s i t i o n . American Journal of Sociology, 80 (4), 871-885. UVIC nursing enrollment shows steady growth. (1984, March/April) RNABC  News, 16_ (2), 31. Valiga, T.M. (1982). The cognitive development and perceptions about nursing as a profession. D i s s e r t a t i o n Abstracts International, (University Microfilms No. 82-23179). Watson, A. (1982). Professional s o c i a l i z a t i o n of registered nurses as measured by attitudes and problem i d e n t i f i c a t i o n s k i l l s . D i s s e r t a t i o n  Abstracts International, 43, (University Microfilms No. 83-04197). Watson, J . (1981). S o c i a l i z a t i o n of the nursing student i n a professional nursing education program. Nursing Papers, 13, 19-24. Whelan, E.G. (1984). Role-orientation change among R.N.s i n an upper d i v i s i o n l e v e l baccalaureate program. Journal of Nursing Education, 23 (4), 151-155. Workshop Considers Survey Issues (1981, November/December) RNABC News, 13 (8), 7-9. APPENDIX A The Valiga Concept of Nursing Scale VALIGA CONCEPT OF NURSING SCALE (1982) Read each of the statements below c a r e f u l l y . Then, for each statement, please indicate whether you Strongly Agree (SA), (Agree (A), are Undecided or Do Not Know (U), Disagree (D), or Strongly Disagree (SD) with the statement. C i r c l e the one response that best expresses your opinion, and please be c e r t a i n your response to each statement i s c l e a r l y marked. There are no ri g h t or wrong answers, so please respond openly and honestly. Thank you 1. Nurses of today can provide better medical care than many physicians and should replace physicians i n many instances. SA A U D SD 2. Nurses should have legitimate role i n performing physical examinations f o r the sole purpose of a s s i s t i n g physicians i n making the i r medical diagnoses. SA A U D SD 3. Nurses should get approval from the doctor before giving c l i e n t s / p a t i e n t s any information or doing anything for them other than what i s ordered. SA A U D SD 4. Nursing practice must be guided by a conceptual/theoretical framework. SA A U D SD 5. Nurses should be reactors to, rather than creators of, practice s i t u a t i o n s . SA A U D SD 6. Nurses must be w i l l i n g to stand up for what they believe i n no matter what the "cost". SA A U D SD 7. Nurses should i d e n t i f y with and seek approval from professional colleagues inside and/or outside their i n s t i t u t i o n . SA A U D SD 8. Nurses should be w i l l i n g to move from one i n s t i t u t i o n to another i n an attempt to seek challenging p o s i t i o n s . SA A U D SD 9. Fostering personality development of the c l i e n t / p a t i e n t i n the d i r e c t i o n of maturity should be a function of nursing. SA A U D SD 10. Nurses must be f a i t h f u l followers of s p e c i f i c rules imposed by the physician and other sources. SA A U D SD 11. There should be one s p e c i f i c d e f i n i t i o n of nursing that a l l nurses can follow. SA A U D SD 12. The practice of t r u l y professional nursing can occur only i n settings or si t u a t i o n s where a physician i s not d i r e c t l y involved. SA A U D SD 13. The administration of medications i s of such a serious nature that i t should be a primary a c t i v i t y of nurses. SA A U D SD 14. There i s d e f i n i t e l y a righ t and a wrong way to do things and to approach nursing s i t u a t i o n s . SA A U D SD 15. Nursing i s practiced most e f f e c t i v e l y i n situations which are l a r g e l y r e p e t i t i v e and routine. SA A U D SD 00 16. Nurses, i n the performance of t h e i r roles and r e s p o n s i b i l i t i e s , a s s i s t i n d i v i d u a l s and groups i n society to a t t a i n , maintain, and restore health. SA A U D SD 17. Nurses should be expected to be involved with research i n ways appropriate to t h e i r SA A U D SD preparation as a routine aspect of t h e i r p r a c t i c e . 18. Nurses must be able to provide leadership to t h e i r peers and to the profession i t s e l f . SA A U D SD 19. It i s useful for c l i e n t s / p a t i e n t s to l i k e n the physician to the "father", the nurse to the "mother", and themselves to the "children" i n a r e l a t i o n s h i p . SA A U D SD 20. Nursing can be practiced anywhere people are. SA A u D SD 21. Nurses have the obligation to help c l i e n t s / p a t i e n t s seek t h e i r highest possible l e v e l of functioning. SA A u D SD 22. Nursing i s deliberate, health-related action performed by i n d i v i d u a l persons on behalf of others, i n d i v i d u a l l y or i n groups. SA A u D SD 23. Conducting nursing rounds with the entire health team should be a r e s p o n s i b i l i t y of nurses. SA A u D SD 24. There i s a scholarly dimension to the practice of nursing. SA A u D SD 25. A primary r e s p o n s i b i l i t y of nurses should be taking the c l i e n t ' s / p a t i e n t ' s v i t a l signs. SA A u D SD VO* APPENDIX B Demographic Data Sheet 81 Age Sex 17-20 21-25 26-29 Female DEMOGRAPHIC DATA SHEET 30-39 40-49 50 + M a r i t a l Status: Single Married Divorced Male Separated Widowed Occupation Held p r i o r to E n r o l l i n g i n your Current Nursing Program. Student L.P.N. Long Term Care Aid R.P.N. Other (please specify) Post High School Education p r i o r to E n r o l l i n g i n your Current Nursing Program. a. None b. Some post high school education (please specify) c. Graduation from a technical program (please specify) d. Graduation from a u n i v e r s i t y program (please specify) e. Other (please specify) APPENDIX C Introduction to the Research Instrument (College Y) VIEWS ABOUT NURSING QUESTIONNAIRE •83 Introduction My name i s L o u i s e l l e Ouellet. I am presently completing a master's program i n nursing at the University of B r i t i s h Columbia. My research i s i n the general area of nursing as a profession, an area that i s becoming of c r i t i c a l importance as nursing establishes i t s e l f within the health care system. Would you please a s s i s t me i n my research by completing the attached questionnaire and returning i t using the enclosed, stamped envelope. Completion of the questionnaire, which requires approximately twenty minutes of your time, i s i n no way associated with course requirements and your decision w i l l not a f f e c t your status or grade i n the nursing program. Completing the attached questionnaire w i l l i ndicate your willingness to pa r t i c i p a t e and thus your consent to be part of the study. You may withdraw from the study at any time. To ensure anonymity, you are asked not to write your name on the questionnaire or i d e n t i f y yourself i n any other way. There are no ri g h t or wrong answers, so please try to be honest and open i n your responses. I want to thank you for your assistance. APPENDIX D Reminder Note FOLLOW-UP REMINDER July 30, 1984 Dear Nursing Student, Approximately three weeks ago, the questionnaire "Views about Nursing", was mailed to you. This i s part of a thesis project that I am doing i n the nursing program at the University of B r i t i s h Columbia. I would l i k e to i n v i t e you to complete and return the questionnaire i f you have not already done so. I am including a copy of the questionnaire and stamped envelope for your convenience. If you have already completed the questionnaire, please disregard t h i s note and accept my thanks. I am looking forward to receiving the completed questionnaire. Thank you for p a r t i c i p a t i n g i n my study and best wishes to you i n your nursing career. Sincerely, L o u i s e l l e L. Ouellet APPENDIX E Introduction to the Research Instrument (College X) 87 VIEWS ABOUT NURSING QUESTIONNAIRE Introduction My name i s L o u i s e l l e Ouellet. I am presently completing a master's program In nursing at the University of B r i t i s h Columbia. My research i s i n the general area of nursing as a profession, an area that i s becoming of c r i t i c a l importance as nursing establishes i t s e l f within the health care system. Would you please a s s i s t me i n my research by completing the attached questionnaire and returning i t to your preceptorship i n s t r u c t o r using the enclosed envelope. Completion of the questionnaire, which requires approximately twenty minutes of your time, i s i n no way associated with course requirements and your decision w i l l not a f f e c t your status or grade i n the nursing program. Completing the attached questionnaire w i l l i ndicate your willingness to p a r t i c i p a t e and thus your consent to be part of the study. You may withdraw from the study at any time. To ensure anonymity, you are asked not to write your name on the questionnaire or i d e n t i f y yourself In any other way. There are no ri g h t or wrong answers, so please t r y to be honest and open i n your responses. I want to thank you for your assistance. APPENDIX F Introduction to the Research Instrument (College Z) VIEWS ABOUT NURSING QUESTIONNAIRE 89 Introduction My name i s L o u i s e l l e Ouellet. I am presently completing a master's program i n nursing at the University of B r i t i s h Columbia. My research i s i n the general area of nursing as a profession, an area that i s becoming of c r i t i c a l importance as nursing establishes i t s e l f within the health care system. Would you please a s s i s t me i n my research by completing the attached questionnaire. Completion of the questionnaire, which requires approximately twenty minutes of your time, i s i n no way associated with course requirements and your decision w i l l not a f f e c t your status or grade i n the nursing program. Completing the attached questionnaire w i l l i n d i c a t e your willingness to p a r t i c i p a t e and thus your consent to be part of the study. You may withdraw from the study at any time. To ensure anonymity, you are asked not to write your name on the questionnaire or i d e n t i f y yourself i n any other way. There are no ri g h t or wrong answers, so please t r y to be honest and open i n your responses. I want to thank you for your assistance. APPENDIX G Table X 91 TABLE X Percentage D i s t r i b u t i o n of Responses of I n d i v i d u a l Items fo r Each Phase of the S o c i a l i z a t i o n Model Phase Item O r i e n t a t i o n / A s s i m i l a t i o n Reaction A s s i m i l a t i o n 1 49.0 39.0 12.0 2 21.2 77.8 1.0 3 53.5 15.7 ' 20.8 4 60.4 12.8 26.7 5 36.1 57.8 6.2 6 43.6 41.5 14.9 7 48.5 37.6 13.9 8 55.4 27.7 16.8 9 48.5 37.6 13.9 10 40.6 41.6 17.8 11 42.6 48.5 8.9 12 67.0 11.0 22.0 13 43.6 49.5 6.9 14 53.0 37.0 10.0 15 60.6 16.8 23.2 16 42.6 2.0 55.4 17 46.5 32.7 20.8 18 61.4 3.0 35.6 19 33.0 5.0 62.0 20 53.5 0.0 46.5 21 36.6 8.0 55.4 22 54.5 16.9 28.7 23 47.5 40.7 11.7 24 59.0 17.0 24.0 25 37.6 52.5 9.9 

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