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Acquisition of a professional role: an empirical study of nursing students' professional self-images… Kariel, Patricia Ann Eells 1965

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ACQUISITIONS A PROFESSIONAL ROLE: } AN EMPIRICAL T T U i ^ Q F N U R S W STUDENTS • PROFESSIONAL SELF-IMAGES AND ROLE CONCEPTS by PATRICIA EELLS KARIEL B.A. Oberlin College, 1946 M.N. Yale University School of Nursing, 1949M.S.N. University of Oregon School of Nursing, 1961  A THESIS SUBMITTED IN PARTIAL" FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS i n the Department of Sociology  We accept this thesis as conforming to th<s required standard  THE UNIVERSITY OF BRITISH COLUMBIA August, 1965  In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make i t freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the Head of my Department or by his representative.  It is  understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission.  Patricia Eells Kariel  Chairman: Dr. R.A.H. Robson  ABSTRACT The purpose of the study was to examine selected aspects of the acquisition of a professional role and to determine what factors might be related to them. The sample consisted of 3 0 1 students i n a school of nursing i n a large general hospital i n a Canadian metropolis. The four groups included entering, newly-capped, intermediate and neargraduating senior students. Data were collected by questionnaire. Two dependent variables were used:  the student's professional  self-image and the concept of the nurse's role adopted. of the self-image were identified.  Four components  I t was hypothesized that, over time,  students would think of themselves increasingly as nurses rather than as students; confidence i n performing their role would increase; they would interact more socially with others i n the institutional setting; and identification wiih graduate and student nurses would increase. The f i r s t three hypotheses were supported, the fourth was not.  I t was also  hypothesized that, i f a l l four components increased over time for the entire sample,.they would also be related for individuals.  For example,  students who thought of themselves primarily as nurses would also be more confident, would interact more socially with others, and would identify more with other nurses.  Statistical analyses using the Chi-  square frequency test did not support this hypothesis. For the second dependent variable, the concept of the nurse's role adopted, two major concepts were identified: the advanced professional, emphasizing newer trends i n the nursing profession, and traditional, favoring institutional values. I t was hypothesized that  iii beginning students would be more l i k e l y to give a higher rating than other groups to lay items, that newly-capped students would tend to rate highest those items which reflected the advanced professional concept, and that seniors would give higher ratings to traditional concepts.  The  trend found was opposite to that hypothesized. Students were asked to rate similar items with respect to Values, things which they believed i t was important for nurses to do; Evaluation, criteria by which they believed they were evaluated; and Confidence, the degree to which the item made them feel confident as nurses. Advanced professional items were rated higher for Values than for the other two; traditional, lower.  Individual students, however, were inconsistent i n  their ratings; no relationships were found among ratings on similar items for the three aspects. Other hypotheses suggested that various independent variables would be related to one or more-elements of the two dependent-variables. Almost twenty independent variables were proposed.  For example, i t was  hypothesized that students favoring advanced professional values would be more l i k e l y to select instructors as role models, and to rate classes such as Sociology, Psychology and Community Ifealth high.  None of the  hypotheses was supported. The mass of negative findings can be interpreted so as to shed doubt upon some assumptions made by role theorists.  Overall, although  trends were discernible i n the data when analyzed by groups, few relationships were found among attitudes expressed by individual students, who were consistently inconsistent.  No factors were found which were  iv related to the acceptance of items representing either an advanced professional or a traditional concept of the nurse's role.  Because of the  lack of significant relationships among items thought to be representative of each concept, i t i s probable that no such simple classification exists i n the minds of students i n the sample.  The lack of relationship  among elements of the self-concept also suggests that the notion of role as a unitary concept may not be valid.  v. TABLE OF CONTENTS CHAPTER I.  PAGE  PURPOSE OF THE STUDY AND THEORETICAL FRAMEWORK Overview:  •  1  purpose and general plan o f the study .......  1  T h e o r e t i c a l framework and review o f relevant l i t e r a t u r e  2  Review of r e l a t e d 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 n t o a profession II.  III.  IV.  ••  THE SETTING: PROFESSIONAL AND INSTITUTIONAL  20  The nursing profession  20  The i n s t i t u t i o n a l s e t t i n g  23 27  FORMULATION OF HYPOTHESES AND DESIGN OF STUDY Statement of hypotheses  32  Sample  38  Procedure  39  L i m i t a t i o n s o f the study  41  FINDINGS OF THE STUDY AND TESTS OF THE HYPOTHESES Hypotheses r e l a t i n g t o the p r o f e s s i o n a l self-image The concept o f the nurse's r o l e h e l d by students  V.  11  SUMMARY AND CONCLUSIONS Summary  42 ....  42 57 83 83  Discussion o f the f i n d i n g s and relevance t o the t h e o r e t i c a l framework Suggestions f o r f u r t h e r research  89 101  BIBLIOGRAPHY  104  QueSTiQNvmRE  i©7  LIST OF TABLES TABLE  PAGE  1. Per cent of students who perceive self primarily as nurse rather than student; and per cent believing others perceive them as nurses, by groups 2. Median ratings for confidence in performing disagreeable or difficult tasks  43 •  45  3. Per cent of students having meals or coffee at least once a week with persons in other statuses, by groups ..  47  4. Median ratings for identification with others in the nursing profession, for the entire sample and by groups  49  5. Median ratings for items of formal recognition of students' progress, for the entire sample and by groups  55  6.  Rank, for entire sample, and median ratings of importance of satisfactions anticipated from nursing, for entire sample and by groups  7. Age at which nursing was first considered as a profession, and age at which decision to enter nursing school was made, for entire sample and by groups 8.  58  6l  Persons and other sources of information judged most influential on decision to enter nursing school, for entire sample and by groups  63  9. Highest school grade completed by parents for entire sample, and by groups  66  10. Rank, for entire sample, and median ratings of importance attached to specified nursing activities, for entire sample and by groups  68  11. Rank, for entire sample, and median rating of importance of factors in evaluation, for entire sample and by groups  72  12. Rank of medians, for entire sample, and factors which make students feel confident as nurses, for entire sample and by groups  74-  vii TABLE  PAGE  13. Summary Table Median ratings of similar items: importance attached to specified nursing activities (V)J emphasis placed on factors in evaluation (E)£ and nursing activities which make students feel confident (C)J for entire sample and by groups  76  14. Median ratings of perceived importance of others as role models, for entire sample and by groups  79  15. Median ratings of perceived relevance of specified courses to clinical nursing experience, for entire sample and by groups  81  ACKNOWLEDGMENT The writer wishes to thank her adviser, Dr. R.A.H. Robson, for his assistance, especially i n formulation of the theoretical framework of the study, and i n criticism of the f i n a l manuscript.  She also  expresses her thanks to those at the hospital and nursing school who made possible the collection of data, but who have asked to remain anonymous.  CHAPTER I PURPOSE OF THE STUDY AND THEORETICAL FRAMEWORK Overview:  purpose and general plan of the study  The purpose of the present study i s to investigate a selected aspect of socialization into a profession namely, the acquisition of a professional self-image. The aims are f i r s t , to discover what course this development takes and, second, what factors are related to i t .  In  order to accomplish these aims, some of the more important elements thought to make up the self-image are identified as composing the dependent variable.  Related social and psychological factors comprise  the Independent variables. The study i s conceived within the framework of role theory, as an empirical test of some of the broad concepts suggested by the conceptualization of role as a set of expectations held by members of a specified: group or groups toward members of another specified group. Reference group theory, learning theory and the theory of cognitive dissonance also contribute to the theoretical framework i n which the study i s cast. Hypotheses are derived from both these theories and related empirical studies. The context for testing them i s the socialization of students into the nursing profession, but i t i s considered as one example of the general problem rather than as a case study of nursing education. Kish (1959) suggests that scientific inquiry proceeds by a series of approximations, the results of each successive step coming  2 closer to providing an adequate explanation of the phenomenon being studied.  The first step may be simply a gross yes-or-no determination  of the presence of a relationship among the variables. Succeeding steps require more precise conceptualization and measurement of the variables, and may lead to expression of the relationships among them in quantitative terms. The present study is viewed by the writer as falling within the first category of a gross determination of the presence of relationships between the variables.  It is an attempt to identify certain  elements of the nurse's role which are related to the individual's image of herself as a nurse, and to discover some of the factors which are related to her acquisition of that self-image. It may be considered as a screening process, as a result of which some of the variables may be eliminated as irrelevant and others may emerge as important. For this reason, gross classifications and simple statistical tests are considered adequate to test the hypotheses. Further study would require more precise definitions of a limited number of variables, possibly with an attempt at quantification, and more sophisticated statistical tests of significance. It would therefore result in a more precise determination of the relationships between the variables. Theoretical framework and review of relevant literature Several theoretical orientations have been drawn upon in developing a theoretical framework for the study. The entire study is cast within the orientation of role theory, which aids in conceptualization of different segments of an individual's activities as distinctive roles.  Learning of a role i s thought to take place i n part i n accordance with some of the general principles set forth i n learning theory, broadly interpreted.  Reference group theory raises the question of how a person  selects the particular groups by which he evaluates his activities. Resolution of conflicts among the expectations held by different individuals and groups toward persons learning the role are considered i n terms of Festinger's notion of cognitive dissonance. Role theory and socialization—Ever since i t s proposal by George H. Mead (1931)» the concept of role has been employed i n the analysis of human interaction.  As Gross, Mason and McEachern (1958, p. 11) point  out^ i t has been used by different people i n different ways, and no one definition has become generally accepted. They state, Many definitions of the term role have been presented i n the social science literature, representing different disciplines, different points of view within a single discipline, and, i n some cases, different formulations of an individual author. They propose three major categories for classifying these formulations.  The f i r s t includes "definitions of role which either equate •  i t with or define i t to include normative culture patterns," (Gross et a l . , 1958, p. 11) used by Linton, Znaniecki, Parsons (in one paper) and others.  The second category includes definitions i n which "a role i s  treated as an individual's definition of his situation with reference to his and others' social positions..."  (Gross et a l . , 1958, p. 13.)  Parsons' major formulation i s seen to f a l l i n this category.  In the  third group are placed "definitions which deal with role as the behavior of actors occupying social positions,"  (Gross et al., 1958, p. 14.)  It is used in this way by Davis and by Parsons in some formulations. The multiplicity of uses of role in the literature suggests that a wide-range of phenomena are being lumped together under one.heading. Age and sex roles, professional roles and functional roles of actors i n small groups would seem to be phenomena of different orders, requiring different conceptualizations for use in empirical research. Although the notion of role has appealed to theorists, i t has been employed very l i t t l e in empirical research. It has often been founa in the natural sciences that similar intuitively appealing notions are often unsupported by the findings of empirical research, which lead instead to new modes of grouping and classification of phenomena. The same might also be true of many notions associated with role theory; but this can be determined only through repeated empirical investigations such as this one. Another area in which there is no agreement is whether role is defined, as i t is by Gross et al, (1958, p. 60) as "a set of expectations, i.e. evaluative standards applied to the incumbent of a particular position," or as the actual performance of an incumbent of a position with regard to two types of expectations: behavior (what he does) and attributes (what he is), which Gross et al, distinguish by use of the term role behavior. In discussing role enactment, which appears to be similar to Gross' role behavior, Lindesmith and Straus (1956) identify 1  four elements: l ) self-identification, 2) appropriate behavior in  5 3) an institutional setting and 4) an evaluation of the role enactment. Similarly, Cottrell (1942) identifies three elements of role: self, others and a situational context. Without specifying the number of elements, i t is apparent that in considering either role expectations or role behavior we must take into account both the individual and the social setting, as well as the interaction between them. This is the essence of social psychology. Separation of the concepts of'" role expectations and role enactment helps to distinguish between attitudes and behaviors as components of the concept of role. In defining'socialization, Merton (1957) is concerned with both. He says, The technical term socialization designates the processes by which people selectively acquire the values and attitudes, the interests, skills and knowledge—in short, the culturecurrent in the groups of which they are, or seek to become, a member (sic) ... (p. 287) and By this (socialization) is meant the process through which individuals are inducted into their culture. It involves the acquisition of attitudes and values, of skills and behavior patterns making.up social roles established in the social structure, (p. 41) Without yet attempting to disentangle or define further the notions of role and socialization, we can at least make some general observations. The concept of role is a complex one, which includes many different elements. Even i f we do not make an exhaustive listing of these elements, we can note that among them are knowledge, skills, behavior and attitudes, as defined by a group of individuals occupying various statuses with respect to persons in the role being defined. The  6 term may refer either to a set of expectations or to the actual behavior of those i n the role.  It provides a set of standards by which individ-  uals enacting a role may evaluate their role behavior.  Socialization i s  the process by which an individual learns the expectations associated with his role and acquires the knowledge, s k i l l s and attitudes which enable him to behave i n a manner congruent with them. Learning theory--Having defined role, and socialization as the process of role acquisition, the next question which arises i s how socialization takes place. Often the phrase internalization of norms i s em- , ployed to describe the process by which individuals adopt the norms and attitudes of the profession or role, but this t e l l s l i t t l e about how i t occurs.  I t i s the author's contention that role learning, l i k e other kinds  of learning, takes place by a process partially explainable by learning theory. Learning theory i s based on the type of learning called operant conditioning, which has proved valuable i n the study of animal behavior. In this process, an animal i s taught to perform a given activity or series of activities by being rewarded for correct responses and/or punished for incorrect ones. During the learning period, partially correct responses may be rewarded, but demands are gradually increased until only the correct response receives a reward. I t has been suggested that a similar model may be applied to human learning.  There are many  objections to this: i n most cases of human learning the task i s more complex, the motivation i s not a relatively simple physiological one, and rewards and punishments are more d i f f i c u l t to specify.  Even i f  7 these problems could be overcome, i t would probably at best provide only a partial explanation for human learning, much of which i s more abstract than animal learning, and i n which knowledge i s often integrated and interrelated. It appears reasonable, nevertheless, to suggest that learning theory helps to provide a partial, explanation for the learning of social roles.  In a given social setting, an individual finds that certain  4  activities are punished, while others are rewarded. Since, i n a setting such as the one of this study, i t i s possible to specify some of the desired activities as well as the rewards or punishments which might arise as a response to them, an empirical test of hypotheses derived' from the general theory appears to be feasible.  Certain specified  activities and attitudes w i l l be considered as the task to be learned; rewards and punishments w i l l be those derived from the responses of' persons i n significant counter-statuses to the students, not only i n grades and formal evaluation, but also i n informal social approval dr disapproval.  I t i s hypothesized that those activities which students  perceive to be rewarded w i l l tend to persist, while activities not rewarded w i l l be extinguished. Reference group theory—Role theory provides the overall theo-r retical framework for the study; learning theory suggests the mechanisms by which students learn their role; and reference group theory helps to suggest hypotheses explaining the particular reference group certain individuals choose, and how i t i s related to the particular concept of the nurse's role which  8 they adopt. Stated a l i t t l e differently, role theory helps to provide many basic concepts for the study; learning theory helps to clarify the developmental process for nursing students considered as a group; and reference group theory i s used for exploring the differential concepts of the nursing role adopted by different students. Like role theory, reference group theory i s not a logically coherent explanatory theory, but rather a general notion that individuals tend to evaluate themselves i n various respects by referring to different groups of individuals.  Merton and Kitts (1950* PP« 50-51) state,  Reference group theory aims to systematize the determinants and consequences of those processes of evaluation and selfappraisal i n which the individual takes the values and standards of other, rindividuals and groups as a comparative frame of reference. In the literature, the groups considered as reference groups vary i n size and specificity from a family to lower class males or the Republican party.  Hyman (I960, p. 395) points out the d i f f i c u l t i e s associated with  dealing with such large and heterogeneous groups. He says we must remember that Such groups are not unified. They have a differentiated structure and a set of norms rather than one norm. Correspondingly, there w i l l be a set of perceived norms. Videbeck (I960, p. 359) concluded from a study he carried out that his findings "tended to support the view that self-conceptions are learned, and that the evaluative reactions of others play a significant part i n the learning process." The questions which arise are: How do people choose the reference individuals or groups against which they evaluate themselves?  Are some  9 i n d i v i d u a l s more i n c l i n e d t o accept the modal evaluation o f the group or groups with whom they associate and attempt t o conform to i t , and others i n c l i n e d to select a reference group whose i d e a l s , standards and values are s i m i l a r t o theirs? require?  How much s o c i a l support does a given i n d i v i d u a l  The l a t e Manford Kuhn, i n a personal conversation with the  author, suggested that few people are w i l l i n g t o stand completely alone. Even those with ideas which deviate from those held by the majority o f the society i n which they l i v e band together f o r s o c i a l support. For -1  example the Friends and other p a c i f i s t groups who stand as a very small minority i n contemporary society r e l y on each other f o r encouragement, evaluating themselves according t o t h e i r own ideas and values. Rogers  (19^2) c i t e s  many.studies of the spread of innovations  which suggest that people who perceive themselves as innovators are usually aware that t h e i r ideas deviate widely from those of the majority of people with whom they come i n contact.  They do not, however,  function i n i s o l a t i o n , but take" other innovators as a reference group, often seeking them out a t meetings and corresponding with them over a period o f time i f they do not know any innovators with s i m i l a r i n t e r e s t s i n t h e i r own v i c i n i t y .  On the other extreme with regard to eagerness t o  adopt new ideas or practices are the laggards, who perceive change as being undesirable u n t i l almost everyone they know thinks favorably o f a p a r t i c u l a r innovation. As used here, the concept of reference group w i l l r e f e r to a s p e c i f i e d i n d i v i d u a l or group o f i n d i v i d u a l s within the i n s t i t u t i o n a l  10 s e t t i n g w i t h whom student nurses are i n frequent contact. Many students choose one or more of these persons as reference i n d i v i d u a l s .  Itis  hypothesized t h a t students tend t o evaluate t h e i r own behavior i n terms of the e v a l u a t i o n , both e x p l i c i t and i m p l i c i t , received from these i n d i viduals.  The concept of the nurse's r o l e which a student adopts w i l l  depend upon the reference group by which she evaluates h e r s e l f .  For  example, i t i s hypothesized t h a t students w i t h c e r t a i n c h a r a c t e r i s t i c s and v a l u e s : b e t t e r s c h o l a s t i c a b i l i t y and i n t e r e s t , a p o s i t i v e a t t i t u d e toward change, and i n t e r e s t i n ideas w i l l tend to adopt an advanced 1  p r o f e s s i o n a l rather than a t r a d i t i o n a l concept of the nurse's r o l e , and t o choose i n d i v i d u a l s h o l d i n g t h i s concept as r o l e models. The theory of c o g n i t i v e dissonance—The theory of c o g n i t i v e dissonance proposed by F e s t i n g e r  (195?)  i s employed t o a s s i s t i n analyzing  the problem of c o n f l i c t among the various sets of expectations and concepts of the nurse's r o l e which students f a c e .  They may enter the school of  nursing w i t h one set of ideas, o f t e n inaccurate and glamorized, and drawn p r i m a r i l y from books or t e l e v i s i o n r a t h e r than from more authentic sources of information.  I n nursing school, they meet d i f f e r e n t concepts  which they attempt t o resolve and i n t e g r a t e w i t h t h e i r own value system; F e s t i n g e r suggests  The terms t r a d i t i o n a l and advanced p r o f e s s i o n a l are used here s i m p l y — to denote two concepts of the nurse's r o l e . They have been taken from a study by Davis and Olesen (1964), where they were used f o r t h i s purpose, and are not intended t o convey any connotation regarding the value or d e s i r a b i l i t y of e i t h e r concept.  11 that when an individual perceives dissonance between two or more of his beliefs or activities, he w i l l seek to reduce i t i n some way. If this theory i s valid for the present study, one would expect that students who perceived dissonance between any two aspects of their educational program would seek to reduce i t i n some manner. One area of dissonance suggested i n previous studies i s the conflict between what students are taught i n class that nurses should do, and the behavior which i s expected of them by ward personnel. Dissonance may also arise from differences between a student's personal ideals and concepts of what a nurse should do and the performance of practising nurses whom she observes on the ward. Several means of reducing perceived dissonance are open to students. As individuals, they feel"powerless to change the expectations within the institutional setting.  The available alternative courses of  action include altering their own expectations, either temporarily or permanently; accepting the dissonance i n the short run for long-run gains such as admission to the profession; or escaping from the profession by leaving school. Review of related literature on socialization into j. profession Related studies have been drawn upon for both the theoretical formulation and the general hypotheses to be tested. There are, however, certain limitations to the usefulness of these studies. Few studies of socialization into a profession have been theoretically oriented. Most have concentrated on a single profession, with the primary aim of  12 i n v e s t i g a t i n g and improving the education o f entrants i n t o t h a t profession.  Hypotheses o f t e n have not been e x p l i c i t l y s t a t e d , but have been  derived post factum from the data which were c o l l e c t e d .  Explanations of  the f i n d i n g s l i k e w i s e have tended t o be of an ad hoc nature.  Since  l i t t l e theory has been formulated i n conjunction w i t h the s t u d i e s , the conclusions have had l i t t l e t i e - i n with any general theory.  Although i t  i s impossible t o review a l l such studies here, s e l e c t e d f i n d i n g s of c e r t a i n r e l e v a n t ones are discussed. Huntington ( i n Merton, 1957) i n v e s t i g a t e d the development of a p r o f e s s i o n a l self-image among medical students.  The percentage of  students who thought o f themselves p r i m a r i l y as doctors r a t h e r than p r i m a r i l y as students i n t h e i r d e a l i n g w i t h p a t i e n t s was found t o be d i r e c t l y r e l a t e d t o the l e n g t h o f time they had spent i n medical school. The question asked was, In the most recent dealings you have had w i t h p a t i e n t s , how have you tended t o t h i n k of y o u r s e l f , p r i m a r i l y as a doctor r a t h e r than as a student, o r p r i m a r i l y as a student r a t h e r than as a doctor? Approximately 30 P©** cent o f the students i n the f i r s t and second years r e p l i e d t h a t they thought of themselves p r i m a r i l y as doctors; t h i s proportion rose t o 59 per cent by the end of the t h i r d year, and 83 per cent j u s t p r i o r t o graduation. F i r s t - y e a r students were a l s o asked about t h e i r self-images v i s - a - v i s persons i n other statuses w i t h whom they i n t e r a c t e d : f a c u l t y , classmates, and nurses.  Less than three per cent of the students  thought of themselves as doctors when d e a l i n g w i t h f a c u l t y o r classmates, or perceived t h a t they were thought of as doctors by these others.  A  slightly larger percentage thought of themselves as doctors i n their dealings with nurses. Almost one-third, however, thought of themselves as doctors i n their dealings with patients, and three-fourths believed that patients thought of them as doctors. The author explains these findings by the hypothesis, formulated as a post hoc explanation, that individuals tend to develop a self-image which reflects the image others have of them.  "  I f the findings of the study of medical students are applicable to other settings, we can formulate the general hypothesis that interaction with persons i n other statuses, i n the relevant institutional setting, facilitates the development of a professional self-image. Over time, students tend to think of themselves increasingly as practitioners rather than as students. Their self-image differs, however, with respect to different statuses; that i s , they are more l i k e l y to think of themselves as practitioners with respect to their patients, and less 1  l i k e l y to do so with respect to their instructors. Two studies of socialization into the nursing profession suggest a relationship between success or satisfaction i n role enactment and the development of a professional self-image. The participant observer technique was used i n both studies. Simpson (1956) and Walk (1957), both women graduate students i n sociology, lived, attended classes and worked on the hospital wards with groups of student nurses i n South Carolina and British Columbia respectively.  Student nurses i n both  situations were enrolled i n university programs, and had completed at least one or two years of university before entering the hospital  situation. In one instance, the program was a new one, the objectives of which had not yet been clearly defined; in the other, students began their work in university, then attended a long-established hospital school of nursing for the last three years. In both situations students experienced a subjective loss of status in moving from university student to nursing student and felt almost completely isolated from campus l i f e . They believed that the instruction'they were receiving in nursing was not as good as that they had received at university. Data were collected primarily by unstructured interviews, observation and informal conversations with students. A wide range of topics was covered.  Simpson investigated: social background of student  nurses, reasons for their career choice, interactions and relationships with other university students, corigruency between the students' value orientations and those of the training program, the social relationships and processes involved in induction into the role of a nurse, role expectations of various people in the setting, and changes in the early conception of nursing as students moved through their program. Waik was interested in similar topics, including factors involved in the career choice, students* perceptions of desirable characteristics of a nurse, values held by students and sources of satisfaction in nursing. No hypotheses were explicitly formulated in either study. With regard to acquiring the' nursing self-image, Simpson (1956, p. 162) found that Acquiring the nursing self-image was a process of slow evolution...like army basic training, the training program provided a set of early core experiences which shaped the rudiments of the nursing self-image, to be developed more fully as the students moved through the program...  15 (The) B a s i c N u r s i n g courses d i d more t h a n g i v e d e x t e r i t y and c o n f i d e n c e i n p e r f o r m i n g s p e c i f i c t a s k s . Through them, and e s p e c i a l l y t h r o u g h w o r k i n g w i t h p a t i e n t s i n the h o s p i t a l , the students' i n i t i a l d i f f u s e d e s i r e s t o be s e r v e r s o f t h e i r f e l l o w man were c h a n n e l i z e d i n t o more s p e c i f i c o r i e n t a t i o n s toward t h e d o w n - t o - e a r t h j o b o f n u r s i n g . They l e a r n e d t o assume as t h e i r own a s e t o f r e s p o n s i b i l i t i e s and a p p r o p r i a t e a t t i t u d e s , as t h e s e were d e f i n e d b y t h e h o s p i t a l system and b y t h o s e i n charge o f t h e t r a i n i n g program, r a t h e r t h a n as t h e y m i g h t be i d i o s y n c r a t i c a l l y d e f i n e d by t h e students... Through a p a t t e r n e d s e t o f s o c i a l r e l a t i o n s h i p s and a c t i v i t i e s i n t h e h o s p i t a l , a p a t t e r n o f o r i e n t a t i o n s toward t h e work o f n u r s i n g was i n c u l c a t e d , i n p a r t d i r e c t l y and c o n s c i o u s l y and i n p a r t i n d i r e c t l y . These 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 ( l ) t h e p r o c e d u r e s o f f o r m a l i n s t r u c t i o n , (2) d u a l i s t i c demands o f t h e h o s p i t a l and t h e s c h o o l o f n u r s i n g , (3) r o u t i n i z a t i o n and s p e c i f i c a t i o n o f t a s k s , and (4) s t r u c t u r a l i n s u l a t i o n o f s t u d e n t n u r s e s from h o s p i t a l p e r s o n n e l . The e m p i r i c a l f i n d i n g s o f b o t h s t u d i e s were p r e s e n t e d and were n o t r e l a t e d t o any o v e r a l l p a t t e r n o r t h e o r e t i c a l  topically,  framework.  Simpson f o u n d s i x f e a t u r e s o f t h e n u r s i n g r o l e t o be most h i g h l y e v a l u a t e d by s t u d e n t n u r s e s : 1) s e r v i c e t o o t h e r s , excitement,  2) glamor, a d v e n t u r e and  3) j o b s e c u r i t y , 4) w o r k i n g w i t h p e o p l e r a t h e r t h a n t h i n g s ,  5) l e a r n i n g s p e c i a l a b i l i t i e s w h i c h would be u s e f u l i n m a r r i a g e and 6) b o r r o w i n g p r e s t i g e f r o m t h e m e d i c a l p r o f e s s i o n .  Waik f o u n d s i m i l a r  f e a t u r e s i m p o r t a n t : l ) t h e f a v o r a b l e p u b l i c image o f n u r s e s , 2) c u r i o s i t y a b o u t t h e h o s p i t a l , 3) g l a m o r , 4) h e l p i n g o t h e r s and 5) u t i l i t a r i a n m o t i v e s such as income and j o b In both settings,  security.  t h e newer " c o n c e p t i o n o f t h e n u r s e ' s r o l e  taught  b y some o f t h e i n s t r u c t o r s c o n f l i c t e d w i t h t h e more t r a d i t i o n a l c o n c e p t of the r o l e p r a c t i s e d i n the h o s p i t a l s e t t i n g .  Students b e l i e v e d  that  t h e y were t o l d one t h i n g i n c l a s s and expected t o do t h e o t h e r on t h e  ward, and reported experiencing internal conflict about this,  Simpson  reports that students said they had been taught i n class to "relate to the patient" on the basis of his individual needs but, i n contrast, the qualities valued most highly i n the ward situation were neatness, discipline, efficiency and impersonality, a l l considered to be institutional values.  They resolved this dilemma by what the authors termed showing  concern and kindness to patients while maintaining an impersonal attitude,  ; t  Waik also reported that students believed that, although they  as individuals considered personalized care of patients to be desirable and rated institutional values relatively low, within the hospital ward there was more concern for technique, institutional norms and economy than for the human values they prized. Areas of conflict from which dissonance may arise—Other writers agree that a gap exists between what student;;nurses perceive as their idealized role and as the actual role they are expected to play. Malone, Berkowitz and Kline (1961, P» 5*0 state: It i s clear that the concept of the patient held by these students, which presumably measures their concept of the nursing role, i s of an individual with a physical i l l n e s s — . usually acute—on a hospital ward. They see themselves as meeting their own idealized role concept when giving technical nursing care to bedridden patients. In another report of the same study, Berkowitz and Berkowitz  (i960) hypothesized that nurses would tend to l i k e patients who enabled them to feel that they were acting i n a fashion consistent with theirrole concept more than patients who did not enable them to feel this, way.  They found, as hypothesized, that students tend to prefer  patients who 1) have shown the most improvement, 2) have the best  1? prognoses, 3) make the nurse feel most needed, and 4) require most medical attention, as opposed to those patients who are low on these dimensions. Reissman and Rohrer (1957) reported on a study of the nursing service department of a large general hospital.  The analysis of their  data revealed two seemingly contradictory attitudes to the researchers: the reiterated expression of anxiety about the adequacy of nursing care which patients received, as stated by nurses i n personal interviews; and the impersonal, assembly-line type of care given patients i n the majority of instances observed. These observations would appear to this writer not to be contradictory, but"simply to indicate that the nurses were aware that they were not giving the type of care they f e l t they should.  A similar conflict was found with respect to nursing education.  The authors (Reissman and Rohrer, 1957> P» 57) report, Professional nursing literature emphasizes the idea that the nurse i s responsible for the physical as well as the mental and emotional welfare of the patient. Further, nursing instructors incorporate this philosophy into their classroom presentation"of nursing subjects. I t i s plausible to infer that nursing students acquire values based on this theoretical concept. Yet, i t i s equally logical to assume that nurses who complete their formal education with l i t t l e or no opportunity to develop actual s k i l l s or an understanding of nurse-patient relationships w i l l be unable to give this care when they graduate. The findings of several studies suggest that nursing students resolve this conflict i n some manner at a relatively early point i n their nursing school career.  They tend to drop out i n the greatest  numbers during the pre-clinical and early c l i n i c a l periods. Manystudents find they do not l i k e nursing, and that i t does not offer the  18 satisfactions they had anticipated.  Simpson (195&, P» 156) for example,  reports, The importance of the Basic Nursing experience i n laying the groundwork for the nursing self-image was evidenced i n the rates and timing of dropouts from the school of nursing...students had learned from their experiences i n the hospital i n Basic Nursing II that nursing was not for them... Davis and Olesen (1964, p. 15) discussing research i n progress, report that i t suggests that not only do most changes i n student imagery occur mainly during the f i r s t year, but beyond this point the curriculum ceases to alter to any significant extent the basic configuration of student imagery, consensus and consonance established by then. Similar conflicts between ideal and actuality are reported among medical students.  Becker and Geer (1958) suggest that first-year medical  students find themselves unable to l i v e up to their own expectations of learning a l l that they must know to practice medicine, and find the emphasis i n their studies i s on diseases rather than persons.  The  investigators suggest that students learn to deal with these conflicts i n part by changing their expectations i n the direction of the newly perceived reality and i n part by deferring their expectation for gratification from interaction with patients to the post-medical school period.  Cynicism appears to be specific to the school situation—a  part of the group culture used as a means of meeting day-to-day problems. The general hypotheses from which the empirical hypotheses to be tested are derived, have been suggested above. They have been deduced from the theoretical framework, based on the four theories cited:  role theory, learning theory, reference group theory and the theory of cognitive dissonance.  More specific ideas for empirical hypotheses have  been drawn from the relevant studies discussed i n the preceding section. Before these general ideas can be tested within a given situation, however, i t i s necessary to consider both the profession to which the ideas are to be applied, and the specific setting within which the hypotheses are to be tested. In the following chapter, an attempt i s made to summarize some of the recent developments within the nursing profession and i n nursing education, and to describe the specific setting i n which the study was carried out.  CHAPTER II THE SETTING: PROFESSIONAL AND INSTITUTIONAL The nursing profession The crucial trend in the nursing profession as a whole is that of increased professionalization, as Saunders (1954), Reissman and Rohrer (1957) and others have pointed out. One aspect of this trend has been emphasis on increased education for nurses at the baccalaureate, masters and doctoral levels. There has also been a decrease in the proportion of direct patient care given by nurses and an increase in the proportion of time devoted by them to administration, supervision of the nonprofessional personnel who give direct patient care, and performance of technical procedures formerly performed by physicians or related to new technological developments such as the artificial kidney. Another important aspect of Increasing professionalization is the growing emphasis being placed bh the unique contributions of the nurse to the health team. According to the team concept of medical care, the hospital patient is cared for by a team of specialists; the nursing staff, which includes nonprofessional personnel; physical and occupational therapists; x-ray and laboratory technicians; and dietitians. The doctor is the head of the team, establishing the treatment for the patient and performing certain specialized tasks such as diagnostic procedures and surgery, but delegating other aspects of care to different members of the team. The nursing staff is directly responsible for  21  supervising twenty-four hour care and observation of the patient and coordinating the various other services he receives. With each technological advance, nurses must learn to use new machines and devices such as the artificial kidney, heart monitor and pacemaker, and other mechanical aids. They must have knowledge of the medications they are administering. Although the technical knowledge required of nurses is less than that required of physicians, It also covers many fields, as opposed to the more specialized areas of physical therapy, laboratory technology or dietetics. A less clearly defined function of nurses is lumped under the general heading of "meeting the patient*s needs." It includes recognition of the psychosomatic nature of illness and the need to consider "what patient has the disease as well as what disease the patient has." Nurses are urged to learn about their patients and to personalize the care given; to consider problems wnich they might encounter after leaving the hospital and to teach them to understand their conditions and to care for themselves at home. Nurses must also be aware of resources in the community to which patients may turn for assistance with such problems as finances, nursing care or vocational rehabilitation. Increasing numbers of nurses are being employed outside the general hospital as relatively independent practitioners in public health, school and industrial nursing. They are'also involved in giving other than physical! care in mental hospitals' and out-patient clinics.  It can  readily be seen, then, that the drive., for. professional status is not based merely on desire for-recognitionj but accompanies an increase in  22 the knowledge, skill and responsibility required of nurses. In order to meet these new conditions, nursing education has been moving away from the traditional apprenticeship pattern toward similarity with the educational programs of other professions. In the United States, nursing education is rapidly coming under the administrative control of colleges and universities rather than hospitals; although i t has progressed less far in Canada, the same trend can be noted there. As a consequence, in many schools of nursing today students are under a less rigid disciplinary system and are-treated more as any other college students would be, both educationally and with regard to social l i f e and nonnursing activities. They are considered to be college students, who pay fees and tuition comparable to those of other students. They may live either at home or in dormitories where they pay for their own board and room, rather than receiving these in exchange for service to the hospital. Their ward experience is considered to be clinical practice, for educational purposes, and is not evaluated as service to the hospital, which hires personnel to do the work formerly performed by student nurses. In summary, the role behavibr of nurses is changing from that of giving primarily direct physical care to patients in a hospital setting. Nurses are being given increasing responsibility for coordinating the care of patients within a complex institution, supervising other personnel who administer direct care, carrying out complex technical procedures, teaching patients to care for themselves after discharge from the hospital, and carrying out preventive*health services in the community at  23 large.  Nursing education i n turn i s both changing to meet the demands of  this new role definition and helping to bring i t about. These changes have occurred recently enough—primarily within the past ten to fifteen years—that a wide range of perceptions of the nurse's role exists among graduate nurses*' Many s t i l l emphasize the traditional task-oriented, disease-oriented, institution-centered values, while others understand and practice the newer patient-oriented role concept. In general, nurses employed by a hospital to give care, who are under pressure to meet the demands of the hospital power structure, emphasize the institutional values, while nursing educators attempt to teach the newer professional concepts of nursing to their students, with varying degrees of success.  Both groups of nurses are aware of the problems  created by the conflict of values and expectations.  Nursing service  personnel contend that the demands on their time often preclude the individualizing of patient care, even though they recognize i t as a desirable goal. As nursing service administrators trained i n the newer approach move into key hospital positions, this situation may be expected to change, so that this conflict of values w i l l no longer be as evident. The institutional setting The setting of the study i s a school of nursing run by a large general hospital i n a Canadian metropolis.  Administratively, i t i s  about midway between the two extremes of the traditional hospital school and the newer collegiate ones. The School of Nursing and the Nursing Service are run as coordinated but independent departments, both under  the administration of the Director of Nurses.  Students pay no tuition,  and are provided with their board and room, uniforms and a small stipend in return for services rendered to the hospital. In their clinical experiences, students are controlled and supervised about equally by instructors from the school and from the nursing service personnel working on the ward. Although the attempt is made to assign to students patients whose conditions are related to the topic the students are currently studying in class, the demands of the ward must also be taken into account. In the educational sphere, however, concerted efforts are being made to convey the advanced concept'of the nurse's role. Faculty members feel that they can draw upon the experience of nursing schools in the United States, adopting those innovations which have proven desirable and going slowly on those which have not worked out well in practice. Within the last five years, emphasis has shifted from the traditional procedure-, disease- and technique-centered teaching of nursing toward a patient-centered approach.  Basic nursing procedures  are taught to preliminary students (no longer called by the derogatory term of probationers or probies) oh the ward, with the instructor demonstrating on actual patients and students learning in the ward setting. The traditional method is to' present procedures by lecturedemonstration in the classroom, using a student subject; students then practice on each other in the nursing arts laboratory, moving to the ward to work with patients only when the technique has been perfected. In the new approach, students come into contact with patients within the  25 first week or two of their experience in nursing school, and from the beginning perceive nursing in this context rather than in the artificial one of the classroom. Social and psychological aspects of patient care are emphasized; about one-third of the course work of the preliminary term is devoted to the social sciences. As students move into their clinical experiences, emphasis continues to be on the patient rather than his disease. Students learn to make and carry out nursing care 1  plans for their patients and, on some wards, to work in a nursing team and to function as team leaders. According to a faculty member, continued change is anticipated; students will either live at home*or, i f they live in the dormitory, will pay board and room. Emphasis on the provision of nursing service will decrease as emphasis on education increases but, at least in the foreseeable future, students will continue to provide a large proportion of the hospital's nursing service. The minimum requirement for entrance to the school i s completion of Grade XII and satisfactory scores on pre-entrance nursing aptitude tests. An increasing number of students have, however, completed either Grade XIII or at least one year of university. With increasing selectivity, fewer students have been dropping out because of academic disability. They tend to leave because they find they do not like nursing, because they do poorly in their academic work due to their not having learned how to study, or for various personal reasons. In a personal conversation with the author, one of the senior r  faculty emphasized that the objective of the nursing school remains what  i t has always been: to produce nurses competent to practice, primarily i n the hospital setting.  To accomplish this goal requires continual adjust-  ment; any suggested changes are evaluated with regard to their potential contribution to this goal, and are not adopted simply to keep up with trends i n other schools of nursing.  .CHAPTER III FORMULATION OF HYPOTHESES AND DESIGN OF STUDY A crucial issue in an empirical study which claims to be theoretically oriented is to bridge the gap between theory and empirical research.  One way in which this may be done is by the acceptance of  nominal definitions of concepts which are related to theory and from which operational definitions required to test the hypotheses may be derived. Although role theory is widely used and accepted, the problem of defining role to serve as a concept in empirical research is far from being solved. Gross et al. (1958i p. 3) point out the gap that exists between use„of the concept of role in theoretical formulations and its use in empirical studies. They quote Linton (194-5, p. 113) The concept of role has assumed a key position in the fields of sociology, social psychology and cultural anthropology. Students of the social sciences frequently make use of i t as a central term in conceptual schemes for the analysis of the structure and functioning of social systems and for the analysis of individual behavior... Yet, despite its frequent use and presumed heuristic utility, one finds in the literature statements like, "More adequate operational definitions of role are needed; our present poverty in this respect is paralleled by the paucity of systematic role research." Because of the emphasis on'armchair thinking rather than empirical research in the development of role theory, i t has been possible for a number of ideas to become generally accepted and perpetuated without having been tested empirically. For example, Sarbin  (1954 p. 235) in speaking about the significance of rites de passage, says,  1  The manifest purpose of the intense role behaviors of the ritual is to signify the change from one position to another in society; the effect of the intensity of the role enactment is to modify the participant's selfconcept so that the new role, i.e. adult, may not be incongruent with the self. Tests of strength, for example, allow the person'to add "strong" to his self description. Thus he is better equipped to occupy the position of adult, not only because others know he has strength, but because he conceptualizes the self as strong. A similar analysis is often applied to the importance of cere-  monies, .such, as capping and graduation for nursing students, and the function they serve both for the students and for others about them. Notions such'as this have seldom-been tested empirically, but are generally accepted. One aim of this study is to submit to empirical test some of these notions which are generally accepted even though they have not been tested. The findings may or may not support the notions. Gross et al. (1958), in one such test, found evidence which failed to support the generally accepted assumption of consensus about prescriptions and proscriptions for role behavior. There is always a number of possible explanations for such failure, including inaccurate measurement or faulty conceptualization. Nevertheless, consistent lack of support for hypotheses derived from these^notions would tend to suggest the need for re-thinking of the problem and re-conceptualization of some of the ideas of role theory in a manner which would be more susceptible to empirical test.  The problem here, therefore, i s to conceptualize role and role acquisition i n a manner which w i l l be most heuristic for investigation of the topic under study.  I t should be emphasized that concern here i s  only with the acquisition of a professional role, as distinguished from other types of roles, such as age or sex roles. From the discussion of role theory i n Chapter I, i t i s evident that, i n defining a professional role, self, others and a situational context must a l l be taken into account.  So, also, must the components  of role—the things to be learned--such as behavior, attitudes, knowledge and s k i l l s , mentioned by Merton (1957)*  We might therefore  define a professional role as the behavior, attitudes. knowledge and s k i l l s expected of individuals occupying a given professional status. as held by persons i n that status as well as by others with whom they interact i n the relevant situational context(s). Specifically, we are dealing here with the beliefs of a particular group of students i n a particular profession about the behavior, attitudes and knowledge which they perceive to be expected of them as members of that profession, and about their expectations for their own behavior and attitudes. Although the data have been obtained from student nurses i n a particular sdhool of nursing at a given time and place, i t i s believed that many of the findings are generalizable beyond the immediate setting. To"the extent that the theoretical framework i s valid, specific hypotheses could also be derived from i t which would apply to other settings and conditions. Generalizability of the findings derived from the"present set of hypotheses i s , however,  limited by the extent to which conditions in other settings are similar to those of the present study. Emphasis is placed upon two aspects of the acquisition of a professional role; first, the student's growing perception of herself as a practitioner and, second, the particular concept of the professional role which she adopts. In order to formulate hypotheses about these aspects of role acquisition as dependent variables, i t was believed necessary to develop a notion of the process of role acquisition which was consistent with the theoretical framework developed in Chapter I and which would help to co-ordinate the various ideas about role and role acquisition into a unified basis for the empirical investigation. In the process of role acquisition, a student entering upon professional training brings with her her own set of personal values, beliefs and accustomed modes, of behavior. She must learn to deal with a new physical and social environment in a specific institutional setting. She enters i t with some idea of what a member of her future profession should be or do, however vague, uncertain and inaccurate that idea may be. In her training", she simultaneously acquires knowledge, learns skills and becomes acquainted with the general behavior and attitudes necessary for the practice of that profession. Some of these are learned in the classroom, others by supervised practice, and s t i l l others by observation of members of the profession working in the institutional setting. By her experience in the classroom, supervised practice and informal interaction with others, the student learns what behavior is  rewarded and what is punished by grades, other formal evaluation of the instructors, and social acceptance or rejection. She is likely to be exposed to conflicts not only among the expectations of others toward her, but also between the expectations of others and those she holds for herself. The way in which such conflicts are handled is not known. Some may go unrecognized.  Others"may become relevant to the individual  only when there is need to take action and a dilemma is perceived between two imperatives. It would be desirable to discover, for example, whether resolution of dilemmas between institutional values and patients welfare is resolved consistently in favor of one or the other by individuals, or whether each decision is made on an ad hoc basis. At the same time, she is gradually developing an image of herself as a member of the profession. As she learns and practices appropriate behavior, she tends to think of herself increasingly as practitioner rather than as student. She may perceive, however, that persons in certain statuses, such as her teachers and supervisors, consider her to be primarily a student, whereas persons in other statuses, such as the recipients of her professional services, consider her to be primarily a practitioner. She i s both present- and future-oriented, learning what she must do now as a student and what she should do later as a practitioner. This general picture is believed to be applicable to entrants to any profession, even though the relative amounts of knowledge, skills and other elements required in different types of training vary, as does the opportunity for supervised practice in role enactment.  1  Statement of hypotheses Hypotheses were derived from both the theoretical framework and the empirical studies cited above, drawing upon the author's knowledge of and experience i n nursing. Two aspects of role were selected as dependent variables: the individual's professional self-image and the particular concept of the nurse's role adopted.  The attempt was made to  identify elements of these two variables which might be expected to change over time with interaction i n the institutional setting.  i  I f this  expectation i s borne out, then an explanation of the process by which i t occurs i s needed. For this reason, several independent variables have been identified.  The general relationships thought to exist between  each of the two dependent variables and the relevant independent variables are stated below. I t i s hypothesized that the responses to *  :  the items which constitute the operational definitions of the variables w i l l differ from group to group, i n a direction consistent with that suggested by the general hypotheses.  In order to minimize confusion  arising from the large number of items used to test the hypotheses, specific predictions associated with each item are presented with the findings rather than below. Ii  The professional self-image Four components of the self-image are identified: 1) the student•;  perception of herself primarily as a nurse or primarily as a student, 2) her confidence i n her a b i l i t y to carry out certain emotionally d i f f i c u l t or distasteful activities, 3) her perception of her relationship to others i n the setting and k) her feeling of identification with  others i n the profession. 1.1  The following hypotheses w i l l be tested:  A l l components of the self-image tend to change over time, with the students who have been i n nursing school longest perceiving themselves to be closest to graduate nurses i n a l l respects.  1.1a  There i s a positive interrelationship among a l l of the components.  1.2  Students tend to perceive themselves as they believe others perceive them. Those who think of themselves primarily as nurses are more l i k e l y to believe that others think of them primarily as nurses.  But there i s a range of perceptions; the student believes  that persons who are i n the formal relationship of instructor to her w i l l tend to perceive her primarily as a student, whereas the recipients of her professional services w i l l tend to perceive her primarily as a nurse. 1.3  Formal recognition of progress i s accorded by ceremonies such as capping and graduation, as well as by other changes i n the 1  uniform during the course-of study. It i s generally assumed that these items of formal recognition contribute to making the student feel that she has advanced another step toward her goal, as well as making this progress evident to others. I f the items of formal recognition are perceived "by the student as positive reinforcement of medium range, i n contrast'to the longer-term reward of graduation and the short-term rewards or punishments arising from daily interaction, then i t can be hypothesized that the particular item closest i n time to the student's experience i s the one which w i l l be perceived by her as most important.  Graduation, which recognizes a formal change of  status from student to graduate and the accomplishment of the long-term goal w i l l , however, consistently rate as most important. U.  The concept of the nurse's role adopted by the student. • It i s thought that during the time a student i s i n nursing school,  her concept of the nurse's role develops i n the following sequence:  Her  i n i t i a l concept may be unrealistic, possibly glamorized or romanticized, as the role i s often portrayed i n books, films or television.  As she  interacts i n the setting, she may go through a period of disillusionment when her original ideas are shattered.  This i s the notion of  reality shock suggested by Dorribusch (1955)•  She w i l l then tend to  adopt a concept of the nurse's role based primarily on that taught i n " the classroom and early c l i n i c a l instruction.  As she progresses  toward graduation, she i s increasingly l i k e l y to change her concept towards valuing those activities which she perceives are being practiced and rewarded i n the c l i n i c a l setting. This description i s of the average general tendency; i t i s recognized that there w i l l be considerable deviation from i t on both sides.  Thus, although the majority of the students may,tend to become  more traditional i n their concept over time, there w i l l s t i l l be some who retain the advanced professional outlook. In this way, i t i s possible for change to come about even though the majority of nurses do not accept a particular proposed change. I t must also be remembered that the fact that this description i s based on the notion that students adapt their behavior to correspond with what they believe i s rewarded or punished does not mean that a l l students w i l l respond i n the  same way, or adopt the same standards or concepts of nursing. For one thing, individuals differ i n what they perceive as rewards and as punishments, as well as i n the extent to which they are willing to compromise their own principles to conform with others. Furthermore, as Becker and Geer (1958) suggest, students are often willing to conform with existing norms i n the short run and to l i v e with conflict temporarily for the sake of achieving the long term goal of entrance to the profession. In the studies of nursing education cited, emphasis was placed on the conflict between the advanced professional concept of the nurse*s role usually taught i n the classroom and the more traditional concept practiced on the hospital wards. According to learning theory, i n such a setting students i n the early phases of their educational program would presumably evaluate themselves against the advanced concept taught i n classes and practiced under close, supervision of c l i n i c a l instructors, who would presumably reward activities associated with this concept. They would therefore tend to adopt values associated with the more advanced concept of nursing. Students farther along i n their programs, on the other hand, who are exposed to evaluation and feedback from ward personnel as well as c l i n i c a l instructors, might be expected to adopt a more traditional concept. From this general hypothesis, several specific testable hypotheses have been derived. The dependent variables consist of the importance attached by students to certain attitudes and activities of nurses.  Both  the i n i t i a l role concept and the concept which develops as students progress through school are investigated.  The attitudes and activities  36 are  characterized as lay or glamorized, advanced professional or tradi-  tional, as these terms are used by Davis and Olesen (1964) and their equivalents by others. 2.1  The student's i n i t i a l concept of the nurse's role as judged from the satisfactions she anticipates from nursing, i s influenced by the following factors: 2.1.1 Age at decision: students who decide to enter nursing at age 16 or later tend to have a less glamorized concept of nursing than those who decide at age 15 or younger.  2.1.1a Students who decide to enter nursing at age 16 or older are more l i k e l y to have been influenced i n their decisions mainly by their peers; those who decide at age 15 or younger are more l i k e l y to have been influenced mainly by their families. 2.1.2  Students who are upwardly mobile socially w i l l be more l i k e l y to rate "being i n a profession people respect" as important than those who are not upwardly mobile; that i s , there i s a direct relationship between perceived and actual social mobility.  (Although not directly relevant  to the study, this appears to be a widely accepted assumption which the author doubts and would like to test.) 2.1.3  Students who have worked as aides, either paid or volunteer, prior to their admission to nursing school are less l i k e l y to have a glamorized i n i t i a l concept of nursing than those who have not had such experience.  37 These hypotheses will be tested for Group I, the entering students, only, in order to minimize errors arising from retrospection. 2.2  Over time, students will move from a lay concept of nursing to an advanced professional to a more traditional one.  2.3  A student's concepts of nursing will be influenced by the following factors: 2.3.1  The criteria by which a student perceives she is evaluated: Students who perceive that traditional activities are more highly valued as evaluative criteria than advanced professional ones will tend to adopt a more traditional role concept, and vice versa.  2.3.2  Activities which make a student feel capable of functioning as a nurse: Students will tend to value most highly those activities which make them feel most capable of functioning in the nurse's role.  2.3.2a Since both evaluative criteria and activities which make a student feel capable are hypothesized as being positively related to the concept of the nurse's role adopted by her, they should also be related to each other. 2.3.3  The role model selected: Students who choose instructors as role models are more likely to adopt an advanced professional concept of role than those who choose graduate staff nurses or head nurses.  2.3.4  Relevance of various courses: Students who rate courses in the social sciences and public health higher in their  relevance for nursing are more likely to adopt an advanced professional concept of role than students who rate these courses lower. 2.4  Certain personal characteristics favor the adoption of the advanced professional concept of the nurse's role. Following Rogers (I962), these include: 2.4.1  Above-average academic achievement  2.4.2  An interest in change  2.4.3  Willingness to express one's opinions publicly even when they do not agree with those of others.  Sample The sample was composed of 301 student nurses from the setting described in Chapter II.  The 109 students in Group I had been in the  school approximately one week; the 76 students in Group II about six months, and had just been capped; the 64 students in Group III between one and two years, and the 52 students in Group IV almost three years, so that they were within one week of graduation. Respondents were selected on an availability basis. A l l the beginning students received questionnaires, but because some students in each of the other three groups were away from the hospital on affiliation or vacation, only those in residence at the time were included in the sample. Since students are not grouped for their clinical experience according to scholastic ability or any other criterion considered relevant to the study, such sampling can, for purposes of the study, be considered  39 essentially random. I t must be borne i n mind, however, that students who failed academically, were incompetent i n their nursing, or found they disliked nursing presumably drop out of school. Groups II, III and IV, therefore, w i l l contain fewer students i n these categories than Group I. No quantitative inferences about characteristics of the entire population are being made which would require the use of formal sampling techniques. Procedure Data collection—Data were collected by means of a questionnaire administered to students i n the sample during February and March 1965.  Items were designed to measure each of the variables included i n  the hypotheses.  They were derived from the empirical studies reviewed,  the author's personal experience i n nursing and nursing education, and the theoretical framework discussed i n Chapter I.  Items used were  those which were thought to change over time, and i n the responses to which there would be sufficient'contrast either among groups or among individuals to test the hypotheses. A cross-sectional design was chosen for two reasons.  F i r s t , and  most obvious, was the limitation-of time for a master's thesis.  Second,  and equally valid, was the desire to use this study as a screening process by which both the hypotheses and certain other notions, as yet too unformed to be dignified as hypotheses, could be tested. I t was hoped that a clearer pattern of the process of role acquisition would emerge which would point the way,to possibilities for future studies  involving a smaller number of variables studied more intensively. Some suggestions for such studies are made i n Chapter V. Analysis of data—After a l l data were collected and tabulated, two types of analyses were made. 1) Percentages were computed for responses to items not involving rating.  2) For each item requiring  rating, students were asked to respond on a four-point scale ranging from 0 (responses such as "not at a l l important") to 3 (responses such as "extremely important").  Medians were computed on each item for each  group and for the entire sample. Testing of hypotheses—Three phases were involved i n testing each hypothesis:  l ) The findings for a l l relevant variables were examined.  The change over time was analyzed by inspection of the percentages or median ratings for each group and the direction or pattern of the change from first-year to senior students. 2) Hypotheses were tested by inspection of the apparent relationships between the percentages or median ratings of items comprising each set of dependent and independent variables hypothesized as being related.  Items i n which there were  the greatest change over time were selected for statistical test i n phase 3» 3) The presence of a relationship between pairs of selected items was tested s t a t i s t i c a l l y by the frequency Chi-square test. For each pair to be tested, a 2 x 2 contingency table was made for each group, the responses being divided near the overall median. The Ghisquare statistic was then computed; the null hypothesis was rejected i f  p<.05.  41 Limitations of the study 1) Certain unknown inaccuracies are introduced by use of a cross-sectional rather than a longitudinal design. Admission standards have been raised slightly between the admission of Group IV and that of Group I. The curriculum has, however, remained about the same, the greatest changes having occurred prior to the admission of Group IV. 2) Use of a questionnaire for collection of data results in responses which measure individuals' perceptions of the situation; their relation to the objective"situation is unknown. Since the variables used involve subjective reactions of respondents to the situation, this limitation is not a serious one. The assumption is also made that respondents' answers will be essentially honest and thoughtful. Although i t would be difficult to detect a systematic bias stemming from students* desires to give what they believed to be the proper answers, the sample is sufficiently large that an occasional dishonest answer would not bias the results appreciably. 3) Any study is subject to the usual limitations of time and 1  space. Data are collected in one location at one time. It is assumed, however, that the findings are generalizable within limits to similar situations. 4) A study is necessarily limited, and involves a choice of variables for investigation. No attempt has been made to cover the topic of role acquisition exhaustively; the emphasis has been on a few selected variables thought to be amenable to investigation by the procedure employed.  CHAPTER IV FINDINGS OF THE STUDY AND TESTS OF THE HYPOTHESES The findings are reported, and then applied as evidence for support or rejection of the hypotheses put forth i n the preceding chapter. I. 1.1  Hypotheses relating to the professional self-image Change i n the components over time 1.1.1 The student's perception of herself primarily as a nurse  or primarily as a student—An approach similar to the one employed by Huntington In (Merton, 1957) was used.  Students were asked whether they  thought of themselves primarily as nurses or primarily as students. The findings, shown i n Table 1, are not easily interpreted.  Thirty-four per  cent of the beginning students said they thought of themselves as nurses; the -percentage decreased to 25$ for the newly-capped group, and increased again to 4-5$ for intermediate group and 69$ for the neargraduates.  Apparently some students readjust their i n i t i a l opinions  following experience i n the setting.  Even so, the decrease from Group I  to Group II i s not a large one, and i t might equally w e l l represent sampling ^TTOT-SS change over time.  I t i s surprising, however, that as  many as one-third of the students with no training or experience already think of themselves as nurses, whereas almost one-third of those who w i l l soon be graduates do not yet think of themselves as nurses. As hypothesized, the proportion of students thinking of themselves primarily as nurses increased over time, although the increase was less than had been anticipated.  43 TABLE X  Per cent of students who perceive self primarily as nurse rather than student; and per cent believing others perceive them as nurses, by groups Per cent replying "perceived as nurse" i;  Group II  III  Change IV  34.0  25.0  ^5.5  52.9  Patients  79.8  94.9  93.9  100.0  Practical nurses  46.8  56.5  40.5  48.0  Head nurses  32.0  21.0  27.6  40.5  Doctors  27.5  17.1  21.8  34.6  Clinical instructors  17.4  9.2  7.8  3.8  Self Status of other  109 "  N  76  64  0  52  In this and succeeding tables, where change is shown, the direction is indicated by four symbols: = increases over time = decreases over time ^  = initial decrease, followed by successive increases 0 = no change or no apparent pattern of change  1.1.2  Confidence in ability to perform disagreeable or emotion-  ally difficult tasks—Students were asked how well they believed they could cope with four disagreeable or emotionally difficult tasks. Their responses are shown in Table 2. They were most confident of their ability to deal with excreta, vomitus, etc., less confident of their ability to care for a dying patient or a patient in pain whom they could not help and least confident of their ability to help the mother of a stillborn child. Except for the last item, confidence increased over time, as hypothesized. In addition, the differentials were in line with the findings of other studies that student and graduate nurses feel most confident when giving physical care In situations where they can do something to help a patient, and least confident when providing emotional support to a patient whose physical needs are minimal. 1.1.3  Relationships with others in the setting—Eating with  another in an informal atmosphere is generally considered to be a measure of relative social equality, or at least a type of social interaction expressing familiarity and acceptance. It was hypothesized that the longer students were in school, the closer they would feel to graduate nurses socially and the freer they would be to have meals or coffee with them. Although they might occasionally eat with head nurses, i t would be unlikely that they would do so with supervisors, who are perceived as very distant socially. "The relationship of students to nonprofessional personnel (nursing assistants and practical nurses) is ambiguous; as graduates they will rank higher, but as students they tend to be at the bottom of the heap. One might anticipate, nevertheless,  4-5 TABLE 2 Median ratings for confidence in performing disagreeable or difficult tasks Task  Median rating All  Change  Group I  II  III  IV  Dealing with excreta, vomitus and other malodorous substances  2.5  2.2  2.5  2.7  2.9  Seeing a person in pain when you can do nothing to help him  2.0  1.8  1.9  2.0  2.1  0  Caring for a dying patient  2.0  2.0  2.0  2.0  2.1  0  Talking with a mother whose babywas stillborn  1.7  1.7  1.5  1.6  1.8  that the frequency with which students would have meals with a l l ward personnel would increase over time, as they came to feel more a part of the hospital setting. Although many students might at first be terrified of doctors, i t is likely that some of them at least would soon get acquainted with medical students, interns and residents, and occasionally eat with them. The findings are shown in Table 3»  Group I is omitted from the  tabulation, since over two-thirds of them did not reply to these items. Because of their eating arrangements, they were presumably eating only with other students. As was expected,'students in a l l other groups tended to eat primarily with other students. The percentage who ate with other ward personnel also increased, although not always in a linear fashion. This finding may in part be'explained by the fact that eating arrangements for students vary with their assignments; in certain areas of the hospital they eat in a separate student dining room, but in other areas a l l personnel share the same dining room, so that there is an opportunity for students to eat with persons in other statuses. From observation of Table 3» i t can be seen that students are about equally likely to eat with graduate nurses and' nursing assistants, somewhat less likely to eat with medical students and interns, and only in rare instances to eat with head nurses* supervisors or residents. These findings provide a rough estimate of the social distance between students and other persons. Although they are not capable of clear-cut interpretation, they suggest that as students are in nursing school longer, they tend to feel more a part of the hospital setting and  TABLE 3 Per cent of students having meals or coffee at least once a week with persons in other statuses, by groups Group Status of other persons  II  III  IV  100.0  100.0  100.0  23.6  37.5  40.5  Nursing assistants  27.6  18.8  38.5  Registered nurses  18.4  29.7  21.2  Practical nurses  1.4  12.5  19.2  Medical students  —  4.7  15.4  Interns  —  3.1  1.9  Residents  —  1.6  3.8  Head nurses  —  —  Students  Supervisors  76  64  1.9 52  48  to associate with other nursing personnel, both professional and nonprofessional. They become increasingly comfortable with medical students and interns, but are almost never socially close to supervisory nurses or doctors in statuses higher than interns. In essence, the relative social status of students increases somewhat but not much. This finding appears to be in line with that of Sec. 1 . l i i that although a larger percentage of students in each successive group tend to think of themselves primarily as nurses rather than as students, almost one-third of the students about to graduate s t i l l think of themselves primarily as students. 1.1.4  Feeling of identification with others in the profession—  Students were asked two questions about their identification with others in the nursing profession. The first tapped their perception as to how closely their own ideas, attitudes and interests corresponded to those of most graduate nurses they knew; the*-seeond, how much they enjoyed being with other student nurses, as compared with some of their friends who were not nurses. The findings, shown in Table 4, do not support the hypothesis that identification with others in the profession increases over time. For both items, the median rating is about 2.0 for a l l groups. Identification with values of graduates is slightly lower and enjoyment of other students slightly higher. "One might conclude that students feel closer to other students than to graduates, which responses to other items support. These findings' do not, however, support the oftenexpressed notion that nurses are isolated and prefer each others* company to that of non-nurses. It might well-be, however, that had the questions been worded differently, stronger in-group tendencies would have been noted.  49 TABLE 4 Median ratings for identification with others in the nursing profession, for the entire sample and by groups Median rating Item  All  Group I  II  HI  IV  Interests correspond with those of most graduate nurses you know  1.9  2.0  1.9  1.9  1.9  Enjoy other students as compared with non-nurse friends  2.1  2.2  2.2  2.2  2.1  1.1a .Interrelationships among components of the professional selfimage—Only three of the four components were found to change over time; for the entire sample these three may be related in some way.  For the  self-perceptions of individuals, however, there appear to be no relationships among the variables. The procedure used for statistical tests of a l l hypotheses will be illustrated for this hypothesis only; the same approach was used for a l l of them. In order to test the relationship between perception of self as a nurse and confidence in dealing with difficult or disagreeable situations, an item was chosen for each variable; in this instance, perception of self primarily as a nurse and confidence in dealing with excreta, vomitus and other malodorous substances. For the first of these, no choice was involved, as i t was the only measure. For the second, the item chosen was one of two in which the median rank changed the most over time, that is, which discriminated most between groups, (cf. Table 2). Responses to perception of self primarily as a nurse were either yes or no, so there was no problem in dividing the responses into high and low categories. For the second item, the overall median rating was 2.5. Consequently, response categories 0, 1 and 2 were counted low and 3 as high. For each group of students, a cross-sort was done, yielding a 2 x 2 contingency table. From this, the Chi-square statistic was computed. The null hypothesis was rejected i f p-c.05. The statistical analysis was performed by groups rather than for the entire sample in order to minimize the effect of unidentified differences within groups. It i s quite possible that different relation-  51 ships would be found for Group I than Group IV.  For example, there  might be a reversal of relationships, so that two factors were related directly for Group I but inversely for Group IV; i n such an instance, lumping of a l l groups together would obscure the presence of any relationship. Although each of the items chosen as an operational definition of a variable changed over time, the s t a t i s t i c a l tests showed few significant relationships among them for any of the groups.  Perception of  self primarily as a nurse was found to be related to confidence i n dealing with excreta for Group I, to eating with nursing assistants and registered nurses by Group III, and to enjoyment of other students by Group IV, variables.  There were no interrelationships among the remaining three The three scattered significant findings are not sufficient  to support the hypothesis that a l l four components are interrelated. That i s , the student who thinks of herself primarily as a nurse may be either more nor less confident of her a b i l i t y to perform a disagreeable task (dealing with excreta) than the student who thinks of herself primarily as a nurse.  She does not'feel more at ease socially with  other ward personnel, as measured by eating meals or coffee with graduate nurses or nursing assistants. ' She i s not more l i k e l y to identify with either graduate or student nurses.  Each component of the dependent  variable seems to vary independently for each individual.• This finding, l i k e others arising from the statistical tests of the hypotheses, i s unexpected. I f the notion of role i s empirically valid, one would expect the various components of role to vary together;  52 not perfectly, but at least to show" some relationship. Speculations on the possible implications of this finding, as on others, will be deferred to the final chapter. 1.2  Beliefs about perception of self primarily as nurse or primarily as student by others Students were asked whether they believed that persons in certain  other statuses thought of them primarily as nurses or primarily as students. Their responses are shown in Table 1. Eighty per cent of entering students believed that patients thought of them primarily as nurses; this proportion rose to over 90$ for Groups II and III, and 100$ for Group IV. The percentage of students believing that others thought of them primarily as nurses was smaller with respect to other persons with whom they worked on the wards4 There was no apparent pattern to ?  the differences between groups with"respect to practical nurses' opinions of students. For both head nurses and doctors, however, the same pattern was followed as for self-perception; an i n i t i a l decrease, followed by successive increases. The percentage of students who believed that clinical instructors"thought of them primarily as nurses decreased from 17$ for Group I to about 4$ for Group IV. It might be concluded from these findings that the formal relationship of students to persons in each of the other statuses is an important factor in influencing students' beliefs about whether they are thought of primarily as nurses or as students. The patient, who is the recipient of professional services, is in the same relationship to a student nurse as to any other nurse. Practical nurses in most cases have  only informal relationships with students, as they are usually outside the chain of command which includes students. It is interesting to note that, as in the question involving social distance, students* relationships with practical nurses appear to be unclear. This might possibly reflect the ambiguous position of the status of practical nurses, which is relatively new within the hospital. The pattern for head nurses and doctors is virtually the same; in relation to persons in these statuses, the student is quasi-nurse and, although recognized as a learner, i s performing many of the same functions as other nursing personnel. With clinical instructors, on the other'hand, the relationship is always one of student-teacher.  This relationship may begin to chafe as a student  progresses through school and perceives herself as increasingly capable of functioning as a nurse while she"is s t i l l being treated as a student by her instructors. Overall, there is less difference within each item from group to group than between items for a l l groups. Except for practical nurses and clinical instructors, change is"in the predicted direction. These findings are in line with those of Huntington (Merton 1957) and Gross (1958), who found that persons in different statuses perceive members of a given status differently from"each other and from the way in which members of that status perceive themselves. When the hypothesis that perception of self was related to one*s beliefs about others* perceptions of self was tested, only one significant relationship was found. The"only two items measuring others* perceptions used in the test were the beliefs of nurses and doctors,  because of the low level of percentages with respect to clinical instructors ' perceptions and the high level-of those related to patients' perceptions. The one significant relationship was that between perception of self and belief about perception'of self by doctors for Group I. Thus, although the percentage of students believing that nurses or doctors thought of them as nurses Increased from Group I to Group IV for the entire sample, there was n6 relationship between the way individual students thought of themselves and the way they believed that nurses or doctors thought of them. 1.3  Formal recognition The relative importance attached by students to different items  of formal recognition of change of status i s shown in Table 5»  For the  entire sample, graduation ranked highest, then capping, followed by receiving the senior and junior uniforms, with admission to nursing school and first day on the ward last. Although the ratings vary from group to group, the rankings remain "about the same. It was hypothesized that the"group nearest to each particular item would rate that item higher than would other groups.  This is  partially supported. Group U, which had just been capped, rated capping higher than did other groups.•-Importance of the senior uniform was greatest for seniors and intermediates, soon to become seniors. Intermediates also rated the junior uniform higher than did a l l other groups. This pattern was not characteristic" of ratings of admission, but did follow for the first day on the ward, the importance of which declined for successive groups.  55 TABLE 5 Median ratings for items of formal recognition of students' progress, for the entire sample and by groups Item  All  Median Rating  Change  Group I  II  III  IV  graduation  3.0  3.0  3.0  2.9  2.9  0  capping  2.5  2.0  2.7  2.6  2.5  0  wearing senior uniform  2.2  2.1  2.3  2.4  2.4  wearing junior uniform  1.9  1.7  2.1  2.4  1.9  admission to nursing school  1.8  1.0  1.8  1.8  1.5  first day on ward  1.4  1.8  1.7  1.5  1.0  0  56 The ratings of capping are i n t e r e s t i n g .  Entering students  attached much l e s s importance to i t than d i d a l l other groups, agreed c l o s e l y .  who  I t i s probable that the importance accorded t h i s cere-  mony i s s p e c i f i c to the nursing school culture, to which entering students have as yet been l i t t l e exposed;,-\ Since i t comes only s i x months a f t e r admission, students are s t i l l - a long way from graduation and as yet  f l e d g l i n g nurses.  Entering students may i n t e r p r e t i t i n t h i s l i g h t ,  whereas older students are impressed by the formal recognition accorded by the presence of parents, as well^as by the ceremony i t s e l f . The studies reported by Simpson  (1956) and  Waik  the stress associated with the f i r s t - d a y on the ward.  (1957)  emphasize  Although the  highest median ratings on t h i s item were assigned by Groups I and I I , as hypothesized, the median ratings f o r t h i s item and f o r admission are lowest of any item f o r a l l . groups.;.* The high r a t i n g accorded graduation, as contrasted with these low ratings, helps to v a l i d a t e the rating scale, showing that students d i d discriminate i n t h e i r ratings and d i d not respond i n d i s c r i m i n a t e l y or a t random.  Comparison of group medians  suggests a reasonable amount of consensus between groups, differences between items f o r a single group often being l a r g e r than those between groups f o r a single item.  Consensus within groups i s also indicated f o r  most items by the concentration ofGratings. Responses tend to be either almost evenly divided between two  rating  l e v e l s or concentrated at one  l e v e l , with the balance of responses^ about evenly divided between the r a t i n g l e v e l s on either side.  Because of the consequent f a i l u r e of  these items to discriminate, none of the relationships between percep-  57 tion of self and these items was tested s t a t i s t i c a l l y . II. 2*1  The concept of the nurse's role held by students I n i t i a l role concept Students were asked to rate a l i s t of satisfactions anticipated  from nursing at the time of admission.  In previous studies, similar  items had been classified i n different ways by different investigators. Although these classifications were generally ad hoc i n nature, and were not parallel, they were used here i n order to f a c i l i t a t e comparison with findings of other studies. The median responses to these items for each group are shown i n Table 6. Two main impressions are derived from scanning this table. F i r s t , the satisfactions anticipated from nursing by these students are similar to those of students i n other studies cited above.  (Simpson  1956, Waik 1957, Davis and Olesen 1964) Second, most of the students held what might be considered a realistic i n i t i a l view of nursing** rather than a glamorized one, i n that i t was similar to the concept of more experienced students and did not rate glamor items highly. Students were asked to rate each item rather than to rank the items or make a forced choice between them because of the investigator's belief that many items might be equally important to students. This idea was supported by the finding that the two anticipated satisfactions most commonly mentioned by students i n the studies cited—helping sick people and learning about diseases and their treatments—were rated almost equally and were consistently highest for a l l groups.  In two studies  (Shuval 1963, Reissman and Platou i960) a humanitarian-technical  TABLE 6 Rank, for entire sample, and median ratings of importance of satisfactions anticipated from nursing, for entire sample and by groups Anticipated satisfactions  Median ratings of importance  Rank All  Group I  II  III  IV  Humanitarian Helping sick people get well  1  2.8  2.9  2.9  2.7  2.5  Technical Learning about diseases and their treatments Working in the operating room  2 5.5  2.7 2.0  2.8 2.0  2.6 1.8  2.6 2.1  2.5 1.9  8 10  1.7 1.0  1.7 0.8  1.7 1.1  1.9 1.3  1.5 1.7  Status Being in a respected occupation Being part of the medical team  3 4  2.1 2.1  2.2 2.3  2.3 2.1  2.1 2.1  2.0 2.0  Advanced professional Teaching disabled patients to care for themselves Using initiative in solving problems Working with mentally i l l persons  5.5 7. 9  2.0 1.9 1.4  2.3 1.9 1.9  2.0 2.0 1.5  1.8 2.0 1.1  1.5 1.9 1.3  Glamor Mystery and excitement of the hospital Wearing a nurse's uniform  Change  0 0  0  "A  CO  59 dichotomy was suggested which assigned these items to mutually exclusive classes. The present findings suggest, in contract, that both expectations are of almost equal importance in vocational choice, and outweigh other considerations. Findings are reported by groups. For a l l but Group I, which has had l i t t l e contact with the nursing school setting, responses are retrospective and likely to have been influenced by experience in the school. Although change over time is not analyzed for the variable, differences which show up between groups may act somewhat as controls for other analyses. It is suggested, for example, that Group IV tends to rate a l l items lower than Group I. This tendency is found for almost a l l items in Table 6. The glamor items ranked among the lowest, with wearing a nurse's uniform being the least valued. The other low-ranking item was working with mentally i l l people; this finding is in line with those of other studies that students prefer to care for patients who have acute physical illnesses.  (Berkowitz and Berkowitz i960, Reissman and Rohrer 1957)  Desire for status, two of the advanced professional values and a technical one, working in the operating room, were a l l considered moderately important. Although this item is intended to reflect the initial concept of nursing held by students, the fact "that i t is retrospective for a l l but Group I may have influenced students' responses. For four items, either there is l i t t l e difference between groups or the difference is not systematic. For six others, the small decrease from Group I to Group IV  60 probably suggests some disillusionment over time. One might wonder whether, i f the students in Group IV had been asked the same questions during their first week in nursing school, their responses would also have been higher, but in retrospect none of the items seem quite so important to them as they do to the new students in prospect. For only one item, wearing a uniform, does the appeal increase over time. This increase is systematic from group to group, suggesting that i t is the graduate rather than the student uniform which appeals. 2.1.1  Age at decision—Students were asked the age at which they  first considered nursing as a career and the age at which they actually decided to enter nursing school. Since nursing and teaching are the two traditional female professions, i t is to be expected that many girls would consider the possibility of following them at an early age. Few girls would, however, be likely to"make an actual decision before senior high school. Answers to these two'questions are shown in Table 7* About half of the students said they first thought of nursing as a career at age 11 or younger, about, one-fourth between 12 and 15, and the remaining one-fourth at age 16 or older. Actual decision to enter nursing school came later, with only  % reporting decision at age 11 or  younger, almost 30$ between 12 and 15, and the remaining two-thirds at age 16 or over. These percentages"would suggest that, for the majority of students, actual career decisions"were made fairly close to the point of forced choice. Although differences between' groups in age at which nursing was first considered and age at decision were not of interest for testing  TABLE 7 Age at which nursing was first considered as a profession, and age at which decision to enter nursing school was made, for entire sample and by groups Per cent of students  Age  Group  All  Per cent of students All  Group I  I  II  III  IV  51.1  57.0  56.5  43.8  40.5  11 and under  26.6  38.5  26.4  20.3  30.8  22.1  14.6  17.1  36.0  28.8  99.8  100.1  100.0  100.1  100.1  301  109  76  64  52  II  III  IV  5.6  5.6  6.6  3.1  7.7  12 to 15  28.9  34.8  27.6  18.7  30.6  16 and over  65.4  59.5  65.9  78.0  61.5  Totals  99.9  99.9 100.1  99.8  99.8  64  52  N  301  109  76  ON  H  the hypotheses, the variations from group to group are more than might be expected f o r such items.  Age at which nursing was f i r s t considered  as a vocation increases from Group I to Group IV.  Age at d e c i s i o n  varies from group to group, but shows no consistent pattern.  These  differences are d i f f i c u l t to i n t e r p r e t , because many p o s s i b i l i t i e s exist.  Whether they are the r e s u l t of sampling error, actual d i f f e r -  ences among the groups, or other unidentified factors i s not knowrii and cannot be ascertained from the available data. S t a t i s t i c a l tests of hypotheses related to vocational choice and i n i t i a l role concept were made f o r Group I only, i n order to minimize errors from retrospection.  No s t a t i s t i c a l l y s i g n i f i c a n t relationships  were found between age at decision and r a t i n g on a glamor item, mystery and excitement of the h o s p i t a l ; or on an advanced professional item, teaching disabled patients to care f o r themselves.  Using these items  as c r i t e r i a , age at decision d i d not a f f e c t students* expectations; those who decided to enter nursing at age 16 or l a t e r d i d not have either a l e s s glamorized or more advanced professional i n i t i a l  r  concept  of nursing than students who decided at age 15 or e a r l i e r .  2.1.1a  Age at d e c i s i o n to enter nursing as related to persons  having the greatest influence on vocational choice—Students were.asked which of .a number of persons such as family, other r e l a t i v e s , and friends or other sources of information including books and t e l e v i s i o n were most important i n influencing t h e i r decisions to enter nursing school.  Their responses are shown i n Table 8.  About one-third chose  the family as most important; only 8$ selected friends t h e i r own  age.  63 TABLE 8 Persons and other sources of information judged most influential on decision to enter nursing school, for entire sample and by groups Person or source of information  Per cent of students All-  Group I  II  3%0  34.0  36.5  28.2  38.5  Other relatives  7.3  9.2  7.9  3.1  7.7  Friends the same age  8.3  5.5  7.9  9.4  13.4  Teachers  2i?  1.8  2.6  3.1  3.9  Doctors  0.6  1.8  -  -  -  Books  9.6  14.4  7.9  6.3  5.8  -  -  -  -  13.7  20.4  24.6  10.8  13.5  Experience in hospital as patient or aide  7.0  3.7  10.5  14.1  -  Vocational counselling  1.7  1.8  1.3  3.1  -  Desperation  2.3  0.9  -  6.3  3.9  Inexpensive professional training  2.7  -  -  10.8  1.9  Future nurses' club in school  0.3  0.9  -  -  Registered nurses  2.0  4.6  -  1.6  -  Other  2.3  1.8  -  -  9.6  No response  2.0  -  2.6  3.1  3.9  Totals  99.9  99.7  100.0  100.1  100.2  76  64  52  Family  Television  III  IV  Other "My own idea"  N  301  109  Almost 10$ said that books were influential, but none admitted to being influenced by television. Over one-third of the students rejected the choices offered, preferring to add their own in the "other" category. Almost 14$ of a l l students gave responses such as "my own idea" or "my own interests." Seven per cent cited experience in hospital as a patient or an aide, or illness of someone in the family. Other influences cited by a few students were vocational counseling, the fact that nursing education was the least expensive training available, and "I didn't know what else to do," listed in the table as Desperation. No statistical relationship was found between age at decision and influence by parents or peers. Robson (1964) suggested that students who decided to enter nursing at age 15 or earlier were more likely to have been influenced by parents, whereas those who decided at age 16 or later were more likely to have been influenced by peers. This finding was not substantiated by the statistical tests. 2.1.2 Experience as a paid or volunteer aide—Experience as an aide was found to be related to ratings on mystery and excitement of the hospital but not to helping disabled patients. As hypothesized, students who had had experience as paid or volunteer aides were more likely to rate mystery and excitement low than students who had not had such experience. This may well be a fairly specific relationship for these two items, which would not necessarily apply to other items classified as "lay." 2.1.3 Upward social mobility—Nursing is often considered to be a profession which serves as an avenue of upward social mobility.  Social mobility i s frequently defined as an individual's social class status i n relation to that of his parents. Although occupation i s considered to be the best single indicator of social class, education i s almost as adequate. Because education i s more precise and simpler to classify than occupational status, i t was used as an indicator of social class i n this study. The highest educational level completed by each parent of the students i s shown i n Table 9. About 55$ of the fathers and 60$ of the mothers had completed Grade XII or less; 19$ of the fathers and 14$ of the mothers had a bachelor's degree or better. Thus, i f a l l students i n the sample complete their nursing course, about 56$ w i l l have more education than their fathers and about 19$ w i l l have less.  For over  half these students nursing does, i n fact, constitute an avenue of social mobility. 2.1.3a Other investigators (Simpson 1956, Reissman and Rohrer  1957* Shuval 1963) have suggested that desire for upward social mobility i s an important motivation for many nursing students. In North America today, there i s a marked increase i n educational level, as measured by number of years of schooling completed.  Nursing i s  often cited as an occupation which gives access to upward social mobilr i t y through education, especially since i t i s available at a much lower cost than a university education. "What was questioned here was whether there was any relationship between the fact of upward social mobility, as measured by the student's completion of more years of education than her parents, and the expressed desire for social mobility, or perceived  TABLE 9 Highest school grade completed by parents for entire sample, and by groups Highest grade completed  Father  Mother Per cent of students  Per cent of students  I'  Group  All  Group  All  II  III  IV  I  II  III  IV  15.3  13.8  13.2  18.8  17.3  Less than Grade VIII  ll 3  11.9  11.8  14.1  5.7  26.2  32.2  23.7  23.4  21.2  Grades VIII-XI  29.6  29.4  31.6  26.6  30.8  14.0  12.9  17.1  14.1  11.5  Grade XII  18.9  20.2  14.5  18.7  23.2  19.9  18.3  22.4  18.8  21.2  Vocational training  15.3  16.5  15.8  9,4  19.2  4.9  4.6  6.6  4.7  3.8  Some university  7.7  11.0  5.3  7.8  3.8  6.0  5.5  3.9  3.1  13.5  Bachelor's degree  4.6  3.7  6.6  '^.7  3.8  13.0  11.9  13.2  15.6  11.5  Graduate or professional training  12.0  6.5  14.5  17.2  13.5  0.7  0.9  1.6  -  0.7  0.9  1.6  -  LOO.O 100.1 100.1 100.1 100.0  301  109  76  64  52  No response Totals  ?  100.1  100.1 100.1 100.1 100.0  301  109  76  64  52  social mobility. No relationship was found between actual social mobility, as defined, and perceived social mobility as measured by desire to be in an occupation which other people respect. This would at least suggest that desire for status is not limited to persons striving to be upwardly mobile socially, as well as the fact that interest in nursing as a profession is not necessarily based on desire for social mobility, even when that may be the result. 2.2  Relative importance of various nursing activities The instructions for these items were worded so as to tap the  students' expectations of what nurses should do and, presumably, what they would expect of themselves as nurses. It was hoped that responses would reflect what students actually would do rather than what they thought they ought to do. The question asked to elicit responses for these items was, In nursing school you learn many things a nurse should do. Some of them are more important than others. How important do you believe i t is for a nurse to do each of the following? Items ranged in specificity from the general "be of service to humanity" to more specific ones such as "allay a pre-operative patient's fears i f he seems apprehensive." They were selected so as to include some classed by Davis and Olesen (1964) as traditional and others considered as advanced professional. Some items such as "give medications accurately" were thought to be universally applicable, and were so classified. Median ratings are shown in Table 10. Two of the twelve items  TABLE 10 Rank, for entire sample, and median ratings of importance attached to specified nursing activities, for entire sample and by groups Activity  Rank  Median rating of importance  change  Group  All I  II  III  IV  Advanced professional Meet the emotional needs of the patient  3  2.7  2.5  2.8  2.8  2.9  Modify procedures to suit the individual patient  4  2.6  2.2  2.7  2.9  2.9  Take responsibility for planning the nursing care of patients  5.5  2.5  2.3  2.7  2.7  2.5  0  1.8  1.6  1.7-  1.9  2.0  yr  Supervise non-professional personnel  12  Universal  •  •-  Give medications accurately  1  3.0  3.0  3.0  3.0  2.9  0  Observe, report and record accurately  2  2.9  3.0  2.9  2.9  2.9  0  Maintain a proper appearance  5.5  2.5  2.8  2.3  2.3  2.3  Ik  Get to work on time  7.5  2.4  2.7  2.4-  2.3  2.2  \  Be of service to humanity  7.5  2.4  2.8  2.2  2.4  2.2  \  Help to keep the ward clean and tidy  8  2.1  2.4  2.0  2.1  2.3  0 ON 00  Traditional Finish assigned work on time  9  2.0  2.3  2.0  2.0  1.8  TABLE 10—continued Activity  Rank  Median rating of importance All  Group I  II  III  IV  Carry out nursing procedures exactly as they are taught  10.5  1.9  2.3  1.9  1.4  1.5  Find additional work to do when the assignment i s completed  10.5  1.9 1.9  1.9  1.9  1.9  Stand when a doctor enters the room  13  1.1 1.5  1.0  0.9  0.9  70 received near-maximum ratings of 3.0 and 2.9 respectively: students considered i t essential to "give medications accurately" and to"observe, 1  report and record accurately." Both of these are classed as universal, because there would be a high consensus about their importance among nurses.  Five items received overall median ratings between 2.4 and 2.7.  Two of these are universal items, three advanced professional. Among the lowest-rated items were a l l the traditional ones; one advanced professional, the supervision of non-professional personnel; and one universal, "keeping the ward clean and tidy," which might equally well 5  have been placed i n the traditional class.  The lowest i s "standing when  a doctor enters the room," which seems to be on i t s way out as an expectation for nurses. It was hypothesized that, given the usual situation i n a school of nursing, where advanced professional ideas were emphasized by the instructors and more traditional ideas by ward personnel, students would tend, over time, to rate advanced professional activities as less important and traditional ones as more. The findings do not support this hypothesis, but are exactly the opposite. Ratings for a l l the advanced professional items increased over time; for three of the four traditional ones they decreased, as they did for three universal ones for which no change had been hypothesized.  For most of the items that changed, the  actual amount of change i n the median ratings was greatest i n the f i r s t six months, and decreased or leveled off thereafter.  I t i s interesting  to note, however, that although the median ratings of each item varybetween groups, there i s l i t t l e difference i n the ranking of items by the four groups.  -71 2.2.1  Students  1  perceptions of the relative importance of  various evaluative criteria—Students were asked to rate the importance of various criteria by which their c l i n i c a l work was evaluated.  Other  investigators (Simpson 1956, Waik 1957» Reissman and Rohrer 1957) have pointed out the discrepancy perceived by students between the values taught to them i n class and the criteria by which their c l i n i c a l work i s evaluated.  Presumably, i f a similar discrepancy existed i n this  setting, less advanced students, who are evaluated primarily by their c l i n i c a l instructors, would be less l i k e l y to perceive i t than would advanced students, who are evaluated both formally and informally by ward personnel as well as by their•clinical instructors.  Student  responses are given i n Table 11. "Ability to perform procedures correctly received a median rating of 2.9 from the entire sample, although i t s importance declined over time.  The other five items  received almost the same overall median ratings of 2.5 to 2.6.  Two of  the items which might be considered traditional—neatness of the unit when work i s completed and completing the assignment within the allotted time—showed the pattern of an i n i t i a l decrease followed by an increase, with the result that the ratings of Groups I and IV were almost identical.  For the other three there wis' no clear pattern, although for two  advanced professional items—rapport with patients and meeting patients' social and psychological needs—the median rank assigned by Group IV i s considerably lower than that of Group I. These findings do not display any clear pattern which i s applicable to testing of the hypotheses.  For a l l items, both traditional  TABLE 11 Rank, for entire sample, and median rating of importance of factors i n evaluation, for entire sample and by groups Factor  Rank  Median rating of importance All  Change  Group I  II  III  IV  Advanced professional Rapport established with patients  2.5  2.6  2.6  2.7  2.6  2.1  o  Understanding of patients* social and psychological problems  5  2.5  2.8  2.3  2.5  2.0  P  2.5  2.6  2.6  2.4  2.8  2.4  O  2.9  3.0  2.9  2.8  2.7  *  Universal Relationships with other ward personnel Traditional Ability to perform procedures correctly Neatness of the unit when patient care i s completed  5  2.5  2.7  2.2  2.4  2.7  ^  Ability to complete assignment i n the time allotted  5  2.5  2.7  2.4  2.4  2.6  ^  ro  73 and advanced professional, Group IV gave lower ratings than Group I. I t would therefore be d i f f i c u l t to ascribe this differential to any change related to the traditional-advanced professional continuum. I t i s more l i k e l y that this change reflects the older students* tendency to rate a l l items lower, as was noted above. 2.2.2  Factors which make students feel confident of functioning  as nurses—Ratings  of the factors which make students feel confident of  functioning as nurses are shown i n Table 12.  Knowledge of nursing pro-  cedures received the highest overall rating, but decreased over time. The only item to increase over time was planning of nursing care, rated lowest by Group I but highest by Group IV.  This i s an advanced profes-  sional item which i s mastered after the simpler basic s k i l l s have been learned, so i t would be more relevant for advanced than beginning students.  For knowledge of disease conditions and a b i l i t y to talk with  patients, the ratings of a l l groups were similar and no change was noted. For both meeting the psychological"and social needs of patients and knowledge of medical terms, almost the same pattern of decrease i n ratings between Group I and Group IV was shown. Since, of the three advanced professional items included, one increased, one remained the same and one decreased, i t must be concluded that the hypothesis of 5  change i n a given direction along;the advanced professional-traditional continuum i s not supported. 2.2.1 a and 2.2.2  a Relationships between relative importance  of various activities. relative importance of various evaluative  TABLE 12  Rank of medians, for entire sample, and factors which make students feel confident as nurses, for entire sample and by groups Factor  Rank  Median rating of importance All  Change  Group I  II  III  IV  Advanced professional Ability to plan the nursing care of a patient requiring intensive physical care  2.5  2.7  2.4  2.8  2.8  2.8  Ability to talk with patients  4  2.6  2.5  2.7  2.6  2.5  Understanding of the psychological and social aspects of illness  5.5  2.4  2.6  2.4  2.2  2.2  Knowledge of nursing procedures  1  2.9  3.0  2.8  2.8  2.5  Knowledge of disease conditions  2.5  2.7  2.7  2.7  2.7  2.6  0  Knowledge of medical terms  5.5  2.4  2.7  2.2  2.1  2.1  •a.  0  Technical  -0  criteria, and factors which make students feel confident—In order to simplify the wording of the following discussion, the relative importance of various activities will be termed Values; the relative importance of various evaluative criteria will be termed Evaluation; and the factors which make students feel confident will be referred to as Confidence. Items which were considered to be roughly equivalent for at least two of the three categories are shown in Table 13. As can be seen from this Table, there were only two items for which data were comparable for a l l three categories; for others, items in two of the three categories were compared. Group I is omitted from the tabulation, because the concern here isswith students* reactions to actual experience in nursing school rather than their anticipatory beliefs about i t . A l l three groups placed relatively low values on performing procedures exactly as they were taught. They perceived, however, that correct performance of procedures was the most important evaluative criterion; they also believed that i t was among themost important factors in making them feel confident. For meeting patients* social and psychological needs, the picture was almost the reverse; this factor was valued highly, but perceived as relatively less'important as an evaluative criterion or in giving the student confidence.  These were  the only two items which could be compared for a l l three categories. In Group II, there is a relatively close correspondence between values and evaluative criteria for the two traditional items of neatness and completion of the assignment; this gap widens, however, for Group IV, where these items are rated lower in value andhigher in evaluative  TABLE 13 Summary Table Median ratings of similar items: importance attached to specified nursing activities (V)' emphasis placed on factors in evaluation (E)* and nursing activities which make students feel confident (C)* for entire sample and by groups Median rating Item  Group I  Traditional  Group II  Group III  E  C  V.  E  C  V  E  2.8  1.4  2.8  2.8  1.5  2.7 2.5  2.4  Perform procedures correctly  1.9  2.9  Neatness  2.0  2.2  2.1  Completion of assignment  2.0  2.4  2.0 . 2.4  2.8  2.3  2.6  2.7  2.7  C  2.3 2.7 • *  1.8  2.6  2.5  2.4  2.9  2.0  2.2  2.6  2.6  2.1  2.5  Advanced professional Social and .psychological support Rapport with patients Planning nursing care  2.7  2.8  2.8  2.7  2.8  2.5  2.8  Dash indicates no data available for this entry. -N3  ON  77 criteria.  Planning nursing care rates about equally for values and con-  fidence.  The importance of rapport with patients declines from Group II  to Group IV for both Evaluation and Confidence. Within each group, there appears to be a closer relationship f  between ratings on Confidence and on Evaluation than between ratings on values and those of either of the other categories, for most items. 2  Stated more generally, students' perceptions of the importance of various activities as evaluative criteria appear to be f a i r l y close to their perceptions of the importance of the same activities i n making them feel confident, whereas the value which i s attached to any activity appears to be less related to either of the other two categories. In the s t a t i s t i c a l tests of the relationships between similar items i n these three categories, only two significant relationships were found, both for Group III only. The relationship between evaluation and values was significant for rapport with patients; that between evaluation and confidence was significant for meeting patients' social and psychological needs. The hypothesis i s therefore not supported. Although, for the entire sample, confidence and evaluation appear to be related, this i s not true for individuals; that i s , the activities which a student says are important are not necessarily those by which she perceives she i s evaluated or those which she feels give her confidence i n functioning as a nurse. 2.2.3  Choice of role models—It was hypothesized that choice of  instructors as role models would be related to adoption of an advanced professional concept of nursing, and choice of graduate nurses or head  nurses- would be associated with adoption of a more traditional concept. For the sample as a whole, there was l i t t l e discrimination between median rankings of any of the choices given, as is shown in Table 14. Classmates were rated lowest by a l l groups. For a l l other choices, however, there was too l i t t l e discrimination between them to draw any conclusions about tendency to accept persons in any status more than those in any other. Within groups, responses to this question showed the^widest range of variation, or the least consensus for any question. This lack :  of consensus within groups or within items, and the failure to discriminate between statuses suggests that students base their selection of role models not on the status of an individual but on her personal characteristics and their evaluation of her ability as a nurse. Tendency to rate head nurses highly as role models was tested against two value items—importance attached to performing procedures correctly, and to supervision of non-professional personnel—and on© confidence item—confidence gained from performing procedures correctly. For both Groups I and II, significant relationships were found between high ratings of the head nurse as, a role model and high ratings of procedures for both values and confidence. No relationships were found for any other pairs of items. High rating of clinical instructors as role models was tested against the same items, with no significant relationships for any of the groups. Although the four significant relationships were in the predicted direction, they do not constitute substantial support for the hypothesis in its present form as here tested; i t must therefore be rejected.  79 TABLE 14 Median ratings of perceived importance of others as role models, for entire sample and by groups Status of others  Median ratings All  Groups I  II  III  IV  Graduate nurses  2.4  2.5  2.6  2.1  2.3  Clinical instructors  2.4  2.5  2.6  2.1  2.4  Head nurses  2.4  2.7  2.3  2.1  2.3  Instructor in Introduction to Nursing  2.2  2.6  2.2  2.1  2.1  Older students  2.2  2.0  2.4  2.2  2.2  Other classroom instructors  2.0  2.2  1.9  2.0  2.2  Classmates  1.7  1.5  1.9  1.9  1.9  2.2.4 Relevance of courses—Students were asked to rate certain courses for their relevance to nursing practice. As shown in Table 15, both Anatomy and Physiology (one course) and Medical-Surgical Nursing were given almost maximum ratings. The least-valued courses were Introduction to Nursing, Sociology and Community Health. Psychiatric Nursing and Psychology received intermediate ratings. Psychiatric Nursing was the only course receiving a higher rating from Group IV than Group I; decline in the ratings for four other courses suggest the previouslynoted disillusionment over time. If any conclusions can be drawn from these findings, they would be related not to the advanced-professionaltraditional continuum, as hypothesized, but to the findings of the Values-Bonfidenee-Bvaluation comparison.  Students tend to value most  highly those courses which help them feel confident in the clinical situation. Knowledge of human anatomy and physiology and of disease conditions, their medical treatment and nursing care are essential for nurses. Although human relations may not come naturally, they are more !  easily ignored. Another possible"explanation of the findings is that, except for the two essential courses, students tend to react primarily to the instructor and the manner in which the course is presented. If they like the instructor, the course is considered relevant; i f not, i t is judged to be irrelevant. In the statistical tests, high ratings for values on selected advanced professional items were found to be unrelated to high ratings on either Community Health or Sociology. Only one significant Chisquare emerged, which is not sufficient to lend support to the hypothesis.  81 TABLE 15  Median ratings of perceived relevance of specified courses to clinical nursing experience, for entire sample and by groups Courses  Median rating All  Group I  II  III  IV  Anatomy and Physiology  2.9  2.9  2.9  2.9  2.9  Medical-Surgical Nursing  2.9  2.9  2.9  2.9  2.9  Psychiatric Nursing  2.5  2.5  2.3  2.4  2.7  psychology  2.3  2.7  1.7  2.3  2.2  Community Health  2.0  2.3  1.9  2.1  1.5  Sociology  1.9  2.5  2.1  1.9  1.8  82 Personal characteristics favoring adoption of the advanced professional concept of the nurse's role It was hypothesized that innovators, who would favor the advanced professional concept of the nurse's role, would be students with better academic ability, an expressed interest i n change, and willingness to express unpopular opinions publicly.  None of these hypotheses was  supported by the statistical tests. In this chapter, the data have been presented, and used as evidence to test the hypotheses.  The results of relevant statistical  tests have been reported. Findings have been compared with those of other empirical studies. In the following chapter, the possible significance of some of the findings, both positive and negative, i s discussed, and their relevance to the theoretical framework considered. Suggestions are made for further research.  CHAPTER V  SUMMARY AND CONCLUSIONS Summary The general purpose of t h i s study was to investigate the process by which a professional r o l e i s acquired.  The a c q u i s i t i o n of a r o l e by  student nurses was chosen as a s p e c i f i c example of the general problem. The sample consisted of 301 students i n a school of nursing i n a large general h o s p i t a l located i n a Canadian metropolis.  The four groups  included entering, newly-capped, intermediate, and near-graduating senior students.  Data were collected by questionnaire, the items of which were  derived from previous empirical studies, a t h e o r e t i c a l framework evolved by the writer, and the writer*s personal experience i n and knowledge of nursing. •The o v e r a l l aim was. to determine the extent to which the empirical ' f i n d i n g s would conform to expectations derived from four relevant sociol o g i c a l and s o c i a l psychological theories; r o l e theory, learning theory, reference group theory and the theory of cognitive dissonance.  Role  theory, which provides the basis f o r the t h e o r e t i c a l framework, has been widely used by s o c i o l o g i s t s and s o c i a l psychologists i n theoret-i c a l formulations, but not as a framework f o r empirical studies. Some^ of the problems encountered i n carrying out t h i s study may r e f l e c t thed i f f i c u l t i e s associated with l i n k i n g empirical studies with r o l e theory, and i t s inadequacy f o r t h i s purpose i n i t s present state. The concept of r o l e encompasses many elements, including knowledge, s k i l l s , behavior and attitudes expected of one performing a r o l e  by i n d i v i d u a l s occupying various statuses w i t h respect t o persons i n the r o l e being defined.  I n constructing a study design t o t e s t some of  these elements, two dependent v a r i a b l e s were i d e n t i f i e d : the student's p r o f e s s i o n a l self-image and the concept o f the nurse's r o l e adopted by her. Four components of the self-image were i d e n t i f i e d .  I t was hypoth-  esized t h a t , over time, l ) students would come t o think of themselves i n c r e a s i n g l y as p r a c t i t i o n e r s rather than as students; 2) confidence i n performing t h e i r r o l e would increase; 3) they would i n t e r a c t more soc i a l l y w i t h other persons i n the i n s t i t u t i o n a l s e t t i n g and k)  identifi-  c a t i o n w i t h both graduate and student nurses would increase.  The f i r s t  three hypotheses were supported, the f o u r t h was not. The second v a r i a b l e , the concept of the nurse's r o l e , was more d i f f i c u l t t o define and the f i n d i n g s r e l a t e d t o i t were l e s s c l e a r - c u t . Three sets of items were used t o tap d i f f e r e n t aspects of students' r o l e concepts. The f i r s t , termed Values, measured what students believed i t was important f o r nurses t o do; the second, Confidence, what made them ?,  f e e l confident as nurses; and t h e " t h i r d , E v a l u a t i o n, what f a c t o r s they b e l i e v e d were emphasized i n evaluation of t h e i r c l i n i c a l work.  Following  other i n v e s t i g a t o r s , two contrasting concepts o f the nurse's r o l e were i d e n t i f i e d : t r a d i t i o n a l , i n which t e c h n i c a l competence and i n s t i t u t i o n a l e f f i c i e n c y are most valued, and advanced p r o f e s s i o n a l , i n which, w h i l e t e c h n i c a l competence i s s t i l l valued, i n t e r p e r s o n a l r e l a t i o n s h i p s between nurse and p a t i e n t , the importance o f s o c i a l and p s y c h o l o g i c a l f a c t o r s i n i l l n e s s , and the f u n c t i o n of the nurse i n planning and supervising  patient care are emphasized. Generally, the former concept tends to be held by persons responsible for nursing care of the hospital wards, whereas the latter is taught by instructors in the school of nursing. By application of the principles of learning theory, i t was anticipated that students would tend to think and act in ways which they perceived to be rewarded through both formal evaluation and informal approval or social acceptance. In investigating change over time, the initial role concept, or satisfactions anticipated from nursing, was analyzed for entering students only; later concepts of the nurse's role were analyzed for the remaining three groups. A lay concept, in which nursing is viewed in a glamorized fashion, as often portrayed in films, books and television, was also identified. It was hypothesized.that beginning students would be more likely to accept items representing this lay concept; that newly-capped students would tend to rate advanced professional items higher than other items and that seniors would assign higher ratings to traditional items. This hypothesis was, for the most part, not supported. For the first aspect of the nurse's role identified here, Values, there was high consensus between groups on most items. Glamor items were generally rated as low in importance for nurses, advanced professional items high or medium, and traditional medium or low. Seniors tended to rate advanced professional items somewhat higher and traditional items somewhat lower than did other groups, indicating increasing acceptance of the advanced professional rather than the traditional role concept.  86  The correspondence between ratings on Values, Evaluation and Confidence was investigated for a l l but the group of entering students. Other investigators had noted that students believed that they were taught by their instructors to value advanced professional items, whereas their clinical work was evaluated by more traditional criteria. This was found to be true to some extent in the present study. Over time, students rated advanced professional items more highly as Values; in contrast, they tended to rate traditional items more highly as Evaluation. The dissonance which might have been expected to arise from the resulting conflict between what students believed they were being taught and the criteria by which they were evaluated should, however, be considered in the light of the third factor, Confidence. There appeared to be closer correspondence between ratings on items which made students feel confident in nursing practice, Confidence, and similar items when used as evaluative criteria, Evaluation, thatobetween similar items on Values and either Confidence or Evaluation. Unfortunately, however, not enough comparable items were included in the three categories to test this notion adequately. It appears, on the basis ofavailable data, that a factor not included in the original formulation might have been operating as an intervening variable. This could be called an essential-peripheral dimension. Some nursing activities, such as giving medications accurately, might be thought of as essential while others, such as standing when a doctor enters, might be considered peripheral. Thus, the same activities which make students feel confident in their  87 nursing practice.would also be those which were important in evaluation, because they are essential to the practice of nursing. Other factors might be valued highly, but yet be less essential with respect to dayto-day patient care. Since the data are inadequate to test this speculation, i t can only be suggested here, and its testing left for further studies. Although not a l l of the findings were in line with the hypotheses, interpretation of differences between groups for the entire sample, representing change over time in the concept of the nurse's role held by students, is not too complex. For most items, the direction of change was clear-cut. Ratings of advanced professional and traditional items in each of the three categories were relatively consistent, indicating that the classification of'the nurse's role into these concepts was a useful one. For a second aspect of the study, however, the findings were almost completely negative, and few of the expected relationships showed up.  It was believed that, i f each of the factors identified as part of  the professional self-image changed over time, there would be some relationship among the items. For example, i t was hypothesized that those students who thought of themselves primarily as nurses would also tend to have greater confidence in-performing their role, to interact more socially with other persons in the institutional setting, and to identify with other nurses, both'students and graduates. If the concept of role is indeed a unitary one, and each of these elements is part of i t , then one would expect their acquisition to proceed in a more or less  88 orderly fashion. Such was not found to be the case; no statistical relationships were found among any of the factors. In the above discussion, emphasis has been on change in each of the dependent variables over time. It is recognized that time in itself is not responsible for the change, but that other factors must be related to the acquisition of a professional role. From the literature, the theoretical framework, and the author's personal experience, a number of independent variables were hypothesized as being related to one or more elements of each of the dependent variables. For example, i t was thought that choice of nursing before the age of 15 would be related to acceptance of a glamorized rather than"a realistic initial concept of nursing, and that experience in the hospital as an aide would facilitate acceptance of a realistic rather than'"glamorized initial concept of nursing by beginning students. The first hypothesis was not supported; the second was partially supported. Evidence of relationships among the variables was lacking for almost every hypothesis. There were, for example, no relationships among items in the categories of Values, Evaluation and Confidence. Neither the role model selected nor the perceived relevance of various courses was found to be related to the concept of the nurse'srole adopted.  The hypothesis that interest in change would be associated  with acceptance of the advanced professional concept of role, aboveaverage academic achievement, and willingness to express an unpopular opinion publicly likewise received no support. Since these findings contrast with what had been deduced from the theoretical framework, their interpretation warrants further speculative discussion.  89  Discussion of the findings and relevance to the theoretical framework Four theories were drawn upon for construction of the theoretical framework upon which the empirical hypotheses were based: role theory, learning theory ^ reference group theory and the theory of cognitive dissonance.  Only a few of the many possible implications of the find-  ings relative to these theories can be-discussed here.  The ones chosen  are those believed to be most relevant i n terms of implications for future studies. As might be anticipated i n an exploratory study such as this, more questions' have been raised than answered. Some of the findings of other studies have been confirmed, others have not.  Empirical tests  often have not supported hypotheses derived from the theoretical framework. In order to be heuristic, such an exploratory study should point out the areas of agreement and disagreement and suggest improvements for future studies which would bring the empirical findings and theory closer together. In" attempting to explain some of the negative findings, as many alternatives as possible should be considered and evaluated, so that the most l i k e l y ones may be accepted. One possible source of negative findings i s measurement error arising from either faulty construction of the measuring instrument or the collection of inaccurate or biased data.  As has been emphasized previously, because of the exploratory  nature of the study, the questionnaire employed for data collection included items designed to measure a large number of variables extensively rather than a smaller number more intensively. For this reason  90  among others, the findings must be considered as tentative. More intensive study of variables which appear to be relevant, on the basis of the data collected for this study, would be necessary to substantiate them. The possibility of complete data inaccuracy may be rejected as highly unlikely, because of the consensus exhibited both within and between groups, and the fact that many of the findings agree with those of previous studies as well as with the expectations of the writer. Hypotheses' derived from role theory and learning theory—Little support was gained for hypotheses derived from the theoretical framework. Five ideas have been selected for discussion: l ) the notion of evaluatich as a positive reinforcement which leads to behavioral changes on the part of the learner in the direction of conformity with the reinforcement; 2) the possibility that certain assumptions of learning theory were not met in this situation; 3) conceptualization of role as an internally consistent set of behavior patterns; 4) the general applicability of learning theory to explaining the acquisition of a professional role and 5) the assumption that development of a professional self-concept is essential to acquisition of a professional role. 1.  Evaluation as positive reinforcement: During their time in  nursing school, students* iralues tend to coincide increasingly with those termed advanced professional. At the same time /their perceptions of the relative importance*-of various evaluative criteria and of factor! which made them feel confident as nurses either remained about the same-or tended to become somewhat more traditional. It had been hypothesized that perception of traditional factors as important evaluative criteria  would be associated with acceptance of traditional rather than advanced professional values as being important i n nursing. Stated i n terms of learning theory, i t was believed that evaluation by certain criteria would act as reinforcement for behavior*—in this case, specified nursing  activities ^|h±s hypothesis, was not supported; where change did occur, & cr  i t was in a direction opposite^to that which had been predicted. f  ¥>  A question arises as to whether this discrepancy represents a perceived conflict between students' personal values and their perceptions of the criteria by which they are evaluated, as was suggested i n other studies. Although the data are inadequate to answer this question, they suggest alternative possibilities to be ruled out before the alternative of conflict i s accepted.  The fact that, for the entire  sample, closer correspondence was'found between Confidence and Evaluation than between Values and either of the other two factors suggests the need f o r a different conceptualization, which takes into account the nature of the nurse's task. This problem can be stated i n more general terms, as i t applies to role theory.  As was pointed out above, most conceptualizations of  role involve the elements of s e l f o t h e r s and a situational context. Aside from a token mention i n most discussions based on role theory, J  however,,emphasis i s often placed'primarily on self and other^ with the situational context providing a miscellaneous category to account for various unidentified factors which" may be operating. In nursing, at least, the situational context cannot be ignored; knowledge of the nature of the nurse's task i s of paramount importance i n analyzing her  92 role.  In the process of role acquisition, a nurse must learn to meet  the pressing and often conflicting demands of the institutional situation.  There are certain essential tasks she must learn, such as inter-  pretation of doctors' orders, proper administration of medications and performance of nursing procedures. Without these a student cannot become a nurse, no matter what her relationships with patients, or how understanding she i s of their psychological problems. She does not have the same relationship to her patients that a social worker or psychiatrist does to his. It would seem that only brief observation of nurses at work would be needed to discredit the idea expressed by Johnson and Martin (1958) i n their sociological analysis of the nurse's role that the doctor's role i s instrumental; he i s concerned with getting the patient well.  The nurse's role, i n contrast, i s expressive, with emphasis  on psychological support. Such a dichotomous analysis assumes that instrumental and expressive- qualities are mutually exclusive members of a single dimension.  It would appear to be more r e a l i s t i c to consider  these as different dimensions, eadh of which i s i n turn continuous rather than dichotomous. The nurse cares for her patient's physical welfare; she also offers emotional support.  So does the physician.  The  demands of the situation are, however, often such that physical care takes precedence.  Emotional support should be an adjunct to i t , not  something which i s provided on ah':either-or basis. Following this line of thinking, i t would appear to the writer that analysis of the nurse's role could well involve a scaling of nursing tasks on an essential-peripheral continuum. The germ of such a  93 scale can be found i n the ratings of some items i n this study. For example, items such as giving medications accurately which were rated 2.9 or 3.0/by a l l groups would be considered essential; those rated 1.5 or less as peripheral, with a continuum i n between. Comparison of advanced professional and traditional items of about the same ratings on this essential-peripheral scale might then shed more light on the relationships among Values, Confidence and Evaluation which this study has only suggested. 2.  Assumptions of learning theory not met i n this study: The  inadequacy of learning theory for explaining role acquisition might be due i n part to failure of the conditions of the study to meet certain assumptions of learning theory, as had been anticipated.  In order to  apply learning theory, i t i s necessary to specify the desired behavior, the rewards to be given when this^behavior i s emitted, and the punishments meted out i f i t i s not.  I t had been assumed that there was  enough consensus among persons i n the situation that a l l of these could be specified reasonably well.  The behavior to be rewarded or punished  was classed as either traditional or advanced professional.  I t was  then hypothesized that advanced professional behavior would be rewarded more for beginning than for advanced students, whereas the opposite would be true of traditional behavior.  In formulating the hypotheses,  i t was assumed that there was sufficient consensus among individuals in the situation and enough consistency among the values of each individual that certain patterns relating to traditional and advanced professional values could be identified.  Although the f i r s t of these  94 assumptions was probably correct, the findings suggest that the second was probably incorrect, so that the conditions of learning could not be adequately specified, as had been assumed. Another assumption which was. made was that rewards or punishments for tasks, which were the selected nursing activities, could be specified.  Learning theory takes into account only the immediate responses  of an organism to a stimulus which act as rewards or punishments. Humans, however, are concerned not only with obtaining immediate, shortterm rewards of the type that act.as reinforcements i n animal experiments of operant conditioning, but with medium- and long-range rewards as well.  In uncontrolled observation, i t i s d i f f i c u l t to separate  these types of rewards so as to determine the relative influence of each.  I t appears that, i n some way, the balance of rewards and punish-  ments i s such that a student perceives she i s receiving net rewards i n the long run, regardless of the short-term balance. A nursing student may remain i n school for any of a number of reasons: she may love nursing, she may like the patients even though she dislikes the nursing school, she may feel the need to save face or prove herself by completing the course once she has started i t , or any other of a myriad of reasons.  I f not, she may take' a different course of action, such as  leaving school. Evidence from this study as to the relative importance of various items of formal recognition suggests that long-range goals far outweigh medium-range ones, which act primarily as supplementary encouragements along the way. Ratings on the importance of wearing a graduate uniform  95 are consistently higher for a l l groups than those on any other item of formal recognition. 3. Conceptualization of role as an internally consistent set of behavior patterns: The conceptualization of role upon which the study was based i s a common one which implies, i f i t does not state directly, that a role i s a more or less homogeneous complex of factors which i s internalized by persons being inducted to i t , somewhat l i k e swallowing a vitamin p i l l containing a number of different vitamins i n fixed proportions.  Slater (1955» P« ^98) says'; "We might define role as a more or  less coherent and unified system of items of interpersonal behavior." Similarly, Cottrell (19^2, p. 617) states, I shall be using the term role to refer to an internally consistent series of conditioned responses by one member of a social situation which represents the stimulus pattern for a similarly internally consistent series of conditioned responses of the other(s) In that situation. Neither of these statements"'is supported by the findings of this study.  The one consistent finding is the lack of consistency among r  ratings of various items by individuals.  Although there i s considerable  consensus both within and between*groups on the median ratings for most items, when comparisons are made for individuals, almost no relationships are found.  Gross et a l . have l a i d open the question of consensus  on different items of role behavior both on the part of those i n a role and of those i n other statuses related to i t .  I t appears to this  writer that, i f the findings of the present study are valid, they would also shed doubt upon the notion of role as being an internally consistent set of expectations.  96 It may well be that the notion of internal consistency arose from the desire of role theorists to f i t their ideas into a logical framework. What resulted was a notion of role as an abstract construct which cannot be investigated empirically. In its ideal form, i t may be amenable to analysis by application of learning theory; considered as a finite but large number of specifIc*beliefs and activities which are associated in different kinds and"degrees in different individuals, i t is not.  Considering the possible number of beliefs and activities, and  the range of opinion on each one, the total number of combinations i s !  far beyond the realm of practical research.  Possibly identification of  dimensions other than the traditional-advanced professional one investigated here would be more productive.  Casual observation of human  behavior, however, lends l i t t l e credence to the notion of internal consistency of role. 4. General applicability of learning theory to explaining the acquisition of a professional role": Many role theorists assume with Merton (1957) that a professional role is somehow learned through interaction in a situation. As to the" process by which role acquisition occurs, l i t t l e is said. This study does not appear to have added much information on this point, other than to suggest possible directions for future studies. Some hypotheses were derived by application of learning theory to the subjective elements of role investigated. Although learning theory may be useful in explaining at least partially the acquisition of more objective elements of role, such as skills and knowledge, in this study i t did not seem to help much in accounting for  the acquisition of subjective elements such as the professional selfimage or the concept of the nurse's role. 5.  The assumption that development of a professional self-image  is essential for fulfilling a professional role is likewise open to question.  Although external validation was not included in the study,  the fact that students in the sample had succeeded well enough to remain in nursing school indicates at least a minimum degree of achievement, especially among intermediates and seniors. The wide range of variation in perception of self as a nurse and in other items related to the selfconcept suggests that development of a professional self-image:is relatively independent of an individual's ability to play a professional role. Hypotheses derived from reference group theory—Another group of hypotheses was derived from reference group theory, which has been proposed as an adjunct of role theory in order to help account for differential perceptions of role by different individuals. According to this theory, the total range of expectations rather than only the modal ones may be considered as acting upon individuals being socialized into a culture. From this range, individuals in some unspecified manner select the persons and criteria by which to evaluate their own beliefs and ' actions. Unfortunately, however, in this theory no propositions are stated from which hypotheses can be derived. Studies such as Merton and Lazarsfeld's (1950) analysis of The American Soldier and the studies reported by Rogers (19&2) resulted in the formulation of post factum explanations which were frequently  98  not productive of hypotheses for empirical test.  The question as to how  people choose the individual groups by which to evaluate their activities and beliefs remains unanswered. In this study, four hypotheses related to reference group theory were tested: a) the choice of a role model as related to the concept of the nurse's role adopted by a student, b) the effect of an individual's belief about others' perceptions of her upon her perception of herself, c) influence of family or peers oh vocational choice, and d) relationship between attitudes toward change and other personal characteristics. a.  It was hypothesized that adoption of an advanced professional  concept of the nurse's role would"be associated with choice of c l i n i c a l instructors as role models or reference individuals, and the adoption of a more traditional role concept with the choice of head nurses. This hypothesis was not supported.  Furthermore, there were few differences  between groups i n the median ratings of each status, and there was the least within-group consensus for these items of any i n the study. Apparently personal characteristics of an individual rather than her status are important i n choice as a role model. b.  For another question, however, the status rather than the  individual appeared to be important.  Students believed that they were  perceived differently by persons In different statuses. Their beliefs appeared to be related to the nature of their formal relationships with these persons, especially with respect to patients and c l i n i c a l instructors.  The relationships between perception of self and beliefs about  about the perceptions of others are unclear. Obviously a range of self-  99 perceptions exists. The lack of significance among the statistical tests of relationships between perception of self and belief about the perceptions of nurses and doctors suggests that a number of different perceptions of self may exist side-by-side in the same individual, with no relationship to each other. c. It is generally thought" that, whereas young children and preadolescents are influenced primarily by their parents, adolescents are more likely to be influenced by their peers. This relationship was not found to hold for vocational choice of this group of students; age at decision was unrelated to influence by parents or peers. d. The last set of hypotheses based on reference group theory was concerned with characteristics associated with interest in change. Several characteristics were suggested by Rogers (19&2) as being associated with innovators. The characteristics tested here were better academic achievement, expressed interest in change, and willingness to express unpopular opinions publicly. None was found to be related to acceptance of the advanced professional concept of the nurse's role. Relevance of the findings to the theory of cognitive dissonance— Relevance of the findings to the theory of cognitive dissonance is also questionable. This theory states that, when an individual perceives that a dissonance exists between two or more of his beliefs, he will seek to reduce i t in some way.  In order for a dissonance to be per-  ceived, the two beliefs must be perceived as relevant to each other; in order for action to be taken, the magnitude of the dissonance must be large enough to make the person uncomfortable.  100  The conflict between students* expressed values and the criteria by which they believed they were evaluated, which was found in other studies, was investigated only incidentally here. Median ratings of some advanced professional items were high on Values but low on Evaluation, and those of some traditional items were low on Values but high on Evaluation, suggesting that these Students also perceived that they were evaluated by criteria which differed from their own values. Certain other findings would justify the modification of such a conclusion. Most important of these is the suggested close relationship between Confidence and Evaluation, which suggests the need for an analysis taking the essential-peripheral dimension of a nurse's tasks into account, as outlined above. In addition, a new question relating to the validity of applying the notion of cognitive dissonance was brought out by the unanticipated finding that different components of the self-image were almost unrelated i n individuals. The curriculum of a nursing school provides for sequential learning of the more objective components of the nurse's role, such as skills and knowledge, and assumes that the acquisition of these proceeds at a relatively even rate for'all students, although i t is recognized that a range of achievement exists. For subjective components of role, on the other hand, no such'pattern appears to exist. The one consistent finding of the study is this apparent inconsistency among various components of student's self c6ncepts. Although i t was !  possible to discern some pattern of role concept and its acquisition among a group of students, when the relationships among the factors  101 involved were analyzed for individuals, almost no statistically significant ones were found. The possibility of respondents* having replied randomly or insincerely has already been discussed and discarded as a probable explanation of this lack of relationships. It is so consistent that the alternative possibility that each of the items Is somehow perceived independently by each individual must therefore be seriously considered. It appears that students learn to respond one way to a given stimulus, a different way to another.  For example, when asked  what she values, a student might respond that meeting patients* social and psychological needs is important.  On the other hand, to a question  of what makes her feel confident'as a nurse, she might reply that proper performance of procedures"is most important.  She may or may not  be aware of any conflict between the two replies. These reactions may be learned one at a time and independently, with only occasional integration among them. Inconsistencies between them are usually ignored or not recognized, ruling out application of the theory of cognitive dissonance. Suggestions for further research" From the writer's experience in this study, i t is easy to see why there has not been a large number of empirical studies based on role theory. It does not appear to include conceptualizations which are heuristic for such research. It might be argued that the absence of relationships among the beliefs of individuals is due to not having asked the right questions, especially not having enough parallel items in the Values, Evaluation and Confidence categories to test the  102 hypotheses adequately.  It might well be true that analysis of a larger  sample of parallel items would disclose relationships among these factors which was not evident in the findings. In order to test such a possibility, i f the writer were to pursue further research along this line, she would first formulate a limited number of questions, the answers to which might contribute' in a small way to the development of theory. Data could then be collected by intensive observation of a small number of subjects. If some promising leads developed, they could be followed up in a larger study. In their search for knowledge, social scientists should be able to benefit from the experience df others. Progress has been made in the physical sciences only as observations have been analyzed and compared with predictions from existing theory. Often the theories which appeared most plausible were found to be at variance with observed data, and the theories which were developed from data were not ones which would have developed from armchair thinking alone. Such a reconceptualization of some of the ideas related to role theory appears to be in order. There is also need for new methodological approaches and techniques of measurement, Zetterberg  (1963)  suggests several ways in which  variables studied by sociologists may be related. One of these is a situation in which a small change in one variable leads to a small change in another, which in turn leads to another small, change in the first.  The writer believes that this is the nature of much human inter-  action. Unfortunately, no satisfactory methods of study of such inter-  action have as yet been developed. When i t is studied by before-andafter measurements of its long-term effects, significant relationships are often missed. Development of a suitable technique would make possible the collection and analysis of new types of data which might be more productive in the development of theory than data resulting from existing techniques has been. The writer has found the production of this thesis to be a highly rewarding experience. Thinking through the problem of how to analyze the vague notions with which she began, stating the resulting ideas as hypotheses, developing an instrument to collect data with which to test them, and the final agonizing appraisal of the results have given her clearer insight into the nature of scientific research, and. of the long road s t i l l to be travelled by the social sciences.  BIBLIOGRAPHY Becker, H.S. and Carper, J. The elements of identification with an occupation. Amer. Sociol. Rev.. 1 9 5 6 , 2 1 , 341-348. Becker, H.S. and Geer, Blanche. The fate of idealism in medical school. Amer. Sociol. Rev.. 1 9 5 8 , 2 3 , 50-56. Berkowitz, Joanne E. and Berkowitz, N.H. 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Huntington, Mary Jean. The development of a professional self-image. In Merton, R.K., Readher, G.C. and Kendall, Patricia L. (Eds.). The student-physician. Cambridge, Mass.: Harvard University Press, 1957.  Hyman, H.H.  Reflections on reference groups. Pub. Opinion Quart..  I 9 6 0 , 24, 383-396.  Johnson, Miriam M. and Martin, H.W. A sociological analysis of the nurse's role. Amer. J. Nsg., 1 9 5 8 , 5 8 , 3 7 3 - 3 7 7 . Katz, F.E. and Martin, H.W. 1 9 6 2 , 41, 149-153.  Career choice processes. Soc. Forces.  105 Kish, L. Some statistical problems in research design. Amer. Sociol.  Rev., 1959, 24, 328-338.  Lindesmith, A.R. and Straus, A.L. Social Psychology. New York: Dryden Press, 1956. Malone, Mary, Berkowitz, N.H. and Klein, M.W. Amer. J. Nsg., 1961, 6 l , 52-55.  (Rev. ed.).  The paradox in nursing.  Merton, R.K. and Lazarsfeld, P.F. Continuities in social research: studies in the scope and method of "The American soldier." Glencoe, 111.: Free Press, 1950. Merton, R.K. and Alice S. Kitt. Contributions to the theory of reference group behavior." In R.F. Merton and P.F. Lazarsfeld, (Eds.), Continuities in social research: studies in the scope and method of "The American soldier." Glencoe, 111*: Free Press, 1950. Pearlin, L.J. Alienation from work: a study of nursing personnel. Amer. Sociol. Rev.. 1962, 27, 314-326. Ravitz, M.J.  Occupational values and occupational selection. Nsg. Res..  1957, 6, 35-^0.  Reissman, L. and Platou, R.V. The motivation and socialization of medical students. J. Health and Human Behavior, i960, 1, 174-182. Reissman, L. and Rohrer, J.H. (Eds.). Change and dilemma in the nursing profession. New York: G.P. Putnam's, 1957. Rogers, E.M. Diffusion of Innovations. New York: Free Press of Glencoe,  1962.  Sarbin, T.R. Role theory. In G. Lindzey, (Ed.). Handbook of social psychology. Cambridge, Mass.: Addison-Wesley, 1954. Saunders, L. The changing role of nurses. Amer. J. Nsg., 195^, 5^,  1094-1098.  Shuval, Judith T. Perceived role components of nursing in Israel. Amer. Sociol. Rev.. 1963, 28, 37-46. Simpson, Ida H. The development of professional self-images among student nurses. Unpublished doctoral dissertation, Univer. of North Carolina, 1956. Slater, P.E. Role differentiation in small decision-making groups. In T. Parsons and R.F. Bales, (Eds.), Small Groups. New York: Knopf, 1955.  106  Turner, R.i (Reference groups of future-oriented men.  34, 130-136.;/:.,  Videbeck, R.  self-conception and reaction of others.  I960, 23, 351-359.  Soc. Forces. 1955> Sociometry,  Waik, ELvi. Becoming a nurse—socialization into an occupational role. Unpublished master's thesis, Univer. of British Columbia, 1957. Wallace, W.L. Institutional and life-cycle socialization of college freshmen. Amer. J. Sociol.. 1964, 70, 303-318.  QUESTIONNAIRE The information obtained from this questionnaire will be used in a study about changes in the attitudes and ideas of student nurses during the time they are attending a school of nursing. This i s not a test, and a l l information will be kept strictly confidential. You are not asked to write your name on the answer sheet; this is anonymous. Instructions; 1) Read each question and a l l of the instructions very carefully. 2)  Seriously consider each question and give answers which accurately reflect your present position.  3)  Please answer every question. While we realize that a few questions may be difficult for you to answer, please choose the response that i s closest to the one you would like to give.  4)  Circle the number corresponding to your answer to each question. Anything enclosed in brackets i s only for tabulation, and should be disregarded.  May we thank you very much for co-operating in this study. Sample question: (x)  Have you ever read a book about someone who was a nurse? yes  2.  no  In this case, number 1, "yes," was circled. In the same way, go on to the items on the next .page. Please turn to the next page and begin.  DO NOT WRITE IN THIS SPACE —FOR TABULATION ONLY (1) 1 (2,  3 , 4)  I.D.  168 (5)  When did your class enter the School of Nursing? 1. 2. 3.  (6-7)  (8)  4. Sept. 1964 5. Feb. 1965  How much formal education did each of your parents have? level completed.  Mark the highest  Highest level completed  Father  Mother  less than 8 years some high school completed high school vocational or technical training some college or university completed college or university graduate or professional training  1 2 3 4 5 6 7  1 2 3 4 5 6 7  At what age did you f i r s t consider nursing as a career? 1.  (9)  Feb. 1962 Sept. 1962 or Feb; 1963 Sept. 1963 or Feb. 1964  11 or under  2. 12 - 15  3- 16 or over  At what age did you actually decide to enter nursing school? 1.  11 or under  2.  12 - 15  3-  16 or over  (10) Which of the following was most important i n influencing your decision to enter nursing? 1. 2. 3. 4.  family other close relatives friends your own age teacher(s)  5. your family doctor 6. books about nurses 1. TV programs 8. other (specify)  ( l l - 2 l ) In entering nursing, you expected to find certain satisfactions. much did each of the following influence your decision?  (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22)  being part of the mystery and excitement of a hospital working closely with doctors learning about diseases and their treatments teaching disabled patients to care for themselves being i n an occupation which other people respect helping sick people wearing a nurse's uniform being part of the medical team using your i n i t i a t i v e i n solving problems working i n the operating room helping people who are mentally i l l  moder-  How  not at  very  a great  all  little  ately  2  3 3  4 4  deal  1 1  2  1  2  3  4  1  2  3  4  1 1 1 1  2 2 2 2  3 3 3 3  4 4 4 4  1 1 1  2 2  3 3 3  4 4 4  2  Had you ever worked as a volunteer aide or paid nursing assistant b e f o r e entering nursing school? 1. yes 2. no .  - ; _  /a?.  (23-28) Other people's opinions o f you often h e l p to shape your opinion of yours e l f . Do you b e l i e v e that each of the f o l l o w i n g persons or groups of persons considers you to be p r i m a r i l y a nurse or p r i m a r i l y a student or l e a r n e r ?  (23) (24) (25) (26) (27) (28)  your c l i n i c a l i n s t r u c t o r the head nurse on the f l o o r where you now work, or where you worked most r e c e n t l y your p a t i e n t s doctors p r a c t i c a l nurses and ward a s s i s t a n t s yourself  primarily a nurse  primarily a student  1  2  1 1 1 1 1  2 2 2 2 2  129-34) The change from being an o u t s i d e r t o being a nurse takes three years. During t h i s time, your progress i s recognized by such ceremonies as capping and graduation, as w e l l as by changes i n your uniform, so that other people know whether you are a beginning student or a s e n i o r . How important would you r a t e each of the f o l l o w i n g i n making you f e e l accepted and recognized as a nurse? not a t a l l r e l a t i v e l y important unimportant (29) (30) (31) (32) (33) (34)  admission to n u r s i n g school f i r s t day on the ward capping wearing the l a r g e b i b wearing s e n i o r uniform graduation  1 1 1 1 1 1  2 2 2  important  extremely important  3 3 3 2  2 2  3 3 3  4 4 4 4 4 4  (?5-42) Your ideas o f what a nurse should be and do are i n f l u e n c e d by the nurses you know. How much does each of the f o l l o w i n g groups of persons i n f l u e n c e your i d e a l of what a nurse should be and do? at (35) (36) (37) (38) (39) (40) (41)  your i n s t r u c t o r i n I n t r o d u c t i o n to Nursing other classroom i n s t r u c t o r s c l i n i c a l instructors head nurses graduate nurses (general duty) o l d e r student nurses your own classmates  not all  very little  1 1 1 1 1 1 1  2 2 2 2 2 2 2  moderately  a great deal 3  3 3 3 3 3 3  4 4 4 4 4 4 4  (42-47) Your c l i n i c a l i n s t r u c t o r evaluates your work both i n her d a i l y s u p e r v i s i o n and by marks. How much emphasis do you think most i n s t r u c t o r s you have had place upon each of the f o l l o w i n g i n e v a l u a t i n g your work? none (42) (43) (44) (45) (46) (47)  a b i l i t y to perform procedures c o r r e c t l y rapport e s t a b l i s h e d with your p a t i e n t s neatness of the u n i t when your p a t i e n t care i s completed a b i l i t y to complete your assignment i n the time a l l o t t e d understanding of your p a t i e n t s ' s o c i a l and p s y c h o l o g i c a l problems r e l a t i o n s h i p s with other ward personnel  very little  seme  a great deal  1 1  2 2  3 3  4 4  1  2  3  4  1  2  3  4  1 1  2 2  3 3  4 4  no, (48-58) As you have discovered, nursing school involves both class work and practice on the wards. With regard to the class work, (48)  How does the amount of class work compare with what you had expected there would be? 1.  (49)  2.  about what I expected  3-  more than I expected  What are your marks? Ii  (50)  less than I expected barely passing  2.  below average 3-  about average 3»  above average  How much difficulty do you have with your class work? 1.  none at a l l 2.  very l i t t l e  3.  about average 4.  more than most students  (51-57) How much do you believe that each of the following courses relates to nursing; that is, how much does i t help you in your actual nursing practice?  (51) (52) (53) (54) (55) (56) (57)  Anatomy and Physiology Psychology Sociology Introduction to Nursing Medical and Surgical Nursing Psychiatric Nursing Community Health  not at a l l 1 1 1 1 1 1 1  very little 2 2 2 2 2 2 2  moderate- a great ly deal 3 3 3 3 3 3 3  4 4 4 4 4 4 4  (58-72) In nursing school you learn many things that a nurse should do. Some of these are more important than others, How important do you believe i t is for a nurse to do each of the following? not at slightly all impor- important tant (58 (59 (60 (61 (62 (63 (64 (65 (66 (67 (68 (69 (70 (71 (72  be of service to humanity carry out nursing procedures exactly as they are taught give medications accurately modify procedures to suit the individual patient, as long as the basic principles, as of asepsis, are observed finish assigned work on time observe, report and record accurately find additional work to do when her assigned work is completed heip to keep the ward environment clean and tidy meet the emotional needs of the patient stand when a doctor enters the room get to work on time maintain a proper appearance: hair neat, uniform clean, shoes polished take responsibility for planning the nursing care of her patients supervise non-professional personnel (aides, nursing assistants) allay a pre-operative patient's fears i f he seems apprehensive  1 1  1 1 1 1  important  essential  2 2  3 3  4 4  2 2 2  3 3 3  4 4 4  2 2 2 2  3 3 3 3  4 4 4  2  3  2  3  2  3  2  3  4  4 4 4 4  (73-78) As you progress i n your n u r s i n g course, you gain confidence i n your n u r s i n g ability. How would you r a t e each of the f o l l o w i n g items as to i t s importance i n making you f e e l capable as a nurse? not at slightly a l l impor- important tant (73) (74) (75) (76)  (77) (78) (79)  f a m i l i a r i t y with medical terms and the vocabulary used i n the h o s p i t a l knowledge of disease c o n d i t i o n s a b i l i t y to perform n u r s i n g procedures properly a b i l i t y to p l a n the n u r s i n g care of a patient requiring intensive physical care a b i l i t y to t a l k with p a t i e n t s understanding of the p s y c h o l o g i c a l and s o c i a l aspects of i l l n e s s  essential  1 1  2 2  3 3  4 4  1  2  3  4  1 1  2 2  3 3  4 4  1  2  3  4  I f one of your p a t i e n t s had a disease which you had never heard of and wanted to know about, which would you be most l i k e l y to do? Mark only one answer. 1. 2. 3. 4.  (80)  important  look i t up i n a book ask another student nurse ask my i n s t r u c t o r ask the head nurse  56. 7. 8.  ask ask ask ask  a medical student an i n t e r n a resident a s t a f f doctor  A doctor i s s i t t i n g at the desk h o l d i n g a chart and t a l k i n g with the head nurse. A f t e r ten minutes, he i s s t i l l t a l k i n g , but i s not u s i n g the c h a r t . You are w a i t i n g to c h a r t so you can go o f f duty. What would you do? 1. 2. 3.  say nothing, but wait u n t i l he i s through excuse y o u r s e l f and ask him i f you can have the chart f o r a few minutes i f he i s not u s i n g i t report the problem to your i n s t r u c t o r  [81-86:  2+  I.DTJ  (87-95) Do you have meals or c o f f e e v/ith each of the f o l l o w i n g at l e a s t once a week? Yes (87) (88) (89) (90) (91) (92) (93) (94) (95)  other student nurses nursing assistants p r a c t i c a l nurses graduate nurses head nurses supervisors medical students interns residents  (96)  I f a graduate nurse were l o o k i n g f o r another nurse to a s s i s t her with an emergency, what do you t h i n k she would be most l i k e l y to do? 1. 2. 3.  1 1 1 1 1 1 1 1 1  No 2 2 2 2 2 2 2 2 2  ask you to look f o r a graduate to help her ask you to h e l p her ignore you, and consider you more of a nuisance than a h e l p  (97-100) How  Nurses are c a l l e d upon to perform many disagreeable and d i f f i c u l t tasks. w e l l do you b e l i e v e you could cope with each of the f o l l o w i n g s i t u a t i o n s ? not at all  (97) (98)  Caring f o r a dying p a t i e n t t a l k i n g with a mother whose baby was stillborn (99) d e a l i n g with excreta, vomitus, and other unpleasant or malodorous m a t e r i a l (100) seeing a person i n p a i n when you can do nothing to help him  just barely  fairly well  with no difficulty  1  2  3  4  1  2  3  4  1  2  3  4  1  2  3  4  (101-105) The f o l l o w i n g questions deal with the k i n d of a person you b e l i e v e that you are r i g h t now. They are concerned not j u s t with nursing, but with some of your a t t i t u d e s toward l i f e i n general. (101)  How c l o s e l y do you b e l i e v e that your own i n t e r e s t s , a t t i t u d e s and values i n l i f e correspond to those of most graduate nurses you know? 1.  (102)  3-  f a i r l y closely  4.  very c l o s e l y  not at a l l  2.  somewhat l e s s  3-  persons  2.  things  3.  about the same  4.  much more  i s most i n t e r e s t e d i n  ideas  In r e l a t i o n to other nurses, 1 b e l i e v e that I am 1. 2. 3.  (105)  very l i t t l e  I b e l i e v e that I am the k i n d of person who 1.  (104)  2.  How much do you enjoy being with other student nurses, as compared with some of your f r i e n d s who are not nurses? 1.  (103)  not at a l l  more i n t e r e s t e d i n changing things which seem to me about as i n t e r e s t e d i n change as most others l e s s i n t e r e s t e d i n change  to need changing  In a s i t u a t i o n where you ideas c o n f l i c t with those of other members of a group you are i n , do you u s u a l l y 1. 2. 34.  go along with the crowd say very l i t t l e or nothing, but s t i c k to your own opinion express your opinion once or twice, then keep quiet i f other people disagree with you continue to argue your own point of view regardless of what other people say  

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