Open Collections

UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

Becoming a nurse : socialization into an occupational role Waik, Elvi 1957

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata

Download

Media
831-UBC_1957_A8 W15 B3.pdf [ 14.67MB ]
Metadata
JSON: 831-1.0106302.json
JSON-LD: 831-1.0106302-ld.json
RDF/XML (Pretty): 831-1.0106302-rdf.xml
RDF/JSON: 831-1.0106302-rdf.json
Turtle: 831-1.0106302-turtle.txt
N-Triples: 831-1.0106302-rdf-ntriples.txt
Original Record: 831-1.0106302-source.json
Full Text
831-1.0106302-fulltext.txt
Citation
831-1.0106302.ris

Full Text

BECOMING A NURSE — SOCIALIZATION INTO AN OCCUPATIONAL ROLE  by ELVI WAIK B. A., U n i v e r s i t y o f B r i t i s h Columbia, 1955  A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS  i n the Department of Anthropology, Criminology and Sociology  We accept t h i s t h e s i s as conforming to the r e q u i r e d standard  THE UNIVERSITY OF BRITISH COLUMBIA October, 1957  ABSTRACT  This i s a study on becoming and being a nurse.  The  nursing r o l e i n v o l v e s r o l e - a n t i c i p a t i o n , r o l e - t a k i n g , r o l e p l a y i n g and role-abandonment; i t . involves the moulding, by s p e c i f i c process, of an occupationally-undefined i n d i v i d u a l i n t o a p r o f e s s i o n a l person.  These processes, i f s u c c e s s f u l ,  c o n s i s t of a commitment to n u r s i n g norms by d i s c i p l i n e , i d e n t i f i c a t i o n , and r i t e s de passage.  They are accompanied  by i n c r e a s i n g group u n i t y , i n c r e a s i n g adoption o f i n s t i t u t i o n a l norms and a decreasing a b i l i t y to play other r o l e s and to identify with outsiders.  R o l e - t a k i n g could also be seen i n  terms of d i s t i n c t phases such as the t h e o r e t i c a l phase, the p r a c t i c a l phase, the phase of d i s i l l u s i o n m e n t and the phase of acceptance and r o u t i n e .  There i s a change i n a t t i t u d e s  between the f i r s t and the f i n a l phase. The r o l e of the nurse can be c l a r i f i e d by the use o f a method of occupational a n a l y s i s . The f i v e v a r i a b l e s of the scheme are:  images o f the r o l e , character of the o b l i g a t i o n s ,  rewards, s t r a i n s and r e l a t i o n to others. The methods and techniques that were used f o r t h i s study were questionnaire, guided and unguided i n t e r v i e w s , and p a r t i c i p a n t observation.  In the  presenting  requirements  of  British  it  freely  agree for  that  available  I  copying  gain  shall  by h i s or  not  of  agree  for  at  the  reference  and  study.  I  extensive  may  be  granted  representative. of  Anthropology.  copying  this  of  make  further this  thesis  by t h e  Head o f  It  understood  is  thesis  for  my w r i t t e n  Criminology  Columbia,  of  University shall  allowed without  O c t o b e r . . 195'?.-  degree  fulfilment  Library  The U n i v e r s i t y o f B r i t i s h V a n c o u v e r B, C a n a d a . Date  partial  the  publication be  in  that  for  purposes  or  thesis  an advanced  permission  that  Department  for  Columbia,  scholarly  Department  this  :  my  financial permission.  Sociology  ACKNOWLEDGMENTS  This t h e s i s owes much t o the assistance and good w i l l o f others.  I am unable t o i n d i c a t e to them the extent of my  indebtedness which I am powerless to repay.  Therefore, i t i s  w i t h great pleasure that I take t h i s opportunity t o acknowledge t h e i r help. I owe a personal debt to my teacher and advisor, Dr. Kaspar D. Naegele, who f i r s t introduced me t o Sociology and who helped me t o be c r i t i c a l of what I observed and heard. At a l l times he t r e a t e d my periods o f d i s i l l u s i o n m e n t w i t h understanding patience.  and encouragement, and my p r o c r a s t i n a t i o n s w i t h  I want t o thank him f o r our discussions together  and f o r h i s suggestions, both o f which were important i n c l a r i f y i n g my i d e a s .  I have ceased t r y i n g to note where I  have incorporated h i s i d e a s , expressions or words w i t h my own. My only r e g r e t i s that my f i n a l work does not do c r e d i t t o the c a l i b r e o f h i s help. I would also l i k e t o mention Dr. H. B. Hawthorne, Dr. C. Belshaw and Dr. S. Jamieson o f the Department o f Anthropology, Criminology and Sociology.  They have s t i r r e d  enthusiasm and many o f t h e i r suggestions, whether made i n l e c t u r e o r i n seminar, have been woven, one way o r another, i n t o the substance o f t h i s t h e s i s .  This i s a project which has been p a r t l y supported by a research grant.  I am g r a t e f u l to the Koer.ner Foundation  for t h e i r f i n a n c i a l a s s i s t a n c e .  A r e p o r t w i l l be submitted to  the Foundation i n the near f u t u r e . The success o f the i n v e s t i g a t i o n depended upon the cooperation of the Nursing Schools of the U n i v e r s i t y of B r i t i s h Columbia and the Vancouver General H o s p i t a l .  The  good w i l l and i n t e r e s t of Miss Evelyn M a l l o r y , Miss Helen King and Miss Helen Mussallem have been a great source of encouragement and support. staffs.  I f e e l indebted to them and t h e i r  I would e s p e c i a l l y l i k e to thank Miss Margaret Duncan,  Miss Beth McCann and Miss Margaret Campbell f o r h e l p i n g me to f i t i n t o a strange environment.  Although I would have l i k e d  to have o f f e r e d something c o n s t r u c t i v e to nurses i n r e t u r n f o r t h e i r h e l p , i t i s too much to expect that t h i s t h e s i s could serve that purpose. I want e s p e c i a l l y to thank the nursing class of August '£8,  who w i l l i n g l y provided me w i t h information.  Their  h o s p i t a l i t y , i n t e r e s t and cooperation l e f t nothing to be d e s i r e d . They made my f i e l d work an enjoyable experience and I spent some very happy days i n t h e i r company.  I would l i k e to add t h a t each  person I saw or w i t h whom I spoke during my f i e l d work, contributed to my ideas i n some way.  I am grateful f o r the support of ray parents and my friends, for the way they put up with me during the writing of the thesis, and f o r the help and understanding they have given me. I also f e e l indebted to Mrs. Anne Arthur, who has ably typed this work, and who has uncomplainingly coped with the many inconveniences that have been placed upon her.  TABLE OF CONTENTS  CHAPTER I II  III IV V  VI VII  VIII  IX  X  PAGE  Introduction  1  A Frame o f Reference 1 . General O r i e n t a t i o n to Role . . . . . . 2 . Relevant Work by Others 3. The Major Questions o f This Study . . .  9 10 20 39  Research Methods and Experiences  1^5 70  The T r a i n i n g S e t t i n g The Choice o f Nursing and R o l e - A n t i c i p a t i o n 1 . Making the Choice 2. R o l e - A n t i c i p a t i o n From Probie to Grad —  .  Processes  lOij. lOlj. 118 13k  From Probie to Grad Phases Changes Suggested Typology .  l6l l6l 173 191  P l a y i n g the Role — Being a Nurse . . . . . . 1. Images o f the Role 2. Character of O b l i g a t i o n s 3. Rewards k. R e l a t i o n t o Others S t r a i n s and C o n f l i c t s 1 . The Nature o f S t r a i n s i n Nursing . . . . 2. I n s t i t u t i o n a l Means of Releasing Tension 3 . Functions o f S t r a i n  197 203 215 225 228 237 238 265 267  Conclusions and I m p l i c a t i o n s Findings Recommendations Suggestions f o r Future Research  270 270 289 293  BIBLIOGRAPHY APPENDICES  296 301  TO FORTY YOUNG NURSES THE CLASS OF AUGUST •  CHAPTER  I  INTRODUCTION  The Nature o f the Problem The r o l e of the nurse could be considered from two perspectives.  The f i r s t i s concerned with nursing as the process  of "taking on" an occupational r o l e . the f o l l o w i n g questions: What changes occur?  I t provides the answer f o r  How and why does one become a nurse?  How does the t r a i n i n g p e r i o d f u n c t i o n i n  the development of p r o f e s s i o n a l people? are noticeable i n t h i s development?  What c h a r a c t e r i s t i c s  As these questions i n d i c a t e ,  the "taking on" o f a r o l e i s a dynamic t h i n g , i n v o l v i n g the l e a v i n g behind o f one s t a t e o f "being" and the adoption of another.  I t s i g n i f i e s the l e a r n i n g o f new modes o f a c t i o n and  the f o r g e t t i n g o f the o l d .  Growing i n t o an occupational r o l e ,  such as nursing, and l e a r n i n g to p r e d i c t the expectations o f t h i s r o l e , and to act according to these expectations, i s a process which s o c i o l o g i s t s c a l l s o c i a l i z a t i o n .  I t i s change i n a  s o c i a l l y - d e f i n e d d i r e c t i o n by a person a c q u i r i n g a new r o l e . The r o l e of the nurse, t h e r e f o r e , could be looked at as the r e s u l t o f f a s h i o n i n g the p a r t i c u l a r "role-incumbent" occupationally-undefined i n d i v i d u a l .  from an  This could be taken f u r t h e r  so that the process of becoming a nurse could also be looked at as the process o f becoming a p r o f e s s i o n a l person.  d  The second perspective provides an answer f o r the question: roles?  what i s a nurse and how  does she d i f f e r from other  I t assumes that the i n d i v i d u a l has passed through the  process of "becoming," that she i s involved i n the actual p l a y i n g of the r o l e .  The r o l e lends i t s e l f to d i s c u s s i o n w i t h the help  of selected concepts, which allow f o r the comparison of t h i s r o l e w i t h others.  This i s by nature a descriptive.and s t a t i c  perception i n that i t looks at nursing at a given time and not during a p e r i o d of time. I have t r i e d , t h e r e f o r e , i n t h i s study, to give equal a t t e n t i o n to both aspects of the r o l e :  the process of "taking  on" a r o l e and the " p l a y i n g " of that r o l e .  Reasons f o r S e l e c t i o n At the beginning  of my graduate year, i n September  195>5>> I had to choose a t o p i c f o r a t h e s i s .  Out of the many  areas of sociology i n which I could do a study, I f e l t a t t r a c t e d to the area which i s o f t e n termed "medical sociology."  I feel  obliged to add that my i n i t i a l i n t e r e s t was not i n the  subject  matter of "medical s o c i o l o g y " per se.  Rather I wanted to see  what sociology, which seemed, at the time, rather abstract  and  t h e o r e t i c a l , could contribute to the p r a c t i c a l , a c t i o n - o r i e n t e d medical m i l i e u . A f t e r reading the c o n t r i b u t i o n s of s o c i o l o g i s t s , such as H a l l , Hughes, Stanton and Schwartz, I became convinced that t h e i r work was not merely an i n t e l l e c t u a l exercise or  merely a piece of s c i e n t i f i c r e s e a r c h . practical applicability. to present a new,  They c o u l d also have  T h e i r main v i r t u e was i n being able  a n a l y t i c a l point of view, which would permit  the medical sub-culture to view i t s e l f from a d i f f e r e n t perspective.  This p e r s p e c t i v e would have the added advantage  of being disengaged from n u r s i n g . The r e s u l t could be d i f f e r e n t i n t e r p r e t a t i o n s o f nursing problems and p o s s i b l y new programs of action. I was at t h i s time vaguely aware of c e r t a i n p u b l i c images of the nurse.  I had heard i t s a i d that nurses were  "angels of mercy" and at the same time I had heard comments to the e f f e c t that g i r l s changed when they became nurses and that they became c a l l o u s .  I was e n t h u s i a s t i c about knowing:what  r e a l l y happened when g i r l s became nurses*, what were nurses l i k e ; ;  and what i t was l i k e to be a nurse. A study of t h i s k i n d promised i n t e r e s t i n g f i n d i n g s and i t had the added advantage of being a convenient choice as f a r as f i e l d work was concerned.  On the campus of the U n i v e r s i t y  of B r i t i s h Columbia there i s a School of Nursing, where i n the f a l l of each year approximately f o r t y g i r l s begin t h e i r careers as student nurses.  As at t h i s time I was t a k i n g courses at the  u n i v e r s i t y , the i n i t i a l stages of the study would be f a c i l i t a t e d i f I could study these students.  The teaching s t a f f of the  School of Nursing was approached on t h i s matter.  They consented  and I was encouraged by t h e i r approval and i n t e r e s t .  The  necessary arrangements were made and I began to attend nursing  4  l e c t u r e s and to formulate questions that could he posed. The i n s t r u c t i o n f o r these students involved a t t e n t i o n to both p r a c t i c a l and t h e o r e t i c a l areas.  Conveniently f o r me,  the i n s t r u c t i o n given during the u n i v e r s i t y term, and on the u n i v e r s i t y campus, was p r i m a r i l y t h e o r e t i c a l .  The students were  given a t a s t e of p r a c t i c a l t r a i n i n g i n l a b o r a t o r y periods when they "pretended" that they were working as nurses on a h o s p i t a l ward.  I t was not u n t i l the u n i v e r s i t y term had expired that the  g i r l s were introduced to h o s p i t a l work, t o residence l i f e and to the p r a c t i c a l aspect o f t h e i r t r a i n i n g .  I was very fortunate i n  obtaining permission from the u n i v e r s i t y school and t h e h o s p i t a l school to j o i n the students at the h o s p i t a l i n order to p a r t i c i p a t e i n the p r a c t i c a l t r a i n i n g they were given.  This  gave me the opportunity to construct a f i r s t - h a n d .picture of students adapting to the h o s p i t a l m i l i e u and to formulate a s e l f conception o f "what i t f e l t l i k e to be a student nurse," when one had to sleep i n a residence w i t h f i v e hundred other g i r l s , to give a bed bath f o r the f i r s t time, to do the f i r s t dressing, and to l e a r n how to work harmoniously w i t h head nurses, instructresses  and doctors.  Nature o f I n v e s t i g a t i o n This study, i n i t i a l l y c a r r i e d out as a p a r t i a l requirement  f o r a degree i n the Department o f Anthropology,  Criminology and Sociology, was begun i n the f a l l of 1955. During the w i n t e r that f o l l o w e d the f i e l d work that I could do  5  was somewhat meagre as I was t r y i n g , at the same time, to complete s i x u n i v e r s i t y courses.  I d i d , however, during that time attend  nursing courses, formulate a r a t h e r lengthy questionnaire, do some i n t e r v i e w i n g , and go every second week to a d i s c u s s i o n among nursing students as part o f a course i n Sociology.  Prom  the nursing l e c t u r e s I was able t o c o l l e c t information on the nature of the formal i n s t r u c t i o n given to the students, as w e l l as on instances o f the transmission of r e l e v a n t a t t i t u d e s . Many o f these a t t i t u d e s were a l s o d i s p l a y e d i n the nursing discussions.  The questionnaire, c o n s i s t i n g o f approximately  f i f t y questions, was constructed t o i n d i c a t e the beginning conceptions and the expectations o f the students.  self-  This was  administered i n March, 1956. My i n t e n t i o n was to administer the same questionnaire a f t e r the p e r i o d o f p r a c t i c a l t r a i n i n g and thus t o s p e c i f y change. At the same time I conducted interviews designed t o enquire i n t o :  1) what students b e l i e v e d  motivated them to "take on" the nursing r o l e ; 2) how strong t h e i r wish f o r nursing was. The months o f May and June, 195>6, were the students' f i r s t contact w i t h the h o s p i t a l .  At t h i s time I took on the  r o l e o f " p a r t i c i p a n t observer," becoming i n v o l v e d i n t h e i r l e a r n i n g , work and " o f f duty" a c t i v i t i e s .  At the end o f the  two-month p e r i o d , before the g i r l s l e f t f o r a month's h o l i d a y , I once again asked them to complete the questionnaire and gave each g i r l an i n t e r v i e w . change.  The interviews focussed p r i m a r i l y on  At t h i s point I b e l i e v e d that the f i e l d work f o r my  o  t h e s i s was over.  Daring the month of August and e a r l y September,  when the students were once again on the u n i v e r s i t y campus, t a k i n g courses from the u n i v e r s i t y School of Nursing, I encountered them f r e q u e n t l y . This i n t e r a c t i o n was not i n terms of observer and observed, but r a t h e r on the b a s i s of one student to another. During the p e r i o d from September, 1955  to June,  1956,  I was r e c e i v i n g support and encouragement from three sources. F i r s t l y , I was given constant help and guidance by Dr. K.  D.  Naegele and the department i n which I was w r i t i n g my t h e s i s . Secondly, I had the b e n e f i t of the i n t e r e s t and co-operation of the Schools o f Nursing at the u n i v e r s i t y and at the h o s p i t a l . F i n a l l y , of utmost importance was the favorable r e a c t i o n and acceptance given me by the members of the n u r s i n g class that I was studying. Having devoted nine months to studying the "making" of a nurse, seven months of which the prospective nurse,was, i n r e a l i t y , a u n i v e r s i t y student, I began to f e e l an i n c r e a s i n g d i s s a t i s f a c t i o n w i t h the l e n g t h of time that had been devoted to the study.  The students were to graduate i n August, 1958,  more  than two years a f t e r I had stopped studying them f o r changes and self-conceptions.  I t seemed to me t h a t I had studied one branch  and could not conceive of the whole t r e e . segmental  character of my work.  I became aware of the  At t h i s time I was very  fortunate i n being given a grant by the Koerner Foundation to enable me to continue the research.  7  Therefore, In October, 1956, I returned to the h o s p i t a l m i l i e u and took up where I had l e f t o f f . The s t a f f of the department o f nursing education was most co-operative and gave me the use of a room i n the Nurses' Residence, and permitted me to f o l l o w the students through a l l t h e departments o f the h o s p i t a l where t h e i r work took them. In January, 1957, I conducted another set o f i n t e r v i e w s , questioning each g i r l w i t h my o b j e c t i v e being to b r i n g out i n d i c a t i o n s o f change. This was done during t h e i r l a s t weeks as j u n i o r students, before they entered on t h e intermediate phase o f t h e i r t r a i n i n g .  Again i n May, when the students returned  f o r a two-week p e r i o d to the u n i v e r s i t y campus, I interviewed them i n groups.  Between each set of interviews I assumed the  r o l e o f p a r t i c i p a n t observer, becoming i n v o l v e d i n as many aspects o f t h e i r l i f e as p o s s i b l e .  Presentation o f Data and Conclusions My f i n d i n g s and conclusions are t o be recorded i n two ways.  F i r s t l y , t h i s t h e s i s s h a l l cover i n f u l l the f i r s t phase  of the study, presenting the conclusions from the questionnaire, the f i r s t three Interviews and the data c o l l e c t e d by means o f p a r t i c i p a n t observation.  The nature of t h i s data i s both  q u a l i t a t i v e and q u a n t i t a t i v e .  I t s h a l l a l s o draw on evidence  from the work that was p o s s i b l e o n l y through the support o f the Koerner Foundation.  The second phase o f the work s h a l l be presented i n the form of a report to the Koerner Foundation. emphasize the m a t e r i a l  I t shall  c o l l e c t e d between October, 195>6, and  J u l y , 1957, but s h a l l also r e l y on the data from the f i r s t phase.  CHAPTER I I A FRAME OF REFERENCE  To enable me to c o l l e c t data i n a consistent manner and to organize i t e f f e c t i v e l y I looked f o r a framework. I n order to understand the problem I vras t o study more f u l l y , I found i t necessary t o examine three areas: 1.  General O r i e n t a t i o n to Role.  This involves a  c o n s i d e r a t i o n of the phenomenon of " r o l e , " the o r g a n i z a t i o n and s t r u c t u r e o f r o l e s and the stages i n the t a k i n g of a r o l e . 2.  Relevant Work by Others.  Studies by others played  a part i n h e l p i n g me to perceive and organize my problem. 3.  The Major Questions o f t h i s Study.  With regard to  r o l e - p l a y i n g and r o l e - t a k i n g I had formulated c e r t a i n  hypotheses,  and a framework by which these could be i n v e s t i g a t e d . These three considerations helped me to conduct i n t e r views and f i e l d work, t o formulate appropriate questions and to systematize my data.  This chapter s h a l l b r i e f l y e x p l a i n the  s i g n i f i c a n t contents o f each o f the three areas.  1.  General O r i e n t a t i o n  to Role .  A r o l e i s a p a t t e r n of behaviour and thought indulged i n by i n d i v i d u a l s .  Each r o l e i s d i s t i n g u i s h e d  by a set of norms  and values which the i n d i v i d u a l adopts as h i s own, to which he patterns h i s a c t i o n s .  and  according  A r o l e , t h e r e f o r e , defines  the performance of an i n d i v i d u a l i n a s i t u a t i o n . Roles a r i s e out of i n t e r a c t i o n .  The meaning of  any  one r o l e can only be ascertained i n r e l a t i o n to other r o l e s . t h i s way  In  the expectations of a r o l e , and the manner of f u l f i l l i n g  these expectations, are made known.  The  d e f i n i t i o n of any r o l e ,  t h e r e f o r e , depends upon the d e f i n i t i o n of the other relevant roles.  That i s to say, r o l e s are never alone, they imply a  reciprocity. *  I t can also be s a i d that r o l e s imply some manner of organization.  As the s o c i a l r e l a t i o n s h i p s of any one  are m u l t i p l e , that i n d i v i d u a l has many r o l e s .  individual  Hence one  i n d i v i d u a l can be a woman, a nurse, a daughter, the member of a church, a f r i e n d and a w i f e .  Her  performance i n a s o c i a l  s i t u a t i o n depends upon the d e f i n i t i o n , given by her, to r o l e s o f the others i n v o l v e d .  the  Her behaviour i n the presence  of her mother d i f f e r s from her behaviour i n the presence of husband and d i f f e r s , again, when she i s xtfith a p a t i e n t .  her  When  the s i t u a t i o n becomes more complex, i n v o l v i n g , f o r example, her mother, a f r i e n d and a nursing i n s t r u c t r e s s , her performance i s organized on a combination of the expectations of each.  I f the  s i t u a t i o n becomes so complex that she i s unable to i n t e g r a t e her behaviour on the b a s i s of the combined expectations i n v o l v e d , a c o n f l i c t occurs.  Such an i n c i d e n t of c o n f l i c t i n g or widely-  varying r o l e - e x p e c t a t i o n s a r i s e s only when the system o f o r g a n i z a t i o n employed by the i n d i v i d u a l to i n t e g r a t e h i s varying role-performances i s no longer adequate. to such a s i t u a t i o n are numerous.  The r e a c t i o n s  For example the i n d i v i d u a l  may r e a c t according to her most f r e q u e n t l y performed r o l e or i n terms of the expectations o f the r o l e she defines as "the most important" i n the s i t u a t i o n .  This i m p l i e s , t h e r e f o r e , that when  an i n d i v i d u a l plays many r o l e s simultaneously, a system o f o r g a n i z a t i o n o f r o l e - e x p e c t a t i o n s and performances i s employed. When t h i s o r g a n i z a t i o n i s no longer f u n c t i o n a l , a s i t u a t i o n o f conflict arises. S i m i l a r l y i n the s o c i a l system at large there i s an organization of roles.  Each r o l e i s organized w i t h others t o  make a meaningful whole and the i n t e r a c t i o n between r o l e s i s s o c i a l l y defined.  W i t h i n the s o c i a l system i t s e l f there are  sub-systems and i n s t i t u t i o n s c o n s i s t i n g o f some o f the r o l e s that are evident i n the l a r g e r system. again organized i n a f u n c t i o n a l manner.  These r o l e s are once The i n s t i t u t i o n a l  expectations o f a r o l e have some elements i n common w i t h the s o c i a l expectations o f the same r o l e and some elements d i f f e r i n g from i t .  I n other words the r o l e o f the nurse as defined by the  h o s p i t a l approximates the d e f i n i t i o n by the p u b l i c , but at the same time the expectations are more p r e c i s e and include  i n s t i t u t i o n a l aspects o f which the p u b l i c may not be aware. Both.the p u b l i c and the h o s p i t a l expect a nurse to be both e f f i c i e n t and sympathetic, but i n general, the p u b l i c i s not aware that the nurse must wear short h a i r , must never t e l l a patient what she knows o f the patient's when a doctor comes i n t o the room.  condition and must stand  S i m i l a r l y the r e l a t i o n s h i p  between a doctor and a nurse i n a h o s p i t a l d i f f e r s from t h e i r r e l a t i o n s h i p outside o f the h o s p i t a l . organization  i n each case.  There i s a complex  I n the former case i t i s organized  to a large extent i n terms o f the r e l a t i o n s h i p o f a superordinate to a subordinate, i r r e s p e c t i v e o f other r o l e s played by e i t h e r . In the h o s p i t a l , t h e r e f o r e ,  a young i n t e r n assumes the r o l e o f  the superordinate, even though the nurse may be h i s mother. Outside o f the h o s p i t a l i t i s organized p r i m a r i l y i n terms o f the s o c i a l l y defined mode o f i n t e r a c t i o n between men and women. There t h e i r r o l e s would be reversed, the young i n t e r n would stand when the nurse entered the room.  So complex at times i s the  organization  that contradictions  o f role-expectations  occur even  between a s o c i a l system and segments o f i t . The concept o f r o l e could be considered a l i n k between the concept of p e r s o n a l i t y and the concept o f s o c i a l system. As the preceding two paragraphs have shown, r o l e i s the property of both.  I t i s important i n understanding the s o c i a l system as  i t i s inherent i n every s o c i a l r e l a t i o n s h i p and i n every interaction.  Likewise i t i s important i n the understanding o f  p e r s o n a l i t y , f o r i t develops an awareness o f s e l f as opposed t o  others.  Furthermore the processes of r o l e - t a k i n g and r o l e -  p l a y i n g introduce values and norms which are integrated i n t o the personality.  I t i s i n the concept of r o l e , t h e r e f o r e , that  connections between p e r s o n a l i t y and the s o c i a l system can be found.  C l a s s i f i c a t i o n of Roles There are many methods of c l a s s i f y i n g the numerous kinds of r o l e s that can be observed i n our s o c i e t y . method i s to d i v i d e a l l r o l e s i n t o "general" or categories.  A  frequent  "specific"  The former r e f e r s to the wider area which covers  age and sex, the l a t t e r to the more s p e c i f i c a f f i l i a t i o n s such as nurse, father-confessor or immigrant.  Often a l s o , the  categories of "achieved" and "ascribed" are used.  An ascribed  r o l e , such as age and sex, or a c h i e f of a t r i b e , are  assigned  to the i n d i v i d u a l on the b a s i s of b i o l o g i c a l f a c t s over which the i n d i v i d u a l has no c o n t r o l . An achieved r o l e , such as that of a wife or a stenographer, i s one that i s acquired by a wish to acquire i t .  The d e s i r e to acquire the r o l e may be p o s i t i v e  when the values and aims o f the r o l e are s i m i l a r to those h e l d or d e s i r e d by the a s p i r a n t ; or i t i s negative, when an i n d i v i d u a l i s forced i n t o t a k i n g on a r o l e because doing so i s l e s s uncomfortable than r e s i s t i n g .  Hence a g i r l may  become a nurse because  she l i k e s the k i n d of people that nurses are, or because she wants to please her mother who wants her to become a nurse. should be pointed out t h a t what a g i r l may  It  c l a i m as a motive f o r  becoming a nurse does not n e c e s s a r i l y i n f l u e n c e her performance i n the r o l e . For the purpose o f t h i s t h e s i s I would l i k e t o suggest two p o s s i b l e ways of c a t e g o r i z i n g r o l e s : "changing."  "permanent" and  Permanent r o l e s are those which are the r e s u l t o f  the s o c i a l use o f b i o l o g i c a l f a c t s and o f membership i n a k i n s h i p group.  Permanent r o l e s , t h e r e f o r e , imply age,  sex and t r a d i t i o n a l  status such as e x i s t s among r o y a l t y and a r i s t o c r a c y .  Furthermore  every I n d i v i d u a l plays the permanent r o l e o f son o r daughter, and o f t e n o f brother, s i s t e r , mother or f a t h e r . can be played simultaneously.  A l l of these r o l e s  "Changing" r o l e s , on the other  hand, correspond more t o the achieved r o l e s , i n that they can be consciously  "taken on." Examples o f t h i s are group memberships  and occupational r o l e s . others cannot.  Some o f these can be played simultaneously,  One i n d i v i d u a l can be a lawyer, a member o f a  p o l i t i c a l party and an a d u l t , but he cannot be a member o f a kindergarten group and a member o f a law class at the same time. This case implies a process whereby the a t t r i b u t e s of one r o l e are unlearned o r modified and the a t t r i b u t e s o f the new r o l e are l e a r n t . a lawyer.  The r o l e o f the law student i s exchanged f o r that o f This idea o f the a c q u i s i t i o n o f new r o l e s w i l l be  u t i l i z e d i n t h i s paper.  Attachment to a Role There are four phases t o the a c q u i s i t i o n o f a r o l e : r o l e - a n t i c i p a t i o n , r o l e - t a k i n g , r o l e - p l a y i n g and role-abandonment.  The f i r s t , r o l e - a n t i c i p a t i o n , r e f e r s to the abstract image of r o l e h e l d by the a s p i r a n t .  The future incumbent conceives of  h e r s e l f as f u l f i l l i n g the functions of that r o l e , r e c e i v i n g the rewards and being exposed to the s t r a i n s . A future nurse, hence, sees h e r s e l f c l a d i n a white uniform, f l i t t i n g about a ward, administering help to p a t i e n t s , who gratitude.  i n r e t u r n give her t h e i r  She sees h e r s e l f as the object of p u b l i c esteem.  At times, however, she sees h e r s e l f i n p o s i t i o n s of s t r a i n , such as administering the wrong medication.  Thus i n the image the  prospective nurse foresees the s a t i s f a c t i o n s and a n x i e t i e s of her future r o l e .  Needless to say the a n t i c i p a t i o n takes a  s i m p l i f i e d form of what could be termed " r e a l i t y . " The second, r o l e - t a k i n g , r e f e r s to the process of s o c i a l i z a t i o n which occurs when a new r o l e i s l e a r n t . of a nurse i s comprised of an organized p a t t e r n of  The  role  expectations  of behaviour and thought, as w e l l as functions and techniques which she must perform.  U n t i l the appropriate knowledge and  a t t i t u d e s are acquired, she i s considered only a candidate f o r the r o l e .  She i s "taking on" the r o l e .  I t c o n s i s t s of a process  of d i r e c t teaching and l e a r n i n g , whereby the appropriate  values  and techniques are i n t e r n a l i z e d . I t also c o n s i s t s of a process of unconscious l e a r n i n g during which the t r a i n e e learns a t t i t u d e s , values and techniques that are not h e l d out to her. The t h i r d , r o l e - p l a y i n g , implies the acceptance of the t r a i n e e i n t o the r o l e .  The incumbent now  performs the a c t u a l  functions of the r o l e and f u l f i l s the expectations  and  requirements.  She can claim the p r i v i l e g e s and duties of the  r o l e , and at any s p e c i f i c time she i s i d e n t i f i e d w i t h others who p l a y the same r o l e . The f o u r t h phase, role-abandonment, can occur at two instances i n the a c q u i s i t i o n of a r o l e .  I t can occur before  the process of r o l e - t a k i n g when the attachment to the previous r o l e i s r e l i n q u i s h e d and the requirements o f the new r o l e are learnt.  I t can also occur when the new r o l e i s , i n i t s t u r n ,  discarded.  I t i s the p r e r e q u i s i t e , i n each case, to the  a c q u i s i t i o n o f a new r o l e .  Thus a nurse abandons her r o l e as  student to become a nurse, and unlearns or modifies the a t t r i b u t e s o f the former r o l e i n order to l e a r n the l a t t e r . S i m i l a r l y the r o l e o f a nurse i s r e l i n q u i s h e d f o r the r o l e o f a w i f e o r mother.  Work Roles as Aspects o f S o c i e t y Work i s an i n t e g r a l part of our s o c i e t y .  Every  i n d i v i d u a l i s expected to assume a work r o l e on the b a s i s o f which he takes a meaningful p o s i t i o n i n the s o c i a l s t r u c t u r e . One o f the f i r s t questions i n d e f i n i n g a strange i n d i v i d u a l i s : what does he do? This implies that values i n t e r n a l i z e d i n a work r o l e tend t o f l a v o u r h i s whole behaviour even outside o f the work s i t u a t i o n . Work i s an o b l i g a t i o n to a l l and i d l e n e s s i s considered an avoidance o f o b l i g a t i o n s .  Work, t h e r e f o r e , has unpleasant  connotations.  To counteract t h i s f e e l i n g o f d i s t a s t e there i s  a s o c i a l desire f o r every man t o enjoy h i s work. r i s e to a c o n t r a d i c t i o n .  This gives  As soon as man begins t o enjoy h i s  work, he begins to perform i t f o r i t s own sake}instead o f f o r the r e s u l t s i t brings,and i t takes on the a t t r i b u t e s o f p l a y . He then f e e l s that he i s s h i r k i n g h i s o b l i g a t i o n s , f o r he f e e l s that he i s not working, but r a t h e r , p l a y i n g . The m o t i v a t i o n to work a r i s e s out o f a need to maintain one's l i v e l i h o o d and t o do t h i s i n a s o c i a l l y acceptable manner, namely by acquiring an occupation. The rewards o f an occupational r o l e , t h e r e f o r e , are income, status and psychological security.  The S e l f and the P r o f e s s i o n a l Conscience The " s e l f " i s a product o f both permanent and changing roles.  I t i s a combination o f the innate q u a l i t i e s o f the  i n d i v i d u a l and the a t t i t u d e s and norms that are acquired through p l a y i n g "changing" s o c i a l r o l e s .  I n t h i s way a man and a member  of the E n g l i s h upper c l a s s combines w i t h these c h a r a c t e r i s t i c s the a t t i t u d e s and norms o f a doctor, a husband, a p o l i t i c i a n and a staunch f o l l o w e r o f the church.  These q u a l i t i e s make up the  i n t e r n a l i z e d s t r u c t u r e o f the s e l f . The meaning of the " s e l f " t o the i n d i v i d u a l a r i s e s out of communication w i t h others. The i n d i v i d u a l , so t o speak, steps out o f h i m s e l f , and sees h i m s e l f as others i n the s o c i a l  s i t u a t i o n see him.  These others i n the s o c i a l s i t u a t i o n are  o f t e n r e f e r r e d t o as the "generalized other."  The a t t i t u d e s of  t h i s "generalized other," t h e r e f o r e , are adopted by the i n d i v i d u a l as.his own, identity.  and are the basis f o r h i s sense of  His behaviour i s fashioned on t h i s , and on the  "conscience" that develops from i t .  His actions f o l l o w t h i s  self-image and are c o n t r o l l e d by the "conscience" that i s connected w i t h i t , even during the absence of the "generalized other." Even as s o c i a l r o l e s and the i n t e r n a l i z e d a t t i t u d e s that accompany them are i n a constant state of change, the i s never constant.  "self"  The self-image changes w i t h the changing  a t t i t u d e s of the "generalized other."  A nurse's conception  of  h e r s e l f changes when she r e a l i z e s that the other nurses on her ward regard her as incompetent and u n r e l i a b l e . This undoubtedly also a f f e c t s her behaviour.  S i m i l a r l y her self-conceptions  and  behaviour would change i f she knows that the others regard her as a "good nurse." C o n f l i c t s also d i s t u r b the e q u i l i b r i u m of the s e l f . There can be c o n f l i c t between b a s i c human wants and the norms of s o c i a l i z e d r o l e s . A t i r e d nurse wishes o n l y to r e s t , but the requirements of her s o c i a l r o l e demand that she perform her duties.  There can also be c o n f l i c t s between the norms of two  s o c i a l r o l e s which the s e l f has i n t e g r a t e d .  Hence a man  has  o f t e n to combine shrewdness w i t h p r o f e s s i o n a l trustworthiness as i n the case of a doctor, who must also be a business  man.  19  The P r o f e s s i o n a l S e l f I t i s a c u l t u r a l norm i n our s o c i e t y to acquire an occupational r o l e .  Involved i n t h i s i s the "taking on" of the  relevant techniques  and a t t i t u d e s and an a b i l i t y to i d e n t i f y  oneself w i t h other selves p l a y i n g the same occupational r o l e . A s p e c i a l type of occupational r o l e i s the p r o f e s s i o n a l r o l e . An incumbent of t h i s r o l e must adopt the q u a l i t i e s that p e r t a i n to a l l occupational r o l e s , plus the added q u a l i t i e s that p e r t a i n to a l l p r o f e s s i o n a l r o l e s .  I n t h i s way there develops the  conception o f a " p r o f e s s i o n a l s e l f , " together w i t h the existence of a " p r o f e s s i o n a l conscience."  I t seems, t h e r e f o r e , that a l l  i n d i v i d u a l s who assume an occupational r o l e take on two sets o f characteristics:  those they have i n common w i t h "other men who  work"; and over and above t h i s they assume the added c h a r a c t e r i s t i c s of the type o f occupational r o l e they  fulfill,  whether i t be a r t i s t i c , manual or p r o f e s s i o n a l . A p r o f e s s i o n a l s e l f i n our s o c i e t y conceives of h i m s e l f as being trustworthy and d i s c r e e t w i t h a l l matters that come i n t o h i s area o f competence. He sees h i m s e l f as being i n possession of a s p e c i a l i z e d body o f knowledge, which he defines as being indispensable f o r the f u n c t i o n of s o c i e t y . He f e e l s himself to be under the o b l i g a t i o n to dispense t h i s knowledge whenever i t i s needed.  He must be a l t r u i s t i c and show u t t e r d i s r e g a r d f o r  h i s personal b e n e f i t s .  On the other hand, he i s aware that he  must have the respect and the t r u s t o f prospective c l i e n t s . This depends on the p i c t u r e .of "success" that he can p o r t r a y .  One important method o f showing success i s to present a r e l a t i v e l y high standard o f l i v i n g , which, i n t u r n , depends upon s e l f - i n t e r e s t . C e r t a i n p e r s o n a l i t y c h a r a c t e r i s t i c s are d e s i r e d i n professional selves.  Among other t h i n g s , they are expected t o  be r e l i a b l e , courteous, competent, and sympathetic. A l l p r o f e s s i o n a l t r a i n e e s attempt to i n t e r n a l i z e these expected t r a i t s , o f t e n making them an i n t e g r a l part o f the p e r s o n a l i t y . In such a case the i n d i v i d u a l i s not aware o f consciously u t i l i z i n g these c h a r a c t e r i s t i c s , but qees them as being part of h i m s e l f "as he r e a l l y i s . "  I n other cases there i s a doubt  on the part o f the i n d i v i d u a l i n h i s s i n c e r i t y i n using these t r a i t s , and a b e l i e f that he i s "only a c t i n g . "  Consequently there  i s a tendency towards cynicism. The r o l e - t a k i n g o f student nurses, which i s one major concern o f t h i s t h e s i s , could also be described i n terms o f the development o f p r o f e s s i o n a l s e l v e s .  The other major aspect,  r o l e - p l a y i n g , could be.the a c t u a l performance o f "being" a professional s e l f .  2.  Relevant Work by Others  The t h e o r e t i c a l framework i n terms o f which I have viewed the problems o f t h i s study was, to some extent, stimulated by the works o f others.  I intend, t h e r e f o r e , t o give c r e d i t to  those works which have had some part i n fashioning my i d e a s .  The  Idea of "Role" As f a r as the analysis of " r o l e " i s concerned, I found  the suggestions of Parsons p a r t i c u l a r l y enlightening.  He has  succeeded i n i n t e g r a t i n g vast amounts o f data about r o l e s and i n developing a method whereby the elements of a r o l e can be separated and then reorganized i n a more meaningful whole. To Parsons a r o l e depends on s o c i a l r e l a t i o n s h i p s and should be viewed i n terms o f i t s f u n c t i o n a l s i g n i f i c a n c e to the s o c i a l system.  1  The f a c t that r o l e s d i f f e r i s evident and  Parsons proposes that t h i s d i f f e r e n c e i s a f u n c t i o n of the c u l t u r a l expectations o f each r o l e .  This l e d me to b e l i e v e  an understanding of the i n s t i t u t i o n w i t h i n which a r o l e  that  functions  i s e s s e n t i a l to an understanding o f the r o l e . A l l r o l e s , Parsons suggests, can be defined i n terms of f i v e v a r i a b l e s .  These he c a l l s "pattern v a r i a b l e s . "  Firstly,  a r o l e can be described i n terms of i t s r e l a t i o n s h i p to another role.  On one hand i t can be a r e l a t i o n s h i p which i s personal,  informal and has emotional connotations.  This occurs i n the  case o f a mother and her c h i l d , as compared t o a lawyer and h i s c l i e n t , and i s termed by Parsons as " a f f e c t i v e . "  On the other  hand, i t can be impersonal, formal and o f an unemotional, o b j e c t i v e nature.  This i s an " a f f e c t i v e l y n e u t r a l " r o l e as  with the lawyer and h i s c l i e n t , and i n d i r e c t opposition t o the  I< T a l c o t t Parsons, The S o c i a l System. Glencoe, I l l i n o i s , Free Press, 19H?1, p. 2E~.  22  r e l a t i o n s h i p , between the lawyer and h i s w i f e .  Secondly, Parsons  suggests that the r o l e may f o l l o w " s e l f - o r i e n t e d " o r " c o l l e c t i v i t y oriented" i n t e r e s t s .  By t h i s he means that an i n d i v i d u a l may  d i r e c t h i s a c t i v i t i e s w i t h the wish o f achieving p r i v a t e ends or the i n d i v i d u a l may be a l t r u i s t i c i n h i s outlook and d i r e c t h i s actions towards the "common good."  The c h i l d may tend t o be  " s e l f - o r i e n t e d , " whereas h i s mother and the lawyer are "collectivity-oriented." Parsons'  scheme  is  The t h i r d "pattern v a r i a b l e " o f  "universalIsm" vs. " p a r t i c u l a r i s m . "  The  former r e f e r s t o a r e l a t i o n s h i p that i s governed e n t i r e l y by a prescribed  set o f standards and norms.  A lawyer's r e l a t i o n s h i p  to h i s c l i e n t i s defined by a set o f prescribed  norms f o r  i n t e r a c t i o n with a l l c l i e n t s , and i s devoid of emotionality. The  l a t t e r r e f e r s to a r e l a t i o n s h i p where the other i s evaluated  i n terms o f an emotional connotation based on a s p e c i a l r e l a t i o n s h i p , such as would e x i s t between a lawyer and h i s w i f e . Fourthly, he suggests the d u a l i t y o f "achievement-ascription." This he l a t e r changed t o "performance" and " q u a l i t y . "  A role  that i s attained through conscious e f f o r t i s one that f a l l s under the "achievement" or "performance" category, w h i l e one that i s i n h e r i t e d o r a t t a i n e d without e f f o r t i s "ascribed" o r given because o f " q u a l i t y . "  The f i f t h "pattern v a r i a b l e " defines  the scope o f i n t e r e s t i n the other r o l e .  I t can be e i t h e r  " s p e c i f i c , " where the i n t e r a c t i o n between the r o l e s i s l i m i t e d w i t h i n defined boundaries, f o r instance,  the lawyer's i n t e r e s t  i n h i s c l i e n t i s l i m i t e d only t o the area o f h i s l e g a l problem; or I t i s " d i f f u s e " where the,lawyer's c l i e n t i s also h i s f r i e n d .  To exemplify the use of h i s scheme, Parsons analyses the r o l e of the p h y s i c i a n .  The r o l e i s an "achieved" one,  r e q u i r i n g i n t e n s i v e education and i n c r e a s i n g t e c h n i c a l efficiency.  I t i s " u n i v e r s a l i s t i c , " i n that the actions of  the p h y s i c i a n are governed by a generalized o b j e c t i v e known as medical science.  criteria,  I t i s " s p e c i f i c " i n that h i s  l e g i t i m a t e a u t h o r i t y i s confined to areas of h e a l t h and The  a c t i v i t i e s of the r o l e are not governed by  preferences,  but are " a f f e c t i v e l y n e u t r a l . "  personal  F i n a l l y , the  p h y s i c i a n i s i n t e r e s t e d i n the common good above h i s personal d e s i r e s .  illness.  own  Therefore, the " p r o f e s s i o n a l " r o l e i n our  s o c i e t y i s d i s t i n c t i v e because i t i s achievement-oriented, u n i v e r s a l i s t i c , f u n c t i o n a l l y s p e c i f i c , a f f e c t i v e l y neutral  and  2  collectivity-oriented. goes, Parsons  1  As f a r as the nature of the performance  p r o p o s i t i o n f o r p r o f e s s i o n a l r o l e s i s valuable.  I t d i s t i n g u i s h e s p r o f e s s i o n a l r o l e s from other occupational  roles  The Idea of Occupational and P r o f e s s i o n a l Roles The l i t e r a t u r e on occupational r o l e s i s i n c r e a s i n g . The quantity of the m a t e r i a l i s dependent on the nature of our society.  The growing i n t e r e s t i n occupational r o l e s i n our  s o c i e t y i s connected w i t h the growing complexity of occupations which accompany s c i e n t i f i c and i n d u s t r i a l development.  The need  f o r understanding t h i s phenomenon has become evident, and  2 Parsons, S o c i a l System, p. l ^ l j . .  the  need to f i n d a method f o r i t s a n a l y s i s i s defined as a "problem." Reference i s o f t e n made to Hughes f o r h i s work i n the area o f occupational a n a l y s i s . A few of h i s p o s t u l a t i o n s on " P e r s o n a l i t y Types and the D i v i s i o n o f Labour,"-^ I found s t i m u l a t i n g and r e l e v a n t t o my area o f i n t e r e s t . He suggests that p e r s o n a l i t y changes and e f f e c t i v e performance are achieved by i s o l a t i o n .  I found that t h i s i s also a p p l i c a b l e to the nurse.  Secondly, he proposes that r o l e s can be placed i n p o s i t i o n s on an occupational scale according t o : the r o l e ;  1) the manner of e n t r y i n t o  2) the a t t i t u d e o f the incumbent towards h i s  occupation;  and 3) the status o f the occupation i n the community.  On the basis o f these he d i f f e r e n t i a t e s the missions, the professions and "near-professions," the trades and the jobs.  the e n t e r p r i s e s , the a r t s ,  These three v a r i a b l e s do not cover  the whole occupational p i c t u r e , because they omit too much • that i s r e l e v a n t , yet they should d e f i n i t e l y be considered i n any scheme f o r r o l e a n a l y s i s . His e l a b o r a t i o n of the p r o f e s s i o n a l r o l e i s very enlightening. technique.  He suggests that a p r o f e s s i o n i s a c u l t u r e and a  I t b u i l d s a set o f a t t r i b u t e s , which i s the property  of the group, and incomprehensible t o o u t s i d e r s . i n t e r a c t i o n w i t h i n and without the group.  A code governs  These various  3 Everett Cherrington Hughes, " P e r s o n a l i t y Types and the D i v i s i o n of Labor," The American Journal o f Sociology. 33, 5-7bV68, March 1928.  a t t r i b u t e s become p e r s o n a l i t y t r a i t s w i t h i n the i n d i v i d u a l . Hughes' main t h e s i s i s , t h e r e f o r e , that d i v i s i o n s i n labour a f f e c t the i n d i v i d u a l by developing d i s t i n c t i v e p e r s o n a l i t y types. This idea o f the c u l t u r e and the community o f p r o f e s s i o n a l i s m i s also exemplified by Goode.^" He terms i t a "community o f p r o f e s s i o n " because o f the sense o f i d e n t i t y o f the members, the common values and language, i t s c o n t i n u i t y , and the power that i s exercised over i t s members.  The l i m i t s  of the community are c l e a r and i t s members and outsiders are w e l l defined.  The next generation i s produced s o c i a l l y by a  c o n t r o l l e d process of adult s o c i a l i z a t i o n . an occupation  Goode suggests that  approaches p r o f e s s i o n a l i s m when i t begins t o show  the c h a r a c t e r i s t i c s of a community. Marshall also c l a r i f i e s the p r o f e s s i o n a l way o f l i f e . The p r o f e s s i o n a l creates around h i m s e l f an atmosphere o f trustworthiness upheld by h i s p r o f e s s i o n a l e t h i c s . He f e e l s that he has the r e s p o n s i b i l i t y f o r a s p e c i f i c knowledge, which he must use i n the i n t e r e s t s of s o c i e t y .  His decisions are made  on the. basis o f being r i g h t , not o f being p r o f i t a b l e . Yet at the same time they "are respectable because they do not s t r i v e f o r money, but they can only remain respectable i f they succeed i n  k W i l l i a m J . Goode, "Community w i t h i n a Community: The Professions," American S o c i o l o g i c a l Review, v o l . 22, 2:19lj.-200, A p r i l 1957. 5 T. H. M a r s h a l l , "The Recent H i s t o r y o f P r o f e s s i o n a l i s m i n R e l a t i o n t o S o c i a l Structure and S o c i a l P o l i c y , " Canadian Journal of Economics and P o l i t i c a l Science, 5:325-3lj.O, 1939.  s p i t e o f t h i s pecuniary i n d i f f e r e n c e , i n making q u i t e a l o t of money, enough f o r the needs of a gentlemanly l i f e . "  This shows  a dual, yet c o n f l i c t i n g , expectation from a p r o f e s s i o n a l r o l e , on the part of both the p u b l i c and the p r o f e s s i o n a l h i m s e l f . Caplow, i n h i s study of work, touches on the various 7  aspects of p r o f e s s i o n a l and occupational r o l e s .  Occupational  i n s t i t u t i o n s , he proposes, r e f l e c t the occupational c u l t u r e . Like Goode, he considers the s t r u c t u r a l c h a r a c t e r i s t i c s o f institutions:  recruitment, evaluation of s e n i o r i t y and m e r i t ,  t h e , c o n t r o l of occupational and non-occupational  behaviour,  folkways of the occupation, formation of relevant a t t i t u d e s and the stereotyped view of the occupation.  He a l s o deals w i t h the  i n c r e a s i n g trend towards p r o f e s s i o n a l i z a t i o n , which he proposes involves the establishment o f a p r o f e s s i o n a l a s s o c i a t i o n designed to oust the u n q u a l i f i e d , a break w i t h previous status by change of name, the development of a code of e t h i c s , p o l i t i c a l a g i t a t i o n designed to i n f l u e n c e opinion and the improvement of training f a c i l i t i e s .  I n t h i s he presents a more concrete  of measuring prof e s s i o n a l i z a t i o n .  I have found h i s  way  suggestions  very u s e f u l when considering the r o l e of the nurse as a professional.  6 M a r s h a l l , Canadian Journal of Economics and P o l i t i c a l  5:326,  1939.  Science.  7 Theodore Caplow, The Sociology of Work. Minnesota, U n i v e r s i t y of Minnesota Press, 195^. ~  H a l l , by h i s work on the i n t e r n a l o r g a n i z a t i o n of the medical p r o f e s s i o n , contributed s i g n i f i c a n t l y to my understanding of the o r g a n i z a t i o n a l patterns w i t h i n the nursing p r o f e s s i o n a l g group.  He conceives of these r e l a t i o n s h i p s i n the same terms  as Goode, M a r s h a l l , Hughes and Caplow —  i n terms of i n s t i t u t i o n s ,  formal organizations and i n f o r m a l i n t e r a c t i o n . He suggests that the study of a p r o f e s s i o n a l r o l e should include f i v e b a s i c areas of i n t e r e s t : the e s s e n t i a l a c t i v i t i e s of the group, the services they render, the manner of r e c r u i t m e n t , the manner of a c q u i r i n g c l i e n t s and the means used to oust i n t r u d e r s .  These f a c t o r s  should a l l be considered i n r o l e - p l a y i n g and r o l e - t a k i n g . He makes an e n l i g h t e n i n g c o n t r i b u t i o n by  suggesting  Q  that there could be a typology of r o l e s . careers according to whether they are " i n d i v i d u a l i s t i c " or " f r i e n d l y . "  He defines medical  "colleague,"  I have t r i e d to achieve a  s i m i l a r segregation among the nurses, although the v a r i a b l e s differ.  The value of H a l l ' s p o s t u l a t i o n s l i e , not i n the  p a r t i c u l a r typology he uses, but rather i n the suggestion  that  such an a n a l y s i s would be worthwhile.  8 Oswald H a l l , "The Informal Organization of the Medical P r o f e s s i o n , " Canadian Journal of Economics and P o l i t i c a l Science, 12, l:30-lUl-, February 1946. 9 Oswald H a l l , "Types of Medical Careers," The American Journal of Sociology. 55* 3:3^4-3-3^3, November 191^9.  As there are numerous occupational r o l e s , i t i s important to organize them i n terms of status i n order t o perceive them more c l e a r l y .  " I t i s doubtful whether any s o c i e t y  ever had so great a v a r i e t y o f statuses or recognized such a. large number of status-determining c h a r a c t e r i s t i c s as does ours,"  1 0  w r i t e s Hughes.  He claims that the "struggle f o r  achievement" brings i n d i v i d u a l t r a i t s i n t o r e l i e f and t h e i r p e c u l i a r combinations  l e a d to c o n t r a d i c t i o n s . He postulates  that many statuses are l e g a l and f o r m a l i z e d , w h i l e others are i l l - d e f i n e d w i t h regard to both i d e n t i f y i n g t r a i t s , r i g h t s and obligations.  Many such c o n t r a d i c t i o n s and dilemmas I found w e l l  exemplified i n the r o l e o f the nurse. Statuses, he claims, give r i s e to the expectations o f " a u x i l i a r y " c h a r a c t e r i s t i c s which are associated w i t h them.  For  example, there i s the expectation that the m a j o r i t y of doctors, engineers, lawyers and supervisors i n i n d u s t r i a l plants should be men.  The combinations  o f such a u x i l i a r y c h a r a c t e r i s t i c s take  on the appearance o f stereotypes which are t r a n s m i t t e d by mass communication.  W i t h i n the occupational group, the expectations  for the appropriate c h a r a c t e r i s t i c s c o n t r o l recruitment. are manifested i n sentiment  They  and behaviour and ensure free  communication among members.  This i n f o r m a l brotherhood, the  author proposes, ousts any i n d i v i d u a l who i s the f i r s t o f h i s  10 E. C. Hughes, "Dilemmas and Contradictions of Status," The American Journal o f Sociology. 50> 353-59, March 19^4-5» p. 353.  kind t o a t t a i n a d i f f e r e n t s t a t u s .  He remains a marginal man.  This I have t r i e d t o point out i n the r o l e o f the nurse. The status o f the nurse I consider to be somewhat marginal to that o f a doctor.  Wardwell, i n h i s work on the  c h i r o p r a c t o r , considers the a t t r i b u t e s o f the marginal professional r o l e .  The i n d i v i d u a l involved seeks and wants  acceptance and has only p a r t l y been a c c e p t e d . of status i s c h a r a c t e r i z e d by:  11  Marginality  l e s s t e c h n i c a l competence,  l i m i t e d scope o f p r a c t i c e , lower l e g a l s t a t u s , l e s s income and prestige.  The status o f the nurse c e r t a i n l y seems t o have these  characteristics. One o f my hypotheses was that many o f the dilemmas o f the nursing status arose out o f t h e i r being "women." I t was i n t e r e s t i n g t o note that Gaplow defined the occupational of women as "a problem."  status  He i s i n c l i n e d to dwell on t h e i r  d i s c o n t i n u i t y , t h e i r small wages, immobility, lower status and the pressures writes:  aimed to reduce t h e i r a b i l i t y to q u a l i f y . He  " I t may not be f a r - f e t c h e d t o speak o f a generalized  c u l t u r a l r e s i s t a n c e by men t o a c t i o n i n i t i a t e d f o r them by women 12  to whom they are not r e l a t e d emotionally."  As f a r as nursing  i s concerned, t h i s suggestion i s worthy o f consideration. 11 W. I . Wardwell, "A Marginal P r o f e s s i o n a l Role: Chiropractor." S o c i a l Forces. 30, 3:339-3^8, 1952. 12 Caplow, The Sociology of Work, p. 2l\l.  The  These, b r i e f l y , are the f i n d i n g s that I found r e l e v a n t to my work as f a r as the understanding of occupational and p r o f e s s i o n a l r o l e s i s concerned.  The Idea o f Role-Taking I began w i t h the hypothesis that a nurse becomes i n c r e a s i n g l y aware of i n s t i t u t i o n a l s t r u c t u r e and f u n c t i o n . Parsons supports t h i s In h i s conceptions o f the s o c i a l i z a t i o n of a c h i l d .  He suggests t h a t the " a f f e c t i v e " a t t i t u d e s would be  acquired f i r s t because of t h e i r d i r e c t r e l a t i o n s h i p to dependence and emotional attachment to the mother.  This i s also l i a b l e to  happen i n a h o s p i t a l , where the nurse, p r i o r to the adoption of the proper a t t i t u d e s , i s l i a b l e to form " a f f e c t i v e " o r i e n t a t i o n s , or emotional attachments to p a t i e n t s .  I t s opposite p o l a r i t y ,  " a f f e c t i v e n e u t r a l i t y , " Parsons continues, Is more d i f f i c u l t to acquire.  A nurse f i n d s i t d i f f i c u l t to assume an unattached  manner towards some p a t i e n t s .  " U n i v e r s a l i s t i c " patterns would  be the hardest to acquire. This i s true i n the h o s p i t a l s e t t i n g , where i t i s d i f f i c u l t f o r a nurse not to express preferences f o r c e r t a i n types of p a t i e n t s above others.  Parsons opens up t h i s  valuable area of i n t e r r e l a t i o n a h i p s , between s o c i a l i z a t i o n and 'pattern v a r i a b l e s . " This introduces a concept o f stages i n s o c i a l i z a t i o n . Parsons sees i t , not as a l i n e a r process, but r a t h e r as a  discontinuous, s p i r a l p a t t e r n .  He introduces the terms  " s o c i a l i z e r " and " s o c i a l i z e e . "  The former could be taken to  be the teacher, the l a t t e r the l e a r n e r .  Of these two the former  i s the more powerful and i s a p a r t i c i p a n t i n two stages:  the  higher one, which the s o c i a l i z e e has not yet reached and the lower, i n which he i s being s o c i a l i z e d .  Hence the s o c i a l i z e r  serves a l e v e r i n g f u n c t i o n . This concept o f stages i s f u r t h e r supported by Parsons' ideas on the s o c i a l i z a t i o n o f the c h i l d . i n f i v e phases. ^" 1  He sets out the process  Phase one i s a s t a b l e s t a t e ;  The s o c i a l i z e r ,  i n t h i s case the mother, gives instrumental care and l o v e , acts as a d i s c i p l i n a r i a n , yet does not "expect too much." phase d i s p l a y s a change i n s e v e r a l areas:  The second  there i s a greater  capacity on the part of the s o c i a l i z e e t o perform more s k i l f u l l y ; the s o c i a l i z e r i s responsible f o r representing i n s t i t u t i o n a l expectations to the s o c i a l i z e e , and at the same time the s o c i a l i z e e i s expected to meet these new expectations; the s o c i a l i z e r i s more permissive and tends to withhold punishment; the s o c i a l i z e e i s f r u s t r a t e d and o f t e n aggressive, r e g r e s s i v e or anxious.  The t h i r d phase i s c h a r a c t e r i z e d by a graduation i n t o a  disturbed s t a t e where the s o c i a l i z e e has no p o s i t i v e b a s i c d e s i r e to define objects i n t h i s stage.  The s o c i a l i z e r now gives  support  13 T a l c o t t Parsons and Robert Bales, Family, S o c i a l i z a t i o n and I n t e r a c t i o n Process, Glencoe, I l l i n o i s , Free Press, 1955, P« 1^-O-ip.. Ik. Ibid.,,- pp. 202-216.  which i s r e l a t e d to her acceptance of the s o c i a l i z e e , despite h i s inadequacies; and the s o c i a l i z e r r e l i e s , h e a v i l y on the l a t t e r ' attachment to her. socializee.  This support motivates p o s i t i v e a c t i o n by the  The f o u r t h phase i s one i n which the elementary  adjustments have been made, and the s o c i a l i z e e i s concerned w i t h the i n t e r n a l i z a t i o n of the new  values.  a t t a i n e d the f i f t h phase begins.  When t h i s goal i s  In t h i s f o u r t h phase the agents  of s o c i a l i z a t i o n , i n Parsons' example, the f a m i l y , are conceived by the s o c i a l i z e e as being s i g n i f i c a n t and are expected by to act a p p r o p r i a t e l y .  He i s now  i n a h i g h e r - l e v e l system and h i s  attachments to the lower must d i s s o l v e . d i r e c t s t h i s process,  him  The  chief s o c i a l i z e r  "This takes the form of c o n s i s t e n t l y  holding the relevant c o g n i t i v e cues before the c h i l d ,  and  gradually, according to h i s capacity to 'take i t ' without undue anxiety, withdrawing the l o w e r - l e v e l support, and s u b s t i t u t i n g f o r i t support or .'acceptance' on the 'parental' l e v e l  and  s p e c i f i c g r a t i f i c a t i o n s as rewards f o r adequate performance i n the new  context.  1,1  ^  Phase f i v e , i s a stage of r e o r g a n i z a t i o n  a f t e r the acceptance of new  r e c r u i t s . These c o n t r i b u t i o n s of  Parsons', where the family, mother and c h i l d could correspond to the h o s p i t a l , the school o f nursing and the student nurse, are valuable.  P a r t i c u l a r l y enlightening are h i s concepts of  d e s o c i a l i z a t i o n from the o l d state of e q u i l i b r i u m and h i s reference to a "disturbed s t a t e " where there i s no  motivation  15 Parsons and Bales, Family, S o c i a l i z a t i o n and I n t e r a c t i o n Process, p. 212.  or p o s i t i v e b a s i s f o r d e f i n i n g o b j e c t s . Becker also focusses a t t e n t i o n on these two phases of s o c i a l i z a t i o n and suggests t h a t the t r a i n i n g period i s l i r a i t i as w e l l as expanding, i n that i t prepares the r e c r u i t f o r new l6  d u t i e s , but at the same time i n c a p a c i t a t e s him f o r others. This i s another u s e f u l i n s i g h t f o r the understanding  of the  s o c i a l i z a t i o n of nursing students. This d i s t u r b e d s t a t e of Parsons'  scheme, and the  l i m i t i n g as w e l l as expanding concept of Becker, could also be c a l l e d a p e r i o d of d i s i l l u s i o n m e n t . Supporting evidence i s supplied by Hughes, who w r i t e s of the discrepancy between a n t i c i p a t i o n and r e a l i z a t i o n , and t h a t expectations are u s u a l l y 17  simpler and even d i s t o r t e d and stereotyped. This i s also the " r e a l i t y shock" of Dornbusch, which accompanies the d i s p a r i t y 18  between expectation and r e a l i t y .  16 H. S. Becker and A. L. Strauss, "Career, P e r s o n a l i t y and Adult S o c i a l i z a t i o n , " r e p r i n t from The American Journal o f Sociology. November 195&« 17 E. C. Hughes, "The Making o f a P h y s i c i a n — A General Statement of Ideas and Problems," Human Organization. Xi|.sI4., Winter 1956, pp. 21-25. 18 Sanford M. Dornbusch, "The M i l i t a r y Academy as an Assimi l a t i n g I n s t i t u t i o n , " S o c i a l Forces. 3 3 3 1 6 - 3 2 1 , May 1955-  As f a r as the t r a i n i n g of nurses i s concerned, Parsons and Bales have suggested two types o f "role a c t i v i t y " which have 19 proved h e l p f u l i n analysing the phenomenon.  The f i r s t type  has to do w i t h the i n h i b i t i o n of emotions, the formation of r a t i o n a l views towards s o c i a l s i t u a t i o n s and f i n a l l y , w i t h the handling o f o b j e c t s .  I n short these a c t i v i t i e s could be  described i n Parsonian terms as " a f f e c t i v e l y n e u t r a l , " " f u n c t i o n a l l y s p e c i f i c , " " u n i v e r s a l i s t i c " and "achieved."  It  corresponds to the area o f nursing education that transmits t e c h n i c a l s k i l l s and t h e i r a p p l i c a t i o n . The second type deals w i t h i n t e r n a l s i t u a t i o n s and e m o t i o n a l i t y .  This corresponds to  the area of r o l e - l e a r n i n g that concerns the transmission o f the ideas behind the s k i l l s t h a t are used.  Parsons i m p l i e s that the  f i r s t type leads to a "going apart," w h i l e the second type leads to  a "coming together."  This i s relevant t o the r o l e - t a k i n g o f  nurses where impersonal s c i e n t i f i c techniques are not conducive to a f e e l i n g o f "togetherness" among students, but l e a d r a t h e r to s o c i a l i s o l a t i o n ; w h i l e the transmission o f a t t i t u d e s and b e l i e f s , i n so much as i t involves transmission by group i n t e r a c t i o n , leads t o i n t e g r a t i o n . Therefore as has been suggested by Parsons, Becker, Hughes and others, s o c i a l i z a t i o n , or r o l e - t a k i n g , as I have termed i t , could be seen as stages, and r i t e s de passage. I t 19 Parsons and Bales, Family. S o c i a l i z a t i o n and I n t e r a c t i o n Process, pp. 309-312.  involves a p e r i o d of formal t r a i n i n g and l e a r n i n g and informal transmission of a t t i t u d e s . forgets.  The s o c i a l i z e e l e a r n s , but he also  He becomes i n t e g r a t e d w i t h h i s group, but segregated  from others. These f a c t s have encouraged me Into asking s i m i l a r questions of the nursing r o l e .  Works on the Role o f the Nurse W i t h i n the immediate past much has been w r i t t e n on the r o l e o f the nurse.  There are, however, o n l y three studies which  could be considered of immediate relevance to t h i s t h e s i s . The f i r s t i s one which emphasizes the changes o c c u r r i n g  20 i n the nursing r o l e during the process of r o l e - t a k i n g .  I t Is  suggested that f i r s t year students enjoy t h e i r c l a s s e s , l i k e the head nurses and have ambivalent f e e l i n g s towards the supervisor. They believe nursing i s an i d e a l service f o r the w e l f a r e of man. Second year students are h i g h l y s e n s i t i v e , e a s i l y h u r t , have f e e l i n g s of i n f e r i o r i t y to other students, graduate nurses and other medical s t a f f .  They f i n d i t harder to study because o f  boredom w i t h t h e i r c l o i s t e r e d existence and the monotony of routine.  T h i r d year students f e e l l e s s secure i n t h e i r status  as a c t i v e team members and f e e l that t h e i r work i s d i r e c t e d by doctors.  They tend to look at t h e i r work as a "job," "a never-  ending job." These v a r i a t i o n s seem to i n d i c a t e a " r e a l i t y 20 A l i c e E. Ingmire, "Attitudes of Student Nurses at the U n i v e r s i t y o f C a l i f o r n i a , " Nursing Research. 1:2, October 19£2.  shock," o r the sudden r e a l i z a t i o n of the d i s p a r i t y between the way a job i s envisaged before beginning on the l e a r n i n g process and the way i t i s conceived i n the work s i t u a t i o n . The second study o f importance, as f a r as t h i s t h e s i s i s concerned, compares the p e r s o n a l i t y c h a r a c t e r i s t i c s o f nursing 21  students, o f graduate nurses and o f a norm group.  The r e s u l t s  showed that the students and graduate nurses were more i n t r o v e r t e d than the norm; that graduate nurses were more c h e e r f u l , o p t i m i s t i c , emotionally s t a b l e , c o n t r o l l e d , conscientious, cooperative, agreeable, o b j e c t i v e , s e l f - c o n f i d e n t and more i n c l i n e d to overt a c t i v i t y than e i t h e r o f the other groups; that graduate nurses showed more favourable r e s u l t s w i t h r e g a r d to i n f e r i o r i t y , nervousness, depression and g e n e r a l l y a more fortunate adjustment; that nursing students were l e s s favourable than the norm i n s o c i a l e x t r o v e r s i o n , depression, s o c i a l ascendancy and cooperation. For me the importance of t h i s study does not l i e i n the a c t u a l c h a r a c t e r i s t i c s a t t r i b u t e d to the students as much as i n the i m p l i c a t i o n that these a t t i t u d e s change a f t e r acceptance i n t o the occupational group.  This seems t o i n d i c a t e that A l i c e  Ingmire's r e s u l t s could have taken a complete change had she continued her study a f t e r graduation. I t seems l i k e l y t h e r e f o r e that the t r a i n i n g process engenders f r u s t r a t i o n s and depression which can be d i s p e l l e d w i t h acceptance and f u l l r o l e - s t a t u s i n 21 Irene Healy and W. R. Borg, " P e r s o n a l i t y C h a r a c t e r i s t i c s of Nursing School Students and Graduate Nurses," Journal o f A p p l i e d Psychology. 35:275-280, 1951.  37  the h i e r a r c h y . The t h i r d r e l e v a n t piece of work was  conducted by Ann  22  Morrison and Mary Breed.  They explored the impressions h e l d  by student nurses at two stages i n t h e i r education, the senior and the freshman phases.  F i r s t l y , the juniors had no impressions  or plans as to where they would work, what p o s i t i o n s they would h o l d , nor the type of work they would l i k e to do. other hand, were r a t h e r d e f i n i t e about t h i s .  Seniors on the  Secondly, the  younger g i r l s showed preferences and pleasant expectations towards p e d i a t r i c s and o b s t e t r i c s . were drawn by i t s drama.  They expressed fears of surgery, but The o l d e r g i r l s , however, showed wide  v a r i a t i o n , preferences o f t e n being i n f l u e n c e d by the school they attended and the personnel o f the department.  T h i r d l y , freshmen  on the whole thought the p u b l i c image o f the p r o f e s s i o n was good, while the seniors had a more d i f f e r e n t i a t e d i d e a .  F o u r t h l y , the  younger g i r l s wanted to marry husbands w i t h s e n s a t i o n a l occupations, the seniors placed more emphasis on education l e v e l . F i f t h l y , the authors found f u r t h e r evidence f o r the ment process.  disillusion-  The younger nurses were more o p t i m i s t i c , they  discovered; the older ones were more c y n i c a l .  The former  the a d m i n i s t r a t i o n was attempting to help them, the displayed resentment at being " t r e a t e d l i k e babies."  thought  latter Sixthly,  22 Ann Morrison and Mary Lou Breed, "Some Interviewer's Impressions of Student Nurses a t Two Stages o f Their Education," M e t r o p o l i t a n Nurse Study Work i n Progress No. 2, Kansas C i t y , M i s s o u r i , Community Studies Inc., 1955.  the beginner could envisage an i d e a l nurse and an i d e a l p a t i e n t . Their t r a i n i n g they a n t i c i p a t e d as being harder than i t a c t u a l l y was.  The g i r l s , ready to. graduate, had d i f f i c u l t y i n conceptual-  i z i n g the i d e a l nurse and queried the existence of an i d e a l patient.  They f e l t that they had been unprepared f o r the  t r a i n i n g they r e c e i v e d .  The seventh point mentioned by the  authors was the expected d i f f e r e n c e s i n v e r b a l i z a t i o n , i n the use and understanding of terminology, i n concepts o f status and professionalization.  As expected, the seniors were more  s o p h i s t i c a t e d i n t h i s area. a great body of data.  The authors, t h e r e f o r e , have amassed  The c l e a r e s t i n d i c a t i o n i s that change i n  a t t i t u d e s and conception of s e l f occurs.  The more senior the  students are, the more c y n i c a l they seem t o become. A l i c e Ingmire's f i n d i n g s .  This supports  A l l three studies point out a d i f f e r e n c e  between i n i t i a l conception and f i n a l experience.  The study by  Morrison and Breed, however, i n d i c a t e s that acceptance i n t o the p r o f e s s i o n i s l i a b l e to d i s p e l cynicism. As f a r as these studies are concerned i t should be noted that there i s a discrepancy between what i s staid and what i s meant.  However, the f i n d i n g s of the above three studies are  valuable i n showing that students i n d i f f e r e n t phases o f r o l e t a k i n g say d i f f e r e n t things about the a t t i t u d e s they h o l d .  What  a c t u a l l y i s meant and why they say what they do, can only be inferred.  Some of the ideas put f o r t h i n t h i s study have grown out o f the works mentioned above.  Sometimes works by others  have d i r e c t e d my thoughts i n t o new channels, other times they have stimulated f u r t h e r e n q u i r i e s , and o f t e n they have served to support hunches.  3 . The Major Questions o f t h i s Study The data c o l l e c t e d and the questions answered by t h i s study could be organized under two primary areas: and r o l e - p l a y i n g .  role-taking  By u s i n g these two concepts I found that I  could pose the problems and present the answers more systematically.  Only through u s i n g these two a r b i t r a r y  categories d i d I f e e l I could do j u s t i c e t o the m a t e r i a l I had gathered.  Role-taking As f a r as " r o l e - t a k i n g " i s concerned, I have t r i e d to answer the f o l l o w i n g questions: 1. they?  Are there stages to becoming a nurse?  What are  This query presupposes that s o c i a l i z a t i o n i s not an  u n d i f f e r e n t i a t e d l i n e a r process, but i s o f such a nature that d i v i s i o n i n t o stages i s p o s s i b l e . 2. What reasons do nurses give f o r going i n t o training?  How strong i s t h e i r wish f o r nursing as an occupation?  By what means are they r e c r u i t e d and what q u a l i f i c a t i o n s are  desired?  The area o f m o t i v a t i o n and recruitment i s an i n t e g r a l  part of any c o n s i d e r a t i o n of r o l e - t a k i n g and i s touched on i n t h i s study. 3.  How,  what do they learn?  and what, are the students taught?  How  and  An i n v e s t i g a t i o n of the education and t r a i n i n g  involved i s important, not o n l y i n so f a r as formal and d i r e c t teaching and l e a r n i n g occurs, but also as students o f t e n l e a r n what they are not taught. the question: transmitted?  There should also be an answer to  how are the r e l e v a n t a t t i t u d e s and techniques Is there a mould i n t o which the r e c r u i t i s to be  fitted? ij.. they?  What changes are there i n conceptions?  What are  These questions delve i n t o the area of changing s e l f -  conceptions and a t t i t u d e s .  There seems to be an i n d i c a t i o n of  t h i s change i n the very nature o f s o c i a l i z a t i o n , which i s a dynamic process, subject to constant change. major question: £.  This leads to the  what types of changes are there?  Is there an i n c r e a s i n g i n s t i t u t i o n a l i z a t i o n ?  Do  the students show an i n c r e a s i n g awareness of the h o s p i t a l as an i n t e g r a t i o n of other r o l e s w i t h t h e i r own?  This i m p l i e s that a  nurse, i n the process of r o l e - t a k i n g , develops an i n c r e a s i n g a b i l i t y to place h e r s e l f i n a context. 6.  Is there a changing c a t e g o r i z a t i o n and a t t i t u d e  towards the other r o l e s w i t h whom the student nurse i n t e r a c t s ? This i n v o l v e s the p o s s i b i l i t y of changing views towards people  '1  such as i n s t r u c t r e s s e s , a d m i n i s t r a t o r s , doctors and so on. 7.  Do the students have a p e r i o d o f d i s i l l u s i o n m e n t  or a " r e a l i t y shock"?  The occurrence o f t h i s phenomenon has  been pointed out i n s e v e r a l o f the works reviewed i n an e a r l i e r part o f t h i s chapter and i t would be i n t e r e s t i n g t o discover whether there i s evidence o f i t s occurrence among the subjects I studied. 8. What are the manifest and l a t e n t functions o f the system o f i s o l a t i o n used i n the t r a i n i n g o f nurses?  Does the  l e a r n i n g o f the nursing r o l e also imply the unlearning o f other roles?  I s there a decreasing a b i l i t y t o i d e n t i f y w i t h o u t s i d e r s  and an i n c r e a s i n g s o l i d a r i t y w i t h i n the nursing group?  How are  nursing groups organized? 9.  What types o f nurses seem to be evolving?  This  presupposes that there are d i f f e r e n c e s between the nurses a f t e r the process o f r o l e - t a k i n g . These seem to be the major questions that are i n v o l v e d i n s o c i a l i z a t i o n , and I have t r i e d to provide answers to these i n the context o f t h i s t h e s i s .  Role-playing I n r o l e - p l a y i n g there i s one major question that has to be answered:  What i s i t l i k e to be a nurse?  The problem l i e s  i n how t o look at the r o l e o f the nurse and how to present a l l  k2  the aspects of the r o l e .  I intend therefore to use f i v e v a r i a b l e s ,  which seem to cover a l l the important areas of a r o l e : 1. 2. 3. it-. 5>.  Images of the Role Character of the Obligations Rewards Strains R e l a t i o n to Others  The use of such a scheme o f v a r i a b l e s has a twofold advantage.  F i r s t l y , the r o l e of the nurse can be taken apart,  studied, and then put together i n t o a more meaningful whole. Secondly, the scheme i s such that i t i s a p p l i c a b l e to other occupational r o l e s .  In t h i s way the r o l e of the nurse can be  compared to other r o l e s . The meaning of the f i v e v a r i a b l e s should be b r i e f l y explained.  A more d e t a i l e d explanation w i l l be given i n  f o l l o w i n g chapters. 1.  Images of the Role.  This covers two p o s s i b l e  perspectives on the r o l e of the nurse.  I t r e f e r s , f i r s t l y , to  the p u b l i c image, or the expectations and evaluations of the r o l e held by the p u b l i c . self-image.  Secondly, i t concerns the occupational  This self-image i s constructed on the basis of the  p u b l i c image and the image held f o r t h by the occupational group. I t i s a system of b e l i e f s , i d e a l s , expectations and myths to which the members are committed, and which defines t h e i r course of a c t i o n . I t i s an i d e a l i z a t i o n of the values of the group and shows a d i s r e g a r d f o r r e a l i t y .  The nurse i s moulded p a r t l y by  the p u b l i c image and p a r t l y by the i d e a l self-image h e l d out to her.  2.  Character o f the O b l i g a t i o n s .  The o b l i g a t i o n s o f  the.nurse r e f e r t o the tasks she must perform and the manner i n which she must perform them. Her tasks are both impersonal, dealing w i t h instrumental a c t i v i t i e s , such as doing dressings and g i v i n g medications, and personal, dealing w i t h her i n t e r a c t i o n w i t h others.  Both v a r i e t i e s o f o b l i g a t i o n s  are governed by a  set o f standards which are to be upheld as part o f the o b l i g a t i o n s o f the r o l e . 3.  Rewards. For any i n d i v i d u a l to continue p l a y i n g  a r o l e there must be adequate rewards to balance the weight o f the o b l i g a t i o n s .  Rewards could come i n many forms.  be i n terms o f remuneration, prestige or s e c u r i t y .  They could As long as  the s a t i s f a c t i o n s r e c e i v e d outbalance the d i s s a t i s f a c t i o n s and s t r a i n s , t h e m o t i v a t i o n t o continue p l a y i n g the r o l e i s reinforced. l+. S t r a i n s .  C o n f l i c t s and s t r a i n s are aspects o f  every r o l e and serve both p o s i t i v e and negative f u n c t i o n s .  When  the s t r a i n becomes too oppressive attempts are made t o r e l i n q u i s h the r o l e or to r e d i r e c t a c t i v i t i e s i n t o a more s a t i s f y i n g channel. Often inner desires and s o c i a l expectations are i n c o n f l i c t , a t other times rewards do not balance o b l i g a t i o n s  and s t r a i n s and  i n s t i l l other instances there are d i v i d e d r e s p o n s i b i l i t i e s . Each r o l e acquires ways o f coping w i t h s t r a i n s that are an i n s t i t u t i o n a l i z e d part o f the r o l e and are acquired w i t h a l l the other aspects o f the r o l e .  5.  R e l a t i o n t o others.  There are three p o s s i b l e  r e l a t i o n s that could be discussed i n t h i s context.  There i s  the question as t o how the r o l e i s defined i n r e l a t i o n to other r o l e s i n s o c i e t y and what status i t occupies.  T h i s , because of  the l a c k o f a set o f c r i t e r i a by which each r o l e could be a l l o c a t e d , must be a matter o f s p e c u l a t i o n .  Secondly, there i s  the question of the p o s i t i o n o f the r o l e i n the occupational world.  In t h i s instance i t could be considered a general work  r o l e , a female r o l e and a medical r o l e .  T h i r d l y , there i s the  question o f the r e l a t i o n of the nursing r o l e to other r o l e s w i t h i n the context o f the medical i n s t i t u t i o n of the h o s p i t a l . These categories o f r o l e r e l a t i o n s h i p s should take Into consideration both the conceptions on the p a r t . o f the nurse and the conceptions on the part o f the "others" i n v o l v e d .  CHAPTER I I I RESEARCH METHODS AND EXPERIENCES  This i s a study on the making of a nurse.  Its  leading actors are f o r t y student nurses e n r o l l e d i n the u n i v e r s i t y course l e a d i n g to the degree of Bachelor of Science i n Nursing.  They are to be d i f f e r e n t i a t e d from t h e i r s i s t e r s  i n the h o s p i t a l course, who terminate t h e i r studies by a c q u i r i n g the status of R e g i s t e r e d Nurse.  The main d i f f e r e n c e s  l i e , f i r s t l y , i n the d u r a t i o n of t h e i r t r a i n i n g which exceeds the other by a year; secondly, i n t h e i r a f f i l i a t i o n w i t h the u n i v e r s i t y ; and t h i r d l y , i n that t h e i r t r a i n i n g enables s p e c i a l i z a t i o n i n p u b l i c h e a l t h agencies or i n a d m i n i s t r a t i v e and i n s t r u c t i o n p o s i t i o n s i n the h o s p i t a l s .  Of t h i s four year  period, two years are spent at the h o s p i t a l where occupational t r a i n i n g i s r e c e i v e d i n conjunction w i t h the .hospital c l a s s and the g i r l s experience residence l i f e .  The i n s t r u c t i o n f o r  the remaining two years, i n f a c t the f i r s t and f o u r t h years o f the program, i s given on the u n i v e r s i t y campus. Data f o r the study was c o l l e c t e d during an eighteen month p e r i o d from October, 1955 to A p r i l , 1957.  The i n t e n s i t y  of the research ranged from the observation of a two-weekly campus d i s c u s s i o n group, composed o f student nurses to a dayto-day two month p a r t i c i p a t i o n , i n v o l v i n g l e c t u r e s , ward  r o u t i n e s and r e s i d e n c e l i f e - - i n nurse."  s h o r t , "becoming a student  During t h e time t h a t I had t o devote to l e c t u r e s ,  examinations  and d a t a a n a l y s i s , c o n t a c t w i t h the group was  retained. I t may prove f e a s i b l e at t h i s p o i n t to focus a t t e n t i o n on t h i s group, i n s t i t u t i o n a l l y i d e n t i f i e d as the " c l a s s o f August  ' £8" and f o r t h e purpose o f t h i s r e s e a r c h  o f t e n r e f e r r e d t o as "the c l a s s . "  S e v e r a l o f the g i r l s have  grown up t o g e t h e r , have had t h e i r elementary  education  together and have been f r i e n d s f o r many years b e f o r e e n t e r i n g university.  A l l o f them have had the common experience o f  t a k i n g the f i r s t year i n the F a c u l t y o f A r t s and Science and a few have taken two years i n t h i s f a c u l t y .  (Appendix  A 9)'« .  A f t e r seven months I n the U n i v e r s i t y School o f Nursing the m a j o r i t y were n i n e t e e n years o f age, a few were a year younger or  a year o l d e r .  (Appendix  A 1).  Some belonged t o s o r o r i t i e s  and most were a f f i l i a t e d w i t h one o r s e v e r a l a t h l e t i c ,  social,  p o l i t i c a l o r r e l i g i o u s campus o r g a n i z a t i o n s . Although b i r t h p l a c e s i n c l u d e d such n e i g h b o r i n g l o c a l i t i e s as New Westminster and c o u n t r i e s as d i s t a n t as Japan, t w e n t y - f i v e students gave t h e i r home address as Vancouver and adjacent areas, f o u r t e e n mentioned other B r i t i s h  Columbian  p o i n t s , w h i l e t h r e e claimed homes i n o t h e r p r o v i n c e s . A l l , however, were i n r e s i d e n c e e i t h e r i n p a r e n t a l homes o r t e m p o r a r i l y boarding i n d o r m i t o r i e s o r p r i v a t e d w e l l i n g s . (Appendix A 2, £ ) .  The m a j o r i t y had parents o f what would be considered middle c l a s s socio-economic status and predominately o f Canadian n a t i o n a l i t y and Protestant r e l i g i o u s a f f i l i a t i o n s . (Appendix A 3 , h» 6, 7).  Mothers had, i n the m a j o r i t y , been  employed before marriage i n e i t h e r a semi-professional or white c o l l a r c a p a c i t y and had r e t i r e d a f t e r marriage t o the occupational status o f "housewife."  (Appendix A 7,  8).  To conclude t h i s survey o f the s i g n i f i c a n t actors who made up the'core o f t h i s study, a b r i e f mention o f the h o s p i t a l should not be omitted.  The i n s t i t u t i o n w i t h which  the u n i v e r s i t y school i s a f f i l i a t e d i s a l a r g e metropolitan general h o s p i t a l , o f t e n defined as a "teaching h o s p i t a l " because i t functions as a t r a i n i n g post f o r medical  students,  student nurses, d i e t e t i c i n t e r n e s , h o s p i t a l a d m i n i s t r a t i o n aspirants and others.  Because o f i t s s i z e and d i v e r s i t y i t  i s p o t e n t i a l l y able to o f f e r s u p e r i o r knowledge and t r a i n i n g m a t e r i a l f o r a l l nursing s p e c i a l i t i e s .  Thus i t i s widespread  i n both area and experience, and shows a promise o f s t i l l further  expansion. Such then i s the s o c i a l m i l i e u w i t h i n , which the  research was c a r r i e d out. More d e t a i l e d d e s c r i p t i o n s w i l l be u t i l i z e d where method or i n t e r p r e t a t i o n make i t necessary.  The C o l l e c t i o n o f Data A f t e r the formulation of a hypothesis, however u n c e r t a i n or exploratory i t may  seem, the next step i s research.  This i s the t e s t i n g of the hypothesis toy l o g i c a l s c i e n t i f i c procedures w i t h the aim of e i t h e r proving or d i s p r o v i n g i t . This I intended to do, but soon discovered t h a t t h i s v e r i f i c a t i o n became only a secondary f u n c t i o n of the r e s e a r c h . P r i m a r i l y , i t served i n posing questions which had been unknown at the outset and i n r e d i r e c t i n g ' a t t e n t i o n to other areas, which now became e q u a l l y important.  Whereas i n i t i a l l y  my i n t e r e s t had been centred on occupational a n a l y s i s and r o l e expectation, I soon became aware of the value of considering the complex and embracing concepts of r o l e and s o c i a l i z a t i o n . Whereas I had intended t o concentrate on the student nurse, I found, i n due course, that t h i s was not f e a s i b l e unless I placed her i n the context of the i n s t i t u t i o n a l p a t t e r n s , and at l e a s t contemplated  a b r i e f look at c e r t a i n c u l t u r a l t r a i t s  which i n f l u e n c e d her s o c i a l i z a t i o n i n t o the r o l e .  Thus I was  forced to r e a l i z e that a general e x p l o r a t i o n of the f i e l d of study would he v a l u a b l e .  Only i n t h i s way could the work be  f l e x i b l e and f l u i d enough to permit unexpected and perhaps new i n f e r e n c e s .  I soon expanded my aim from seeking a - ,  v a l i d a t i o n o f my hypothesis to that of g a i n i n g a more intimate view o f the t r a i n i n g , l i f e and perception of the student nurse. I wanted to develop two p e r s p e c t i v e s .  F i r s t l y , I wanted to  view the s i t u a t i o n from the p o s i t i o n of an o u t s i d e r , the  o b j e c t i v e view of an onlooker who i s able to see behavior and a t t i t u d e s as i f they were measurable o b j e c t s . The  second  view-point was that of the s i t u a t i o n as i t would be perceived by the actor, an i n s i d e r .  This would be s u b j e c t i v e and  achieved l a r g e l y through the process of empathy.  Of course,  to describe these two areas as being s u b j e c t i v e and o b j e c t i v e i s a gross understatement.  Where the process of i n t e r p r e t a t i o n  i s i n v o l v e d , o b j e c t i v i t y i s unavoidably marred. A l l i n t e r p r e t a t i o n i s s u b j e c t i v e to some degree, and to say that the researcher should s t r i v e f o r the greatest degree of o b j e c t i v i t y p o s s i b l e , would be c l o s e r to the t r u t h . The c o l l e c t i o n of data was to be conducted i n a d i r e c t manner by p a r t i c i p a n t observation, an i l l - d e f i n e d method which seems to have become a constant t o o l of the s o c i a l s c i e n t i s t as a r e s u l t of repeated use, r a t h e r than c r i t i c a l e v a l u a t i o n . This enabled me to g a i n f i r s t - h a n d knowledge, to observe behaviour and a t t i t u d e s , and to c o l l e c t non-quantitative m a t e r i a l .  I n a d d i t i o n i t gave me the  opportunity o f conducting unguided i n t e r v i e w s and of paving the way f o r other research techniques.  To supplement t h i s  method, I used the guided i n t e r v i e w and a q u e s t i o n n a i r e .  P a r t i c i p a n t Observation I t h i n k I should c l a r i f y what I understood the concept of p a r t i c i p a n t observation to mean and how i t was used i n reference to t h i s study.  The observer becomes part  of the s i t u a t i o n i n e i t h e r an a c t i v e or passive manner.  At  one time or another I u t i l i z e d both o f these r o l e s by e i t h e r i n c r e a s i n g i n t e g r a t i o n and i n t e r a c t i o n or by i n t e r a c t i n g as l i t t l e as p o s s i b l e . This enabled me to gain i m p r e s s i o n i s t i c knowledge, which although i t was n e i t h e r q u a n t i t a t i v e nor s t a t i s t i c a l , proved valuable i n supplying s i t u a t i o n s f o r questioning, i n t e r p r e t i n g a c t i o n s , c o l l e c t i n g case m a t e r i a l s , rendering c e r t a i n behaviour p r e d i c t a b l e , comparing a t t i t u d e s and g e n e r a l l y i n f a m i l i a r i z i n g myself w i t h the context the actors w i t h i n i t .  In t h i s way,  a l s o , I was  d e t a i l s which otherwise would have remained  able to note  unrevealed--such  as the remark that accompanied an a c t i o n , f a c i a l and other behaviour which was apparent to me,  and  expressions  as an observer  and as an o u t s i d e r . This i s a method, then, wherein the dynamics of behaviour and a t t i t u d e can be observed and explored w i t h i n i t s context. P a r t i c i p a t i o n i n the l i f e of the group l e d me diverse s i t u a t i o n s .  into  These included not only sleeping i n  residence and attending l e c t u r e s , but also t a l k i n g to various s t a f f personnel from a l l l e v e l s of the h i e r a r c h y ; s i t t i n g i n the nursing s t a t i o n observing i n t e r a c t i o n among nurses, p a t i e n t s , v i s i t o r s and doctors; partaking i n conversations at the dinner t a b l e ; standing u n o b t r u s i v e l y i n the corner of the operating room; attending movies and beach p a r t i e s w i t h student nurses; l i s t e n i n g to complaints by and about various people; c a r r y i n g out bedpans and c a r r y i n g i n lunch t r a y s ; watching  various nursing procedures; t a l k i n g to p a t i e n t s ; and j u s t d r i n k i n g c o f f e e . There were also the numerous personal contacts which t h i s method made p o s s i b l e . Thus I was able to develop conceptions o f behavioral patterns and i d e n t i f y s u f f i c i e n t l y w i t h the sub-system o f the h o s p i t a l to p r e d i c t a c t i o n . ' In other words, I g r a d u a l l y developed a knowledge s i m i l a r to that o f the h o s p i t a l personnel, o r an i n s i g h t which enabled me t o judge what should be done, what was expected and what should not be done.  This allowed me l a t e r  to o f t e n discount the face value o f statements made to me i n interviews and questionnaires and t o examine them i n terms of what t h e i r r e a l meaning could be.  Such statements were  o f t e n formulated i n terms o f what the g i r l s conceived as group expectation, and t h e i r exact meaning was evaded. At the outset I was made aware o f the n e c e s s i t y f o r the adoption o f a r o l e .  To be accepted by the group, I  had to be defined, t o be placed w i t h i n the standards and values upheld by them.  My aim was t o d i m i n i s h s o c i a l d i s t a n c e .  I wanted t o approach them on an i n f o r m a l , human l e v e l and t h i s was f a c i l i t a t e d by the status that we had i n common. to our status as students.  I refer  E a r l y i n the research I was f o r c e d  to decide on e i t h e r the r o l e o f appearing experienced and w o r l d l y , o r o f being a l e a r n e r , eager f o r new knowledge. In other words, was I to adopt a superordinate or a subordinate status.  I decided on attempting an equal s t a t u s , wherein I  allowed the nurses t o be mentors w i t h i n t h e i r own area o f  specialization.  Although I made e f f o r t s t o keep the r o l e on  t h i s l e v e l , I was soon to f i n d that i t could never remain so simplified.  I t was t o change and to be perceived d i f f e r e n t l y  from d i f f e r e n t status l e v e l s and i n general t o become quite complex.  This I s h a l l t r y to point out l a t e r i n t h i s I was aware, through the reading o f f i e l d  chapter. accounts,  that an observer can never be o b j e c t i v e , although the f u l l i m p l i c a t i o n s and complexities o f t h i s f a c t d i d not s t r i k e me until later.  I r e a l i z e d that I could not observe a s i t u a t i o n  without being a part o f i t and r e d e f i n i n g i t .  The i d e a l  s o l u t i o n , i t seemed t o me, would be to remain as o b j e c t i v e as possible.  I made i t a r u l e , t h e r e f o r e , to t r y to avoid  i n f l u e n c i n g the group, t o r e f r a i n from suggesting a c t i o n and to eradicate any tendencies t o make moral judgments.  I t soon  became c l e a r to me, however, that there would be a r e a c t i o n to my very presence and methods, over which I could r e g i s t e r l i t t l e or no conscious c o n t r o l .  Nevertheless I attempted to  abide by my i n i t i a l r u l e s whenever I could.  This abstention  from the passing o f value judgments and even from the formulation o f c l e a r l y d i s c e r n i b l e p r i v a t e ones, o f t e n proved a weapon o f self-defence and a form o f ensuring f r e e r interaction.  In that way the behaviour that I observed could  not d i s t u r b o r r e d i r e c t me when i t c o n f l i c t e d w i t h my own system o f values.  Thus i t tended to stop the formulation o f  prejudices and strong values and enabled me t o i n t e r a c t i n a far more u n r e s t r i c t e d manner w i t h people possessing d i v e r g i n g  and v a r y i n g c h a r a c t e r i s t i c s . form of  action,  subjective,  it  a n d as is  exercised.  were  intentions  Perhaps to  satisfying to  be  aspect  attempted  consider  the  entirely  forgotten.  this.  d i d not  that  The  work,  my r o l e  a  very tasks  spend eight  hours  I  and t h e n  disappeared elsewhere  for  rest  and s t a y e d authority  as  day.  l o n g as  I went  and d i s c i p l i n e .  was b o t h d e s i r a b l e  to  I wished. I was  to 1  I  g r o u p was  not  affected.  to  you,  you must work h o r r i b l y l o n g h o u r s . "  desirability other, It  it  was t h a t  nurse.  of  Thus  the  on the  of which  I  same a s  that  a l t h o u g h I was p e r h a p s  other came  to  the  hand,  inherent  I  would  unable  seen I  not to  half  again  wished  sorry  to  extreme  a  for  the  student  property of  to  the  nurses. student  acquire the  group,  advantage,  could not  utensils,  lucky being  Although  the  be  My p o s i t i o n  you're  I was  i n a position of  appreciate.  expect  subjected  f r o m one  of  most  prevented  really feel  an o u t s i d e r — i n s h o r t ,  i n f o r m a t i o n w h i c h was was,  "I  o f my p o s i t i o n f l u c t u a t e d  was n e v e r  the  on a ward for  The  or  be  and was n o t  "Gee  these  the  could never  was  them  conform.  group to  able  11  say that  c o f f e e whenever  and u n d e s i r a b l e .  go w h e n y o u w a n t  to  on wards, washing  rather  are  control over  performed  an h o u r  the  ideal which  an o u t s i d e r  and c h a r t i n g ;  of  to  I  s  bathing patients  the  an  f a c i l i t y of  by the  o f my r e s e a r c h  accepted  reliable  may s u f f i c e  and o f my a c c e p t a n c e  so w e l l  I  I  is  w i t h my a t t i t u d e s ,  it  which  Even though I interaction  deals  again this  doubtful whether  c o u l d be the  it  Once  identify  the  I  value  completely  w i t h t h e i r sets o f values and sentiments, and hence I was able to take a more unbiased view, something that would have been impossible had I been a student nurse.  Also information would  become p e r c e p t i b l e to me simply because I was an o u t s i d e r . Had I been a student nurse, i n t e r a c t i o n w i t h others i n the h o s p i t a l would have provided me w i t h c e r t a i n a t t i t u d e s and expectations.  I was at times t o be q u i t e t h a n k f u l f o r the  rather undefined nature o f my r o l e , f o r i t exposed me t o varying kinds o f contacts and enabled the c o l l e c t i o n o f information, which would not have been p o s s i b l e had I had a stereotyped, w e l l - d e f i n e d r o l e to p l a y .  This I s h a l l point  out l a t e r .  Interviewing The research method r e f e r r e d t o above as " p a r t i c i p a n t observation" provided the s e t t i n g f o r much o f the i n t e r v i e w i n g , e s p e c i a l l y that o f the unguided or nondirective variety.  I had c e r t a i n t h e o r e t i c a l l y formulated  hypotheses; I was eager to know how the group perceived t h e i r life.  Often questions that were unconceived at the outset  would a r i s e .  I n p a r t i c i p a t i n g and observing I had the  opportunity, enhanced by a face-to-face contact, to explore some o f these areas.  Whereas my a t t e n t i o n was d i r e c t e d mainly  toward the k i n d o f m a t e r i a l I was seeking, I discovered that t h i s d i r e c t i o n was o f t e n changed by f i e l d experiences and that the l i m i t s o f the interview or conversation were defined by the  interviewee.  In other words, I may  by a query such as "How  Initiate a  conversation,  i s i t going?" knowing that a p a t i e n t  attended by t h i s student had died that morning.  I would  intend to probe f u r t h e r i n an e f f o r t to f i n d out how  death  had a f f e c t e d her.  Often these questions  could not be r a i s e d  as the student may  i n s i s t on t e l l i n g me of an argument w i t h  a p r i v a t e duty nurse or a mistake i n technique that she made.  New  had  questions would a r i s e and the whole i n t e r v i e w would  be d i r e c t e d away from death and would often be productive  of  valuable data, otherwise u n a v a i l a b l e . I also conducted guided i n t e r v i e w s , f o r which I i n v i t e d each student to see me p r i v a t e l y and to be on tape.  interviewed  For t h i s I had constructed, before-hand, a set of  questions which showed promise of p r o v i d i n g answers f o r hypotheses that I hoped to explore.  During t h i s I attempted  to l i m i t my t a l k i n g to the minimum, saying l i t t l e beyond asking the question and reassuring the interviewee where necessary.  Needless to say, w i t h my i n c r e a s i n g f a m i l i a r i t y  w i t h the group, i t became more d i f f i c u l t to l i m i t my contributions.  own  I n some o f the e a r l i e r i n t e r v i e w s , the  accumulated f a c t o r s of the tape recorder, the i l l - d e f i n e d r o l e of the interviewer and a caution at being caused some respondents to appear u n c e r t a i n . cases, much time was  interviewed, Often, i n such  spent i n r e a s s u r i n g the student.  the end of the study I was  Towards  very pleased to note that many of  these symptoms seemed to have disappeared, and on occasion i t  seemed that the interviewee b e n e f i t t e d as much from the interview as I d i d .  Members o f the group o f t e n expressed the  opinion that they enjoyed the i n t e r v i e w , that i t made them t h i n k , or that they were g l a d t o "beef" to someone. During the eighteen month p e r i o d I conducted three separate sets o f i n t e r v i e w s .  The f i r s t occurred a f t e r seven  months o f campus t r a i n i n g and was aimed p r i m a r i l y at the area of motivation and recruitment.  At t h i s time the m a j o r i t y o f  g i r l s were unaware o f my i n t e n t i o n s , or o f the r o l e I was p l a y i n g and knew me only as "the g i r l who goes to the F r i d a y morning l a b " or "the g i r l who marks our Sociology 200 papers." The second disadvantage was that the interviews had to be arranged f o r m a l l y through teachers i n the School o f Nursing and thus became i d e n t i f i e d w i t h the teaching h i e r a r c h y and e n t i r e l y divorced from student a c t i v i t i e s .  Thirdly,  u n c e r t a i n t y and suspiciousness was increased by the f a c t that the interviews were c a r r i e d out i n the formal, academic environment o f Dr. Naegele's o f f i c e .  Needless to say, I f e l t  obliged t o give long explanations and reassurances i n each case before the i n t e r v i e w .  F o r t u n a t e l y the questions d i d not  impinge too h e a v i l y on p r i v a t e sentiments and wishes, and l a s t e d on the average f o r one quarter-hour.  After further  acquaintance w i t h the group, however, I r e a l i z e d how these three f a c t o r s must have i n f l u e n c e d the answers given.  The second i n t e r v i e w , t h i s time formulated to r e v e a l t h e i r p e r c e p t i o n o f the r o l e o f the nurse i n terms of my p r o p o s i t i o n f o r an occupational a n a l y s i s and to emphasize any change of t h e i r s e l f - p e r c e p t i o n .  This was given i n June  a f t e r two months of i n t e n s i v e f i e l d work during which time I had f a m i l i a r i z e d the group w i t h my x>rork, and they had developed a c l e a r d e f i n i t i o n o f my r o l e .  I t r i e d to act as a f r i e n d t o  each and i n v i t e d each one p r i v a t e l y t o an i n t e r v i e w i n my room at the r e s i d e n c e . Although the i n t e r v i e w averaged over one half-hour and the questions seemed more d i f f i c u l t to answer, the  respondents seemed more at ease, showed acceptance o f the  recorder and were w i l l i n g to volunteer more i n f o r m a t i o n . Needless to say i n t e r v i e w i n g conditions were much b e t t e r . The t h i r d set o f i n t e r v i e w s , o f an average o f a quarter o f an hour each, was conducted i n the f o l l o w i n g January.  The questions were designed to show t h e i r perception  of change. The procedure f o r arranging them was again more informal, as I asked each member o f the group whenever they were a v a i l a b l e and unoccupied.  This allowed any i n t e r v i e w t o  continue f o r an u n l i m i t e d p e r i o d .  This arrangement  seemed  more s a t i s f a c t o r y to both p a r t i e s . During any i n t e r v i e w , when any h e s i t a n c y was shown, or I f e l t that I perceived any u n c e r t a i n t y , I would not pursue the  question f u r t h e r .  Any h o s t i l i t y I f e l t to e x i s t , would  have proved most detrimental t o the r e s e a r c h . Often i n the case o f the i n f o r m a l , unguided interviex^ the respondent would  be approached w h i l e she was working i n the s e r v i c e or hopper room or on the ward.  The work s i t u a t i o n thus f r e q u e n t l y l e d  to the termination of an i n t e r v i e w when the student had to continue her work elsewhere, as I had no desire to d i s r u p t work r o u t i n e s .  Questionnaire S t a t i s t i c a l q u a n t i t a t i v e data was acquired through the a d m i n i s t r a t i o n o f a questionnaire, the same set o f questions, w i t h s l i g h t v a r i a t i o n s , being given again a f t e r a three month p e r i o d .  I t was o r i g i n a l l y given to explore the  hypothesis f o r the a n a l y s i s of the occupational r o l e as the experience o f the group at t h i s stage was l i m i t e d to campus t r a i n i n g , w i t h o n l y s l i g h t d i f f e r e n c e s from t r a i n i n g r e c e i v e d i n other academic schools and f a c u l t i e s ; i t could be s a i d to explore also r o l e - e x p e c t a t i o n at i t s i n i t i a l stage.  The  second a d m i n i s t r a t i o n came a f t e r an i n t e n s i v e two month h o s p i t a l experience, and the questionnaire was w r i t t e n i n four d i f f e r e n t instances corresponding t o the four l a b o r a t o r y periods.  To"test the i n f l u e n c e of the questionnaire on the  i n t e r v i e w s , both o f which were being done concurrently, h a l f of the interviews were conducted before the a d m i n i s t r a t i o n o f the questionnaire and the remainder a f t e r i t s a d m i n i s t r a t i o n . The purpose o f the questionnaire and the nature o f the p r o j e c t was explained t o each of the four groups before the questionnaire was handed o u t . Nevertheless, the questions,  being answered during a u n i v e r s i t y l a b o r a t o r y p e r i o d , tended to have examination-flavoured answers, and seemed to cater to what the group thought t h e i r a t t i t u d e s and r e a c t i o n s should be.  I n the second case the answers were undoubtedly a f f e c t e d  by the f a c t that the group had defined my p o s i t i o n , were more f a m i l i a r w i t h my expectations and wrote the answers on t h e i r "off-duty" time.  There were good-humoured complaints about  the l e n g t h o f the questionnaire and such remarks as the f o l l o w i n g were made: "Hot the same t h i n g again?" "I forget what I put the f i r s t time." As would be expected the answers were shorter and a few "nonsense r e p l i e s " were i n evidence. The questions themselves were o f s e v e r a l types. They ranged from m u l t i p l e - c h o i c e , i n terms o f h y p o t h e t i c a l , s t r u c t u r e d s i t u a t i o n s which posed problems and numerical a t t i t u d e s c a l e s , to open-ended questions.  Recording and I n t e r p r e t a t i o n During the research p e r i o d I s y s t e m a t i c a l l y kept a diary.  A f t e r the occurrence of an event I recorded i t i n the  form o f a mental or a w r i t t e n note.  At the f i r s t opportunity  I recorded everything that I could remember as having occurred, whether i t seemed r e l e v a n t at the time or n o t . This o f t e n proved very d i f f i c u l t .  I would take refuge i n the corner o f  the hopper room, or perch myself on the s t o o l i n the washroom  to q u i c k l y make sketchy notes o f what had happened.  A special  l u x u r y was note-making over a coffee cup i n the c a f e t e r i a . When attending l e c t u r e s , many of these d i f f i c u l t i e s solved.  I was able to take notes on the spot.  were  This o f t e n  aroused the c u r i o s i t y o f my neighbor who upon demanding "What did he say?" would look at my paper t o glean the r e l e v a n t information and would be confronted w i t h i r r e l e v a n t m a t e r i a l . Often, however, she would be able t o get the missing l i n k s from my paper, f o r f r e q u e n t l y I found myself making notes on the m a t e r i a l being presented. When I recorded unguided i n t e r v i e w s I attempted to put down i n so f a r as p o s s i b l e , the exact words that were said.  This I found t o be a s k i l l which developed w i t h p r a c t i c e .  In i n t e r p r e t i n g s i t u a t i o n s I found i t necessary to develop the technique of d i f f e r e n t i a t i n g the s p e c i f i c from the general, to become aware o f the discrepancy between what i s s a i d and what i s thought, between what i s thought to have happened and what, i n f a c t u a l terms, d i d happen.  Also I had to overcome ray  desire to ignore the obvious, which I o f t e n forced myself to record as i f i t were new and able to y i e l d f r u i t f u l information.  Ethics A f t e r I had been engaged i n research f o r some time I became aware o f the f a c t that I had constructed a system of  ethics.  This I must have b u i l t without conscious i n t e n t , t o  a l l e v i a t e the g u i l t f e e l i n g s which i n e v i t a b l y arose when I asked myself c e r t a i n questions. into such matters?  What r i g h t have I to probe  This information i s c o n f i d e n t i a l and  personal, how can I use i t ? Was I being deceptive i n t r y i n g to seek acceptance?  Was i t dishonest to l a t e r record  conversation c a r r i e d on i n a casual manner?  I recognized i n  these many o f the queries that have o f t e n been d i r e c t e d a t f i e l d work techniques by s o c i a l s c i e n t i s t s .  Yet on  reconsidering I became convinced that I had a c e r t a i n f a i t h i n what I was doing and I hoped that my s e r v i c e o r i e n t a t i o n s would be s a t i s f i e d and I would be "of h e l p " by p r o v i d i n g what information I could. I r e s o l v e d , t h e r e f o r e , to remove the i d e n t i f y i n g elements from quotations, without d i s t o r t i n g f a c t s . The i n t e r v i e w s , questionnaire and reports on observations were to be h e l d i n s t r i c t confidence, t h e i r contents being u t i l i z e d only i n an anonymous manner.  When reassuring respondents  p r i o r t o i n t e r v i e w s , the i n t e n t i o n was not t o press information from them.  At no time were any o f the group or other  i n d i v i d u a l s i n v o l v e d , ignorant o f the purpose and nature o f the study. In June, at the end o f my two months o f i n t e n s i v e " p a r t i c i p a n t observation" I b r i e f l y discussed f i e l d work techniques and aims w i t h members o f the group.  They expressed  concern as to "how  you can get anything when we have no  answers to the questions or say 'I. don't know.'"  I assured  them that t h i s could be just as v a l u a b l e , although i t s connotation was d i f f e r e n t . r e g r e t t e d when I was and f u r t h e r my study.  This p a r t i c u l a r t a l k I l a t e r  fortunate enough to be able to r e t u r n I changed my o p i n i o n , however, f o r  t h i s imparting of knowledge to the group seemed to be instrumental i n r e l a x i n g t e n s i o n , i n a i d i n g rapport and i n d i s p e l l i n g some of the unpleasant  f e e l i n g s that accompany  the awareness that one i s being observed.  L i m i t a t i o n s to Research As w i t h most research i n the s o c i a l sciences t h i s study has i t s l i m i t a t i o n s , some being ones that are h e l d i n common w i t h other s t u d i e s , others p e c u l i a r to t h i s one.  particular  F i r s t l y , the researcher i s biased and there i s no known  c o r r e c t i o n f o r t h i s inaccuracy.  I t r i e d at a l l times to be  consciously aware of my biases w i t h the b e l i e f that only i n such a manner could I hope f o r the greatest degree o f objectivity.  Secondly, there i s the d i f f i c u l t y of attempting  to keep the s i t u a t i o n pure and hence ensure procedural  clarity.  My presence i n the group i n f l u e n c e d them and only r a r e l y could i t be determined how  i t i n f l u e n c e d them.  T h i r d l y , interview  and questionnaire /answers are l i a b l e to be inaccurate because of the tendency to supply answers that conformed w i t h expectation and the suppressing of ansx^ers that deviated.  b;  F o u r t h l y , I could not assume that the respondent was not dramatizing, withholding relevant information, d e s c r i b i n g i n a c c u r a t e l y or d i s t o r t i n g .  This i s not meant to imply that  such actions were i n t e n t i o n a l , but rather unanalyzed and transmitted without conscious awareness o f t h e i r i m p l i c a t i o n s . F i f t h l y , there i s the i n t e r f e r i n g c o n s i d e r a t i o n of discomfort, a r i s i n g from personal s e n s i t i v i t i e s . I f e l t t h i s o c c a s i o n a l l y i n p o s i t i o n s where my r o l e was i l l - d e f i n e d as o f t e n under ward c o n d i t i o n s , which c a r r i e d the added t h r e a t of the p o s s i b i l i t y of being caught i n a s i t u a t i o n where l a c k o f knowledge would l e a d to severe predicaments.  When I experienced  this I  reacted by withdrawal, f o r i t seemed that where my concentration was focussed e n t i r e l y on personal discomfort, other, p o t e n t i a l l y r i c h , s i t u a t i o n s would escape me.  S i x t h l y , the consideration  of observer empathy and involvement proved of prime importance. I found that on occasion ray morale would vary w i t h that o f the group i n a manner too intense f o r comfort.  To t h i s I reacted  by withdrawing f o r the afternoon or the day, u n t i l I regained what I considered a reasonably o b j e c t i v e p e r s p e c t i v e . These, i n my o p i n i o n , were the s a l i e n t features o f the research methods that I used and some o f the l i m i t a t i o n s and t h e i r  connotations.  S o c i a l i z a t i o n and Evolving Role The r o l e o f the researcher i s instrumental i n determining the nature of the data he i s t o c o l l e c t .  Being  u n f a m i l i a r w i t h the t r a i t s o f the small community into which I was to go and having no standard r o l e t o adopt, I was u n c e r t a i n as to what p o s i t i o n I should f i l l and how I should represent myself t o the people i n v o l v e d .  Through the passage  of time, however, I found that I was being f i t t e d i n t o a context, which was e a s i l y defined by the i n d i v i d u a l or occupational group concerned.  My own a c t i o n s ,  consequently,  were p r i m a r i l y guided by the expectations o f the group w i t h which I was i n t e r a c t i n g .  The complexity and i n t e g r a t i o n o f  varying occupational and s o c i a l r o l e s that made up the h o s p i t a l , accounted f o r the v a r i e t y o f r o l e s given me.  I Play Many Roles Robert Merton suggests that the images o f an interview were:  as a democratic  channel f o r the expression  of o p i n i o n ; as an i n t e l l e c t u a l l y demanding experience; as a moral inventory i n that "I've got nothing to h i d e " ; as a part of an i n s t i t u t i o n a l i z e d p a t t e r n of s o c i a l surveys; as having an ego-building and status c o n f e r r a l f u n c t i o n ; as catharsis.^"  1 Robert K. Merton, "Selected Problems o f F i e l d Work i n the Planned Community," American S o c i o l o g i c a l Review, v o l . XI  A l l o f these images I f e l t at one time or another.  1 ) I was also  t r e a t e d as i f I were a d i r e c t channel t o persons o f i n f l u e n c e i n the nursing h i e r a r c h y and through whom the i n d i v i d u a l could b r i n g about reform. direction.  M a t e r i a l given was o f t e n weighted i n t h i s  2 ) I was made to f e e l l i k e a spy.  analyzing us."  "Look out, E l v i ' s  But f o r t u n a t e l y f o r my personal comfort t h i s  occurred very seldom, "always from the same i n d i v i d u a l s , and presented i n a teasing manner which i m p l i e d t h e i r awareness of my s e n s i t i v i t y i n t h i s area.  3 ) I was used t o eradicate f e e l i n g s  of i n s e c u r i t y and u n c e r t a i n t y by p o r t r a y i n g myself as a sympathetic l i s t e n e r , and by making i t apparent that I was not only observing the members o f the group, but also other  personnel.  Regret was often expressed that I had not been present during a very t r y i n g s i t u a t i o n . been defined thus:  I t reached me v i a the grapevine that I had  "She s o r t o f looks a f t e r us.  to see how we are g e t t i n g along." was  She comes around  This was a r o l e w i t h which I  to become quite f a m i l i a r i n the l a t t e r part o f the study.  Sometimes I found i t somewhat d i s t r a c t i n g when head nurses and supervisors regarded me as a t o o l whereby the problems o f the students could be a i r e d .  I t seemed as i f I c o n s t i t u t e d a threat  to them, w i t h the added l i k e l i h o o d that I could i l l u m i n a t e on t h e i r i n e f f i c i e n c i e s and mistakes.  To the p a t i e n t s I was a  supervisor who came around to examine the techniques o f the student nurses, w i t h whom the p a t i e n t s i d e n t i f i e d .  At approaching  the bed where one o f the group was working, I was once greeted with:  "She's doing f i n e .  It's a l l right."  £) To those that  had no c l o s e r knowledge o f my p r o j e c t , the nature o f my work  from the point o f view o f an a c t i o n - o r i e n t e d c u l t u r e must have determined my s t a t u s . They would see me walk around, t a l k to students, graduates, head nurses, yet do no "work." to be free t o organize my own program.  I appeared  This would place me  i n some p o s i t i o n o f a u t h o r i t y and on occasion I was very embarrassed t o see a head nurse or student nurse stand when I approached the nursing s t a t i o n .  This conception changed,  however, when they were able to observe my i n t e r a c t i o n w i t h the c l a s s o f August  *5>8.  Conversation was f r i e n d l y and could only  be defined as such, f o r I had a t the outset, f e e l i n g myself to be outside the i n s t i t u t i o n a l h i e r a r c h i c a l system, adopted the use o f C h r i s t i a n names i n a c u l t u r e where an index o f " p r o f e s s i o n a l i z a t i o n " was the use o f "Miss Smith" as a form of address.  Conversation o f the informal nature that was reserved  f o r personnel low on the status h i e r a r c h y and the pleasure the group members seemed t o express on seeing me, c o n t r a d i c t e d the previous d e f i n i t i o n s o f a u t h o r i t y , confusing the r o l e assigned to me.  I was sought f o r c l a r i f i c a t i o n .  "Are you a graduate nurse?"  "Just what do you do?"  A f t e r a process o f t r i a l and e r r o r  I adopted an ansxver that was both s a t i s f y i n g and b r i e f .  I  r e s o r t e d to the explanation that I was studying the August j?8 T  c l a s s , or that I was t r y i n g t o understand nursing education or that I was studying the making of a nurse.  This quenched  questioning f o r a while f o r i t d i d e x p l a i n my existence t h e r e . An a c t i o n - o r i e n t e d c u l t u r e turned to the next area o f puzzlement. "Do you do any work?" that?"  "Do you ever do any nursing or things l i k e  To these questions, which arose mainly w i t h reference to :  a c t i v i t i e s on wards, I r e p l i e d that I often  volunteered  elementary nursing duties and that I had f e d p a t i e n t s , washed and d r i e d u t e n s i l s , taken TPRs and c a r r i e d bedpans. I n l e c t u r e s and during informal lounge groupings my a c t i v i t i e s were more easily definable.  A l l of these r o l e s were r a d i c a l l y d i f f e r e n t  from my i n i t i a l p o s i t i o n as "the g i r l i n the F r i d a y morning l a b " and "the g i r l who marks Sociology 200 papers."  The d i f f e r e n c e  i s a d i r e c t r e s u l t o f i n c r e a s i n g acceptance and more i n t e n s i v e parti cipation.  Increasing S o c i a l i z a t i o n and Acceptance My i n i t i a l contacts w i t h my research f i e l d were made w i t h those i n p o s i t i o n s o f a u t h o r i t y , such as professors and i n s t r u c t o r s at the u n i v e r s i t y and h o s p i t a l schools.  After  entering on t h i s l e v e l , contacts w i t h the students were g r e a t l y f a c i l i t a t e d through the cooperation and e f f o r t s o f the former. As time went on, however, I found that I began t o l o s e the f i r s t a f f i l i a t i o n i n favour of the second.  At a l l times, however, I  had the s e c u r i t y o f f e e l i n g t h a t the study was supported by those in control.  I had the impression that they were i n t e r e s t e d i n  the information that I sought, and were w i l l i n g to a i d i n i t s c o l l e c t i o n by cooperation and by c o n t r i b u t i o n s o f t h e i r own. Empathy can p l a y an important part i n the i n s t i g a t i o n of s o c i a l values and standards.  With i n c r e a s i n g involvement  w i t h the l i f e o f the group I began t o f e e l a growing  i d e n t i f i c a t i o n with, them and the development o f sentiments and a t t i t u d e s that resembled t h e i r own.  At the outset I attended  s o c i a l f u n c t i o n s , meals and i n f o r m a l b u l l sessions because o f t h e i r value as observational s i t u a t i o n s . I became aware of the f a c t that soon I was attending them p r i m a r i l y f o r my own pleasure and only s e c o n d a r i l y to observe.  With i n c r e a s i n g i d e n t i f i c a t i o n  and as 1" became more and more s o c i a l i z e d , I adopted h o s p i t a l slang and occupational terminology.  "Peds" r e f e r r e d to  P e d i a t r i c s , "Mat" t o Maternity and so on. I b&came conscious of having h a i r on my c o l l a r , or of a uniform that d i d not meet the standards o f " p r o f e s s i o n a l i z a t i o n . " Although my i n i t i a l r e c e p t i o n measured up to my expectations of suspiciousness, unresponsiveness and coolness, I was to be p l e a s a n t l y s u r p r i s e d .  I was given i n c r e a s i n g l y  v a r i e d and d e t a i l e d information, the interviews became o f greater d u r a t i o n , and I was often made to f e e l that people wanted t o impart information.  "Here's something f o r your t h e s i s . " Prom  g i v i n g me the k i n d o f information that i s displayed to o u t s i d e r s to maintain the p r e s t i g e and p u b l i c image o f the nurse, they showed t h e i r acceptance o f me by i n c l u d i n g me i n "gripe s e s s i o n s . " On the other hand I became o f t e n deeply involved w i t h t h e i r problems and often f e l t disposed to take s i d e s .  When t h i s  occurred I withdrew f o r a day or so. Over and above my p o s i t i o n as a p a r t i c i p a t o r , there were several t y p i c a l i n c i d e n t s that could be emphasized as ones  which heightened my acceptance w i t h the group.  Among these could  be mentioned i n s t r u c t o r s asking me questions i n class because o f t h e i r unawareness as t o my reasons f o r being there, matrons scolding me because they i d e n t i f i e d me- w i t h a student  nurse,  small mistakes made i n nursing procedures, ray w i l l i n g n e s s to help them w i t h small chores and my evident pleasure w i t h t h e i r company.  Above a l l I b e l i e v e that my i n i t i a l step of accepting  t h e i r i n v i t a t i o n to coffee on the f i r s t day o f my attendance at the "Friday l a b " and thus i d e n t i f y i n g myself w i t h the  students  rather than the teachers, proved o f great value. Thus these two processes worked hand i n hand, and were mutually interdependent. increasing i d e n t i f i c a t i o n .  Increasing acceptance came w i t h  CHAPTER IV. THE TRAINING SETTING  There i s w i t h i n our c u l t u r e a d i s t i n c t type of subc u l t u r e , which could be c a l l e d the "medical sub-culture."  The  nursing part of t h i s sub-culture s h a l l be discussed i n t h i s chapter from three perspectives . I s h a l l d e s c r i b e i t w i t h information from my observations, from the i n t e r p r e t a t i o n s o f members of the sub-culture and from inferences and speculations derived from both of these.  I t s h a l l he a presentation of what  I saw, what others t o l d me and how I i n t e r p r e t e d both o f these. The medical•sub-culture  depends for i t s existence on  the general c u l t u r a l i n t e r p r e t a t i o n o f i l l n e s s . Without the c u l t u r a l i s o l a t i o n of " i l l n e s s " and the behaviour that i s s o c i a l l y expected i n every case o f i l l n e s s , there would be no medical sub-culture.  I n other xvords our c u l t u r e defines a  c e r t a i n s t a t e of being as "being i l l , " which i n v o l v e s an o b l i g a t i o n to leave t h i s s t a t e and "become w e l l . "  The  process  of passing from one s t a t e to another takes place through the medical sub-culture, which i s s t r u c t u r e d i n such a way as to make cure p o s s i b l e .  In t h i s way there i s an interdependence  between the general c u l t u r e and the medical s u b - c u l t u r e .  The  general c u l t u r e depends on i t s medical sub-culture to cure i l l n e s s and the medical c u l t u r e can only survive i f there i s  such a phenomenon as i l l n e s s .  The c u l t u r a l norm o f curing  i l l n e s s becomes the dominant value of the sub-culture and i s responsible f o r i t s f u n c t i o n and s t r u c t u r e . The sub-culture i s i n v o l v e d w i t h a l l the processes by which an i n d i v i d u a l , who when he becomes part o f the medical world i s defined as " p a t i e n t , " i s returned t o h i s former status as "person."  During h i s time as " p a t i e n t , " the i n d i v i d u a l adopts  the relevant a t t i t u d e s and norms t h a t are h e l d out to him by the sub-culture.  The complex o r g a n i z a t i o n o f the sub-culture  functions f o r the prevention and treatment o f i l l n e s s and defines t h i s f u n c t i o n as being "to do the utmost f o r the welfare o f the patient." The s t r u c t u r e o f the medical world i s organized around techniques and s k i l l s , behaviour i n t e r r e l a t i o n s h i p o f many r o l e s .  and a t t i t u d e s , and the I t consists of hospitals,  c l i n i c s , p i l l s , doctors, nurses, operating rooms, medical and nursing schools, research l a b o r a t o r i e s and a l l the other phenomena concerned w i t h i l l n e s s and i t s cure.  The nursing r o l e ,  and a l l that i t symbolizes, i s one part o f the medical c u l t u r e . As f a r as the n u r s i n g p o r t i o n o f the medical subc u l t u r e i s concerned, i t can be s a i d that the t r a i n i n g o f nurses functions to f i t them i n t o t h e i r appropriate p o s i t i o n i n the sub-culture.  Once i n the sub-culture they are expected t o  perform i n the defined manner.  This defined manner i s l e a r n t  i n the process o f t r a i n i n g where the student acquires the subject  matter o f her occupation and. the r e l e v a n t norms and a t t i t u d e s . By t h i s method the nursing community w i t h i n the medical c u l t u r e i s perpetuated and maintained.  The Kind o f T r a i n i n g Given Nursing education and t r a i n i n g i s the process by x^hich laymen are made i n t o nurses.  This process i s managed by  s p e c i a l i z e d members o f the nursing p r o f e s s i o n , who are considered experts on the k i n d o f nurse that i s d e s i r e d by the occupational group.  I n s t r u c t r e s s e s , as they are c a l l e d , are i n possession o f  the knowledge o f how a nurse should be made and how and what she should be taught.  These i n s t r u c t r e s s e s , t h e r e f o r e , begin w i t h a  preconceived image o f what every nurse should be, and channel t h e i r energies i n t o moulding every student i n t o t h i s form.  Each  generation o f students i s f i t t e d i n t o the c u l t u r a l mould prepared for i t . This f i t t i n g process i n v o l v e s two t h i n g s .  Firstly i t i s  the duty o f the i n s t r u c t r e s s e s to t each the student the p a r t i c u l a r type o f s k i l l that I s the property o f her prospective r o l e .  This  could be termed the "instrumental, t e c h n i c a l " aspect o f what has to be l e a r n t , and i s u s u a l l y t r a n s m i t t e d d i r e c t l y I n s t r a i g h t forward teaching and l e a r n i n g , supplemented by p r a c t i c e . Secondly, i n s t r u c t r e s s e s t r y t o impart the correct a t t i t u d e s and behaviour which b e f i t the r o l e o f the nurse.  Such a form o f  teaching i s a b s t r a c t , and hence more d i f f i c u l t to t r a n s m i t . I t could be described as the "expressive" aspect o f r o l e - l e a r n i n g .  73  A f t e r observing what students are taught and what they seem to have l e a r n t , I came to the conclusion that l e a r n i n g and teaching are not always d i r e c t , but o f t e n also i n d i r e c t .  Direct  l e a r n i n g and d i r e c t teaching occur when i n s t r u c t r e s s e s c o n s c i o u s l y teach and students c o n s c i o u s l y l e a r n .  I t occurs i n the c l a s s  room where i n s t r u c t i o n i s d i d a c t i c a l l y given and students are, by d e f i n i t i o n , under the o b l i g a t i o n to l e a r n .  Under other  circumstances, however, students may l e a r n i n d i r e c t l y and o f t e n i n o p p o s i t i o n to what has been d i r e c t l y taught.  They l e a r n  "short c u t s , " such as g i v i n g enemas without the use o f stands and clamps, which they are taught to use. of l e a r n i n g two other t h i n g s :  This i s the r e s u l t  that they must balance time and  t h e i r a b i l i t y to perform and that enemas can be given without conforming to the taught procedure.  S i m i l a r l y , a t t i t u d e s not  appropriate to the d e s i r e d outlook of nurses and i n o p p o s i t i o n to what has "been taught, are a c q u i r e d . An i n s t r u c t r e s s may teach the students to always show t o l e r a n c e and k i n d l i n e s s towards p a t i e n t s despite t h e i r f e e l i n g s of exasperation. Yet i n d i r e c t l y the students o f t e n l e a r n to r e f e r to p a t i e n t s as " o l d bags" or "lumps of f a t . "  This form of i n d i r e c t l e a r n i n g , which i s beyond  the c o n t r o l of i n s t r u c t r e s s e s , occurs through i n t e r a c t i o n w i t h more advanced generations o f students, or w i t h other graduate members of the occupational group.  I t can also occur through  d i s t o r t i o n of the m a t e r i a l presented f o r d i r e c t l e a r n i n g as i n s i t u a t i o n s of c o n f l i c t , where the student i s unable to i n t e r r e l a t e what she has been taught w i t h other f a c t o r s . cases of i n d i r e c t l e a r n i n g .  These, then, are  I n d i r e c t teaching occurs when i n s t r u c t r e s s e s , who  are  defined as models of appropriate behaviour, teach one t h i n g , yet p r a c t i c e another.  An instance of i n d i r e c t teaching occurs when  an i n s t r u c t r e s s implies d i r e c t l y that nurses should not d i s p l a y anger, and i f a desire to do so becomes u n c o n t r o l l a b l e , they should simply withdraw and walk away. Yet at the same time students are In contact w i t h angry i n s t r u c t r e s s e s , head nurses and graduates.  I t appears, t h e r e f o r e , that d i r e c t teaching and  d i r e c t l e a r n i n g occur more f r e q u e n t l y i n the t r a d i t i o n a l c l a s s room s i t u a t i o n and i n d i r e c t teaching and i n d i r e c t ' l e a r n i n g occur more f r e q u e n t l y i n the a c t u a l work s i t u a t i o n . The l e a r n i n g of the n u r s i n g r o l e , however, whether i t i s d i r e c t or i n d i r e c t l e a r n i n g , i s concerned w i t h two d i s t i n c t aspects —  the "instrumental, t e c h n i c a l " and the "expressive."  "Instrumental" knowledge shows what should be done, "expressive" knowledge shows how i t should be done.  Adequate command of both  aspects enables a student to p l a y the nursing r o l e w e l l .  The  end r e s u l t of the t r a i n i n g of these aspects i s a d i s t i n c t gap between nurses and o u t s i d e r s .  The Instrumental, Technical Aspect This aspect r e f e r s to the v o c a t i o n a l s k i l l s of n u r s i n g . Students are taught s c i e n t i f i c techniques and how to give p h y s i c a l care.  They are taught the t h e o r e t i c a l knowledge behind  these procedures.  To quote an example, students, having once  acquired an understanding of the c i r c u l a t o r y system i n a  t h e o r e t i c a l sense, put t h i s into p r a c t i c e i n such t h i n g s as hot fomentations to increase c i r c u l a t i o n . procedure i s i m p l i e d .  For t h i s a d e f i n i t e  The necessary equipment i s assembled and  the f l a n n e l that i s used i s placed i n a wringer f o l d e d lengthwise and i s then placed i n the fomentation b a s i n .  I t i s then covered  w i t h a p l a t e and hot water u n t i l the b a s i n i s two-thirds f u l l . I t i s b o i l e d on the gas, from whence i t i s removed a f t e r f i v e minutes and c a r r i e d t o the sink where s t i c k s are adjusted and the f l a n n e l i s wrung as dry as p o s s i b l e .  F i n a l l y placed on the  p l a t e , i t i s covered w i t h a towel and c a r r i e d to the bed-side w i t h any other equipment that i s r e q u i r e d . The covers are folded down, the body exposed and the binder i s put i n p o s i t i o n .  The  fomentation i s removed from the wringer, the moisture i s shaken o f f and the fomentation i s t e s t e d on t h e nurse's w r i s t .  It i s  applied g r a d u a l l y i n such a manner as t o be t o l e r a b l e t o the patient.  Quickly a Venetian c l o t h and f l a n n e l are used to cover  i t and the binder i s fastened.  A hot water b o t t l e i s a p p l i e d .  The procedure seems to have been completed, but I t has a f o l l o w up.  A second f l a n n e l i s put i n the stupe wringer ready f o r the  next treatment.  When the fomentation i s changed, the c o n d i t i o n  of the s k i n i s reported t o the head nurse and v a s e l i n e i s a p p l i e d i f necessary.  When the treatment i s f i n a l l y discontinued, the  area i s d r i e d and covered w i t h d r y f l a n n e l and the binder i s again fastened.  The i n s t r u m e n t a l , t e c h n i c a l aspect i s concerned  w i t h t h i s type o f knowledge.  I t also i n v o l v e s nursing l e c t u r e s .  i n b a c t e r i o l o g y , anatomy, chemistry and physiology.  The  student i s taught to give bed-baths, to prepare p a t i e n t s f o r operations, to understand the i n t r i c a c i e s of a s t e r i l e f i e l d i n o p p o s i t i o n to a clean one, to do wet and dry dressings  and  to measure c o r r e c t l y i n g i v i n g medications. At a l l times emphasis i s placed on speed and p r e c i s i o n . Students are impressed w i t h the "Importance" o f g i v i n g the correct medications, o f applying the correct amount o f heat and of keeping instruments and areas s t e r i l e .  An anxiety about accuracy Is  fostered by the i n s t r u c t r e s s e s , who anecdotes. nurse who  often relate disturbing  One instance was when the students were t o l d of the gave a p a t i e n t a bad bum  b o t t l e on too l o n g .  by l e a v i n g the hot water  "The i l l n e s s was cured, but the boy had to  see h i s doctor s i x months afterwards because of the burns. leave a hot water b o t t l e unchecked." of the nurse who  Or the students are t o l d  administered the wrong medication and of the  complications that set i n . The urgency of the medical i s stressed.  Never  sub-culture  Speed and the a b i l i t y to.act q u i c k l y are considered  valuable as s et s. There seem to be three types o f i n s t r u c t i o n f o r imparting the instrumental, t e c h n i c a l knowledge. are d i d a c t i c a l l y taught t h e o r e t i c a l knowledge.  F i r s t l y , they  This they are  expected to master and to prove t h i s mastery In o b j e c t i v e examinations.  Secondly, they are taught to p a r t i c i p a t e i n an  imaginative ward i n the l a b o r a t o r y and are aided i n applying t h e i r l e a r n t knowledge.  Here i t i s no longer p u r e l y  theoretical knowledge thereby  is  a p p l i e d i n the  elaborated  meets the  demands  Incidental teaching  The  l e a r n i n g , b u t has  out. of  told.  are  taught  above  her  of  the  nurse  She  Is  is  expected  patient,  has  the  to  believe  be  of  the  is  Didactic  reinforcement.  her  action  that  attitudes  perform.  The  occupation  altruistic,  to  of  s h o u l d be  moral  are  place  "A nurse  range  to  be  she,  she  relationships  discreet,  more  than  pointed  the  does  welfare  everything  responsibility"  oriented  and more is  she,  towards  process.  is  others  Towards  kind,  frequent  responsible  in reality,  with  for  the  in  they the  i n the  physical,  patient.  in full  She  control  tolerant.  medical  contact with the  the  patient  h e l p f u l and  any o t h e r  psychological w e l l - b e i n g of her  reparative  student  teaching  appropriate  clearly defined.  closer  and hence  as  the  s k i l l s they  within  of her is  reminded that  sub-culture,  and  is  patient.  sub-culture  the  when the  of uncertainty.  own d e s i r e s .  every  The n a t u r e medical  The k n o w l e d g e  Here the  support  taught  to  their  patient  Ideally,  betterment  also  s o c i a l mannerisms are  patient for  correction,  accompany t h e  and the  possible are  that  Students  the  only i n cases  the  Aspect  Students  beliefs  situation.  of her work s i t u a t i o n .  g i v e s way to  and norms  "real"  Thirdly,  and r e i n f o r c e d by e x p e r i e n c e  and o c c u r s  Expressive  become p r a c t i c a l .  is of  the as  well  even the  led  The nurse i s the to see changes. This nurse can see that he an hour or three days to see the change. A T i i h a t the nurse says.  only person i n a p o s i t i o n baby, who looks OK, the i s n ' t the same as he was ago. She i s the o;hly one l o t o f f a i t h i s put i n  In such a way the "importance" o f her work i s emphasized. comparative  The  "importance" o f her work to t h a t o f others, f o r  instance, that o f the doctor, i s not pointed out, but i s something o f which she becomes aware when she comes into the h o s p i t a l context. She i s also taught how to react towards superordinates. To p r o f e s s i o n a l people, such as doctors, supervisors and so on, she i s t o l d to show f u l l respect by standing when they e n t e r . She has to be cooperative t o graduate nurses and to students above her.  She i s asked to carry out orders without argument  or d i s c u s s i o n , the importance of t h i s obedience being r e i n f o r c e d by reference to emergency s i t u a t i o n s where argument would waste valuable time.  She i s to accept the i d e a that her superiors have  a greater command o f the techniques and knowledge o f the medical culture and hence can act more a p p r o p r i a t e l y i n the m i l i e u i n t o which she i s s t i l l being s o c i a l i z e d . The nurse's behaviour outside of the medical subculture i s also c o n t r o l l e d .  Her behaviour w i t h i n the sub-culture  i s expected to be repeated when she i s away from i t .  She i s to  carry over her occupational mannerisms and t o conduct h e r s e l f as a member o f a " s e r v i c e " p r o f e s s i o n .  I n s t r u c t r e s s e s imply  that students are to be c o n f i d e n t i a l about information and to  guard t h e i r into  knowledge and s k i l l s  u n q u a l i f i e d hands.  administer her of  these  nurses They  are  expected  asked not  language  or  to  is  to  These  frequent  Thus to  the  by i n s t r u c t r e s s e s  or  Students  done  by "good" n u r s e s ,  that  this  behaviour  is  the  or  way i t  for nurses  they  t r y to  make  done.  students  a l l students  the  teachings  of  their  as  taught  "good" nurses, them and t o  the  also  feelings  take  is  In  the  on the  when s t u d e n t s  obscene  functions deviate.  taught  was  best  way to  do i t ,  images  of  themselves  always  the  try  in  ideals  way i t  or  right  to  conform,  a certain  sense,  there-  own i m a g e ,  and  certainly  some e x t e n t  Sometimes  other  actions.  controls,  try  These  uphold. by  by  nurses,  and students  t r y to of  public  transmitted  by model nurses,  students  and  the  as m o d e l s ,  and s e t  group.  traditions,  controlled to  their  general  a favourable  are  form of  i n their  imitate  by instructresses ideals, which  guilt  serve  In  unprofessional  They  the  A l l  group.  To t h e s e  is  out.  r o l e - p l a y i n g are  instructresses.  a d o p t e d as Ideal3  of  students.  of  identify with  the  instructresses  behaviour  as  of  is  this  i t .  their  pass to  for  t o use  continuation of  i n the  the  defined  i n other  that  the  calls  parlours,  this  and i n t u r n t o m o u l d t h e i r fore,  beer  t o l d that  is  obligation  outsiders  of models.  classrooms  are  occasion  aspects  use  a l l o w them t o  "reputation" of  e a c h member  expressive  to  under the  keep  themselves  d i d a c t i c a l l y or by the  facts.  the  uphold the  conduct  entrusted  is  function to  to  untrustworthy ways. image  she  s k i l l s whenever  requirements  are  Yet  and not  to  examples,  become As  such  exercising  I n d i r e c t l e a r n i n g o f "expressive" m a t e r i a l also takes place.  I t u s u a l l y does not comply w i t h the demands o f the  occupational group, and o f t e n i s i n d i r e c t c o n t r a d i c t i o n to the behaviour experience  and a t t i t u d e s d e s i r e d .  I t takes place through  and Is beyond the c o n t r o l o f teachers.  Although  students are taught to respect head nurses and i n s t r u c t r e s s e s and to approach them w i t h t h e i r problems, t h e i r r e a c t i o n s t o these people may be altogether d i f f e r e n t .  I n actual p r a c t i c e  they may come i n contact w i t h i n s t r u c t r e s s e s or head nurses w i t h whom they are incompatible, whom they cannot respect and t o whom they cannot take t h e i r problems.  The d e f i n i t i o n o f head nurses  and i n s t r u c t r e s s e s , which has been taught, becomes changed. The student f e e l s that they are d e v i a t i n g from nursing norms and hence cannot respect them.  She i s placed before the c o n f l i c t i n g  expectations, namely the norm o f respecting superiors and the actual s i t u a t i o n .  Thus i d e a l "expressive" behaviour  i s taught i n  a d i d a c t i c manner by i n s t r u c t r e s s e s , and f a c t u a l "expressive" behaviour i s the r e s u l t o f the balance between the i d e a l and the demands o f the " r e a l " s i t u a t i o n . Whereas the "instrumental" aspect deals w i t h " t h i n g s , " the "expressive" aspect deals w i t h "people."  As c h i l d r e n a t an  e a r l i e r age become more accustomed t o "people" than they do t o the s p e c i f i c "things" o f n u r s i n g , i t can be said that the "expressive" aspect could be acquired at an e a r l i e r age.  This  i s e s p e c i a l l y true o f nursing where the occupational norms are very s i m i l a r t o the c u l t u r a l norms a t t r i b u t e d to middle-class  women with, humanistic i d e a l s .  Thus even as c h i l d r e n , students  are beginning to acquire the r e l e v a n t norms, whereas o f t e n the "instrumental" knowledge i s not gained u n t i l the prospective nurse has been accepted as a student and i s introduced to dressing equipments, hypodermics and so on. with insight:  One student remarked  " A c t u a l l y your t r a i n i n g s t a r t e d a long time before  you even took n u r s i n g . Even as a c h i l d you l e a r n t what people are l i k e . "  Nursing t r a i n i n g , t h e r e f o r e , merely supplements  and c l e a r l y i n d i c a t e s these norms.  The student i s now under a  greater o b l i g a t i o n to "express" these norms as .a member of the nursing group.  Organization of T r a i n i n g M i l i e u There are s e v e r a l contexts w i t h i n which the student nurse i s t r a i n e d .  The subjects of t h i s t h e s i s , being u n i v e r s i t y  program nurses, are t r a i n e d , i n the beginning, i n a u n i v e r s i t y environment.  Secondly, they are introduced to a h o s p i t a l  environment where they are confronted w i t h the r e a l i t y of ward experiences.  At the h o s p i t a l a l s o , they are given l e c t u r e s and  l a b o r a t o r y demonstrations.  F i n a l l y , residence l i f e , vrith i t s  emphasis on group a s s o c i a t i o n s , plays i t s part i n the making of a nurse.  The t o t a l t r a i n i n g process i s not c h r o n o l o g i c a l l y  presented i n these stages, but a l t e r n a t e s between the f o u r . I t begins w i t h u n i v e r s i t y c l a s s e s , then switches to ward experiences, then to h o s p i t a l c l a s s e s , then back to u n i v e r s i t y classes and so on.  The U n i v e r s i t y Located on the campus o f the U n i v e r s i t y o f B r i t i s h Columbia i s a School of Nursing.  I t i s housed i n a b u i l d i n g  which also contains a student h e a l t h centre, a small h o s p i t a l , class rooms and l a b o r a t o r i e s f o r students i n b a c t e r i o l o g y and oceanography.  The s e c t i o n o f the b u i l d i n g where the School i s  s i t u a t e d i s supplied with o f f i c e s , classrooms, a l i b r a r y , a laboratory and common rooms. The School of Nursing i s f o r m a l l y defined as a school w i t h i n the Faculty o f Applied Science, administered by a c o u n c i l nominated by the Dean o f the F a c u l t y .  The courses presented by  the school are s t r u c t u r e d t o meet the professed purpose o f the school: . . .to a s s i s t students t o become competent p r o f e s s i o n a l nurses, capable o f p a r t i c i p a t i n g w i t h other i n d i v i d u a l s , and groups i n a comprehensive h e a l t h programme designed t o assure t o a l l c i t i g e n s a high q u a l i t y o f nursing s e r v i c e i n sickness and i n the promotion o f h e a l t h ; t o help them develop the concepts that nursing i s concerned w i t h the promotion o f mental and p h y s i c a l h e a l t h , as w e l l as the care of the s i c k ; that i t i s a s e r v i c e to the f a m i l y as w e l l as to the i n d i v i d u a l , and i s given i n homes, h o s p i t a l s and other community agencies.  1 The U n i v e r s i t y of B r i t i s h Columbia, Calendar. Forty-Second Session, Vancouver, B r i t i s h Columbia, 193>6-5>7, p. 212.  During the f i r s t year of the degree course i n nursing, students are given l e c t u r e s on the campus, and except f o r short periods of a few weeks, the students do not r e t u r n to the campus u n t i l t h e i r f o u r t h year when they have graduated as r e g i s t e r e d nurses.  Before entry into, the School, students are expected to  have completed t h e i r Senior M a t r i c u l a t i o n or t h e i r f i r s t year i n the F a c u l t y of Arts and Science.  In the f i r s t nursing year  courses i n E n g l i s h , Biology, B a c t e r i o l o g y , Psychology, Anatomy and an i n t r o d u c t o r y course i n Nursing are g i v e n .  Often when  Psychology i s taken i n the Senior M a t r i c u l a t i o n year, a course i n the s o c i a l sciences i s s u b s t i t u t e d .  This arrangement brings  nursing students i n t o constant contact w i t h students a s p i r i n g to other occupational g o a l s .  Except f o r l e c t u r e s i n the rudiments  of nursing, the classes are i n t e r m i n g l e d . The l a b o r a t o r y f o r the i n t r o d u c t o r y course i n nursing techniques i s set up l i k e a ward.  I t has beds, bedside t a b l e s ,  sinks and a service room, a l l equipped w i t h the necessary utensils.  Even a p a t i e n t i s s u p p l i e d . This comes i n the form  of "Mrs. Chase," a l i f e - l i k e , l i f e - s i z e d d o l l , "who has everything."  Using the a v a i l a b l e apparatus and "Mrs. Chase," the  students " p r a c t i c e " and "pretend" by " g i v i n g " the " p a t i e n t " everything from bed baths, to mustard p l a s t e r s to enemas. however, when the procedures to be p r a c t i s e d are not of a d i f f i c u l t or embarrassing nature nursing students use each other as p a t i e n t s , t a k i n g turns at p l a y i n g that r o l e .  Often,  The nature of the teaching given the students i n nursing courses, as w e l l as i n the general science courses, seems to f o l l o w the t r a d i t i o n of u n i v e r s i t y i n s t r u c t i o n . General education and a broad outlook are considered "good t h i n g s " and the primary f u n c t i o n o f u n i v e r s i t y education i s i d e a l l y defined "to stimulate thought and encourage enquiry." Questioning i s t r a d i t i o n a l l y welcomed and d i s c u s s i o n s among students and between students and f a c u l t y are deemed a d v i s a b l e . The o b l i g a t i o n to condone these p r a c t i c e s i s placed on a l l teaching personnel.  The students, on the other hand, expect  such a t t i t u d e s and consider themselves j u s t i f i e d i n expecting a r i g h t to c o n t r a d i c t professors and t o query what has been taught to them. In e x t r a - c u r r i c u l a r a c t i v i t i e s nursing students often collaborate w i t h engineering students, being members of the same faculty.  "Mixers" or "dos" are organized.  There are a l s o  s o r o r i t i e s and campus clubs w i t h which nursing students become affiliated.  High School companions and f r i e n d s made during the  f i r s t year i n the F a c u l t y o f A r t s and Science are among the other attachments.  Added t o these contacts i s the f a c t t h a t the  m a j o r i t y of l e c t u r e s i n the f i r s t year i n the School of Nursing are taken i n conjunction w i t h non-nursing students.  Therefore  the i n t e r a c t i o n w i t h other students i s usual and frequent. Despite these diverse contacts, however, the f i r s t year nursing c l a s s begins to show signs of an inner s o l i d a r i t y . Although they attend classes i n other parts of the campus, they  congregate around t h e i r own b u i l d i n g .  The students spend much  time together, develop f r i e n d s h i p s w i t h i n the group, make f i e l d t r i p s together and p a r t i c i p a t e i n campus a f f a i r s as a group. They begin to see themselves as a group and as being d i f f e r e n t from o u t s i d e r s .  They develop notions o f "we" as opposed to "they,"  who c o n s i s t of a l l other f a c u l t i e s and schools. Even though they p a r t i c i p a t e generously w i t h non-nursing students, they a l r e a d y have a self-image of being nurses, and they p r e f e r t o i d e n t i f y themselves w i t h other nurses, r a t h e r than w i t h other u n i v e r s i t y students. This image becomes a r e c i p r o c a l t h i n g .  Not o n l y do  nursing students i d e n t i f y themselves w i t h nurses and w i t h each other, but non-nursing students,also c l a s s i f y them as "nurses" as opposed to engineers or artsmen.  When speculating on the  image o f student nurses that p r e v a i l s among the campus groups, i t seems that they are diverse and o f t e n c o n t r a d i c t o r y .  Nurses  are o f t e n considered to be "not r e a l l y " u n i v e r s i t y students i n that they have o n l y a few years there and then withdraw to the h o s p i t a l , where they are not able to make themselves f e l t as f u l l p a r t i c i p a n t s i n campus a c t i v i t i e s .  Artsmen o f t e n give them  the k i n d of d i s d a i n that i s accorded to those that apply, or those that p r a c t i c e , by those who consider themselves "pure" scientists.  In that way i t i s not considered as much an  educational course, as a v o c a t i o n a l course.  I t i s considered  by outsiders to be "easy" to be accepted i n t o nursing, and an acceptable career for those g i r l s who are not able to take a  more academic r o l e .  On the other hand nursing students are  considered as s e l f - s a c r i f i c i n g and humanitarian i n t a k i n g on work that i s "hard" and r e c e i v e s l i t t l e remuneration and prestige.  Along w i t h Home Economics i t i s considered a woman's  p r o f e s s i o n and hence students o f the p r o f e s s i o n are o f t e n defined as the "feminine type." The f a c u l t y of the School o f Nursing also induces f e e l i n g s o f s o l i d a r i t y and i d e n t i t y w i t h the nursing group. Unlike the members o f the F a c u l t y o f A r t s and Science, they are f a m i l i a r w i t h the p e r s o n a l i t i e s and backgrounds o f a l l t h e i r students.  They keep a check on t h e i r a t t i t u d e s towards the  occupation by i n t e r v i e w s , which are recorded and then become part o f the p i c t u r e o f the student.  They are thus able t o  understand t h e i r students, to p r e d i c t t h e i r behaviour and thus, to guide them.  From the beginning they begin t o introduce the  idea o f " p r o f e s s i o n a l s e l f " to the c l a s s , and t o i n d i c a t e the norms o f the occupational c u l t u r e .  I n t h i s way they help to  develop a p r o f e s s i o n a l p e r s o n a l i t y In each student and a f e e l i n g of sameness i n the group and a d i f f e r e n c e from o u t s i d e r s .  The H o s p i t a l From the u n i v e r s i t y campus the students move i n t o an e n t i r e l y d i f f e r e n t type o f m i l i e u .  They enter the h o s p i t a l , o r  t h e i r work environment, where they expect t o spend the next two years as w e l l as u n l i m i t e d time a f t e r they graduate.  Oj  The h o s p i t a l could be viewed as an o r g a n i z a t i o n o f s p e c i f i c r o l e s which are s t r a t i f i e d i n such a manner as to enable the most e f f i c i e n t f u l f i l l m e n t o f a common g o a l .  The  common goal i s the cure o f i l l n e s s , and t h i s phenomenon i s the core o f the whole s t r u c t u r e , f o r without i t there would be no such s t r u c t u r e .  Besides being harmful to the p h y s i c a l organism,  i l l n e s s i s considered s o c i a l l y u n d e s i r a b l e .  I t i s treated  almost as a form of s o c i a l deviance which i s o l a t e s the i n d i v i d u a l from others and hence i s unpleasant.  This r o l e o f i s o l a t i o n  involves one o b l i g a t i o n , that i s , t o get b e t t e r . the p a t i e n t i s hence a "changing" r o l e .  The r o l e o f  The p a t i e n t i s expected  to get b e t t e r both by h i s own e f f o r t s and also through the e f f o r t s o f others who are experts i n the ways o f r e t u r n i n g t o health. The h o s p i t a l i s the s t r u c t u r e i n t o which these experts are f i t t e d .  The h o s p i t a l has four groups o f such r o l e s .  Firstly,  there i s the group which includes the p a t i e n t s , the c e n t r a l figures.  Secondly, there i s the nursing group, which i s h i g h l y  s t r a t i f i e d according t o competence.  I t ranges from the d i r e c t o r  of nursing, through supervisors, head nurses, graduate nurses, student nurses to nurses' aides and ward aides.  The higher on  the s c a l e , the greater are the p r i v i l e g e s such as a u t h o r i t y and i t s associate f a c t o r s o f p r e s t i g e and income. are the duties and r e s p o n s i b i l i t i e s .  The greater also  T h i r d l y , there i s the  medical group which c o n s i s t s o f the medical administrator, heads o f departments, v i s i t i n g s p e c i a l i s t s , general p r a c t i t i o n e r s ,  (  \  senior and  junior residents and i n t e r n s .  Fourthly, the h o s p i t a l  administration group, headed by the h o s p i t a l administrator  and  c o n t r o l l e d by a board of t r u s t e e s , includes the o f f i c e s t a f f s , the admittance and discharge departments, s t a t i s t i c s , medical records and so on.  There are other r o l e s which play a u x i l i a r y  parts i n the h o s p i t a l m i l i e u , where the r e h a b i l i t a t i o n of the patient i s the c e n t r a l concern.  This means r o l e s i n the s o c i a l  s e r v i c e d i v i s i o n , i n the l a b o r a t o r i e s , i n d i e t e t i c departments and i n p u b l i c h e a l t h agencies. This formal structure i s made up of sets of h i e r a r c h i e s , where each status i n each hierarchy has i t s own responsibilities.  well-defined  Thus i t i s the duty of the head nurse to  accompany the doctor when he v i s i t s the ward.  Similarly i t is  the duty of the ward aide to supply the ward with the linen.  The  required  functions of each r o l e are s p e c i a l i z e d , and being  t r a d i t i o n a l l y defined, are s t a b l e .  Because of these t r a d i t i o n a l  expectations each r o l e becomes s o c i a l l y p r e d i c t a b l e . expectations are passed on to a l l who r o l e s i n the s t r u c t u r e .  These  "take"'on" s p e c i a l i z e d  Therefore, before t h e i r a r r i v a l at  the h o s p i t a l , student nurses are made aware of t h e i r t r a d i t i o n a l l y defined expectations.  To a c e r t a i n extent, then, the  functions  of a h o s p i t a l depend on t r a d i t i o n . Secondly, t r a i n i n g into a medical m i l i e u i s based on discipline.  Although students know what i s required, they are  not sure of how  t h i s can be l e a r n t .  I t i s achieved i n an  a u t h o r i t a r i a n system, which demands immediate obedience and  precision.  This r a t h e r d i c t a t o r i a l method i s r a t i o n a l i z e d by-  s t r e s s i n g the importance o f speed and d i r e c t f o l l o w i n g o f orders i n an emergency s i t u a t i o n where l i v e s hang by a thread. For t h i s an elaborate set of r u l e s i s set up and enforced. A l l c r i t i c i s m i s discouraged.  I n these respects, the  hospital  m i l i e u resembles a m i l i t a r y i n s t i t u t i o n . Such t r a i n i n g r e s u l t s i n g i v i n g control to a u t h o r i t i e s and i n f o s t e r i n g e f f i c i e n c y . The  continuation o f the e f f i c i e n t functioning  h o s p i t a l depends on a t h i r d p r i n c i p l e . A prerequisite  of the  This i s r o u t i n i z a t i o n .  o f t h i s behaviour becoming the routine behaviour  i s some acceptance of the system and o f what i s r e q u i r e d o f the nurse i n t h i s system.  When t h i s i s accepted the student becomes  conditioned to acting i n the p r e s c r i b e d manner i n a l l s i t u a t i o n s . In t h i s manner d i s c i p l i n e , obedience and consequently e f f i c i e n c y are ensured. When the student leaves the u n i v e r s i t y to come to the h o s p i t a l , she i s subjected to a d i f f e r e n t type o f teaching situation.  The greatest change l i e s i n her l e a r n i n g  s h i p - f a s h i o n on the ward, where she i s placed. in-service training. also becomes a worker.  apprentice-  I t i s a form o f  The g i r l i s no longer only a student, she She i s expected t o perform c e r t a i n  duties and i s under the o b l i g a t i o n t o "learn by experience." Her teachers are her superiors on the ward.  She receives  i n s t r u c t i o n from head nurses, graduate nurses and other students who have been there longer.  O c c a s i o n a l l y she i s helped by an  instructress.  In general, however, her teachers are experienced  nurses, not t r a i n e d teachers. I have been up here f o r two weeks, but I haven't yet seen the i n s t r u c t r e s s . Her teachers, t h e r e f o r e , are numerous and of d i f f e r i n g statuses, and her r o t a t i o n s send her f r e q u e n t l y to new wards where she meets more teachers. What she i s to l e a r n i s standardized. her l e a r n i n g i s d i f f u s e .  Yet  What she l e a r n s on one ward she o f t e n  has to unlearn and then r e l e a r n when she goes to another, so that she can f i t i n t o the requirements imposed by the new head nurse. In t h i s way, a f t e r t h e o r e t i c a l i n s t r u c t i o n at the. u n i v e r s i t y , the students are able to experience t h e i r r o l e i n a c t i o n f o r the f i r s t time.  She i s now c a l l e d upon to give the  mustard p l a s t e r s and the enemas that she performed on Chase."  "Mrs.  She a c t u a l l y makes a bed i n which a " r e a l " p a t i e n t  w i l l sleep. to a d o l l .  She gives a back rub to a " r e a l " p a t i e n t and not She sees what happens i n emergencies,  merely hear about them.  There Is no longer an opportunity to  ask questions and to discuss the advantages and of d i f f e r e n t techniques.  and does not  disadvantages  The student i s expected to a c t .  Any  i n d i v i d u a l i n i t i a t i v e i s d e f i n i t e l y discouraged. . T r a d i t i o n , d i s c i p l i n e and r o u t i n e c o n d i t i o n the student to the norms of the h o s p i t a l . speed.  She i s conscious o f the need f o r p r e c i s i o n and  91  Another aspect o f the new teaching i s h o s p i t a l nursing lectures.  These are conducted by i n s t r u c t r e s s e s from the h o s p i t a l  teaching s t a f f and by doctors who l e c t u r e i n t h e i r s p e c i a l area of competence.  These l e c t u r e s serve several functions  new t r a i n i n g m i l i e u .  Besides presenting new subject matter,  they serve t o break the routine of ward experiences.  i n the  and give r e l i e f from the monotony  They r e i n f o r c e the i n t e r e s t o f students by  g i v i n g them a taste o f what i s coming.  They function also i n  s o l i d i f y i n g a t t i t u d e s that already e x i s t and i n introducing new ones.  Such a t t i t u d e s are introduced by r e q u i r i n g students to  r i s e when a l e c t u r e r comes i n the room, something that was not enforced at u n i v e r s i t y .  They also serve to remind the g i r l s of  t h e i r r o l e as "students," when they are beginning to define themselves as "workers." The present.  atmosphere of u n i v e r s i t y l e c t u r e s , however, i s not  A s t r i c t e r c o n t r o l i s kept on the students by constant  r o l l - c a l l s and by p l a c i n g r e s t r i c t i o n s on what can be done between l e c t u r e s .  Degree students resent t h i s as an infringement  on t h e i r freedom, and as a regression  from t h e i r u n i v e r s i t y  training: I've just been t o l d by one o f the kids i n the u n i v e r s i t y class ahead, of us that a l l our classes w i l l be on t h i s l e v e l u n t i l we graduate . . . That's hard t o take a f t e r the l e v e l of u n i v e r s i t y classes . . . and then t o top i t a l l , we have to r e t u r n to u n i v e r s i t y l e v e l i n our f i n a l year. They begin to f e e l as i f they were being t r e a t e d l i k e c h i l d r e n . This they f e e l to be i n c o n t r a d i c t i o n to the r e s p o n s i b i l i t y and leeway that i s given to them on the ward.  The  Residence When the students leave the u n i v e r s i t y and become  p a r t of the h o s p i t a l program, they also change t h e i r place o f residence.  They are given a room i n the Nurses'  Residence  adjoining the h o s p i t a l , where they l e a d a communal l i f e .  This  l i f e i s l e d w i t h i n a system o f r u l e s which allows the nursing p r o f e s s i o n to c o n t r o l t h e i r i n i t i a t e s i n the most appropriate manner.  The u l t i m a t e purpose o f t h i s control i s to subject the  students to the kinds o f experiences which are l i a b l e t o develop the r e q u i r e d type o f nurse. The students, t h e r e f o r e , are c o n t r o l l e d by s t r i c t time boundaries.  They must be I n the residence at a r e q u i r e d  time each n i g h t , and are allowed a c e r t a i n amount o f time f o r which they do not need to account.  Even "sleep out" nights are  c o n t r o l l e d by residence r u l e s , and such p r i v i l e g e s are only afforded the student when the place o f the "sleep out" i s her home, o r i s at a place approved by her parents and by resident authorities.  I f students do not leave the residence, a l l common  or group a c t i v i t y must cease at a s p e c i f i e d hour, and a l l g i r l s must r e t i r e to t h e i r own rooms.  Then again bedtime i s w e l l -  defined and s t r i c t l y enforced by matrons who p a t r o l the c o r r i d o r s to punish deviants. At ten o'clock on winter evenings and at eleven o'clock on summer evenings the doors of the residence are shut. A l l students are allowed one "sleep out" every week, on the night  before t h e i r day o f f , and a l l students, w i t h the exception o f p r e l i m i n a r y students are granted a " l a t e l e a v e , " which means that they are a b l e to stay out u n t i l midnight.  Under s p e c i a l  circumstances an extended " l a t e l e a v e " may be permitted by the matron i n charge.  The students are not allowed, however, to  accumulate "sleep outs" and " l a t e l e a v e s " and to take them during the one week. This system o f i s o l a t i o n and s t r i c t c o n t r o l compares to that exercised i n . a m i l i t a r y , i n s t i t u t i o n .  The residence i s  o f t e n r e f e r r e d t o as a "nunnery" or a " p r i s o n . " Both terms are significant i n their functional s i m i l a r i t i e s .  With nursing  students residence l i f e separates them from outsiders and forces them i n t o the constant company of t h e i r own group. i t doubly easy to transmit the relevant norms.  This makes  The aspirants  are freed, t o some extent, from outside i n f l u e n c e s , and placed f u r t h e r under the c o n t r o l o f the system that makes them into nurses.  They are, t h e r e f o r e , more o f t e n a v a i l a b l e and i n the  h o s p i t a l m i l i e u , and hence exposed to the a t t i t u d e s that p r e v a i l and t o the expectations that are placed on them.  At the same  time they have l e s s time to acquire or p r a c t i c e norms that do not apply s p e c i f i c a l l y to the medical sub-culture.  Thus they  are constantly l i s t e n i n g t o the views o f other students, nurses and matrons.  They eat w i t h h o s p i t a l personnel, and t h e i r world  seems to be made up o f nursing f u n c t i o n s , of study, o f p a t i e n t s , i n s t r u c t r e s s e s and doctors.  They see other students capped,  graduated and examined. They l i s t e n sympathetically to the  troubles of t h e i r f r i e n d s , and are among the f i r s t to hear and transmit h o s p i t a l news. They begin to know what actions are the beginnings of t r o u b l e and what punishments could occur. They know which i n s t r u c t r e s s e s , head nurses and doctors to avoid long before they meet them. There are two d i s t i n g u i s h a b l e a t t i t u d e s towards residence l i f e .  One sees t h i s form of I s o l a t i o n as a "good  t h i n g , " and a very necessary part of nursing t r a i n i n g .  It is  considered a d i s c i p l i n a r y form which provides the correct m i l i e u i n which the appropriate k i n d of nurse can be moulded.  She i s  prevented from becoming o v e r - t i r e d , and from exposing h e r s e l f to the wrong i n f l u e n c e s . Instead she leads a s t r i c t l y regulated existence and thereby maintains the desired p u b l i c image. i s the view h e l d by members of the p r o f e s s i o n who p o s i t i o n of t r a i n i n g the students.  This  are i n a  I t i s also considered "the  only way" by some students, even though they express displeasure at the imposed l i m i t a t i o n s .  Only by t h i s method can they become  "good" n u r s e s .  The other view, h e l d mostly by students, I s that residence l i f e i s an unpleasant phase that "must be put up w i t h . " I t i s considered unjust and the c o n t r o l s exercised are considered pointless.  Students refuse to admit that there i s any value i n  such a l i f e and eagerly look forward "to the day we can get out of here."  Their behaviour i n the residence f o l l o w s  i n s t i t u t i o n a l i z e d forms of deviance.  They complain about the  rooms, the l a c k o f p r i v a c y , the unimaginativeness o f the food, the hours and the r u l e s . controls.  They develop ways t o outwit and avoid  They keep quiet w h i l e the matron examines the h a l l s ,  thus g i v i n g the impression that each g i r l i s i n her own room, while four or f i v e are i n the one room.  They s t u f f the mat  under the door so that the l i g h t does not show i n t o the c o r r i d o r . They eat meals i n the residence even when only snacks are allowed. They even work out ingenious methods of s t a y i n g out a l l n i g h t . In these ways they can channel aggression i n d i r e c t l y at residence a u t h o r i t i e s , who l i m i t t h e i r behaviour.  Group A f f i l i a t i o n s The frequent a s s o c i a t i o n o f working, studying and l i v i n g together serves s e v e r a l s i g n i f i c a n t functions i n the r o l e of the student nurse. led  I t can be assumed that the l i f e that i s  plays a major r o l e i n moulding the s o c i a l i d e n t i t y o f the  student.  As the l i f e o f a l l students i s s i m i l a r , t h e i r mode  of existence serves an a s s i m i l a t i n g f u n c t i o n . The r e s u l t i s that each nurse i s somewhat s i m i l a r t o every other nurse. This a s s i m i l a t i o n begins w i t h c o - h a b i t a t i o n . This common existence i s emphasized by the i s o l a t i o n imposed by residence r u l e s , which force the student i n t o the company o f her f e l l o w s and l e s s i n t o the company o f outside f r i e n d s . are also bound together by common work and common study. process ends w i t h the establishment o f i n t e r n a l bonds.  They The  Students  now are no longer i n the company o f t h e i r f e l l o w s because they  are f o r c e d to do so, but because they want to do so.  They tend  to have fewer f r i e n d s outside of the residence, and more w i t h i n the residence. A common i d e n t i t y becomes evident. There i s an i n creasing s o l i d a r i t y .  Other classes are r e f e r r e d to as "they,"  t h e i r c l a s s i s "we."  When asked how many f r i e n d s they have  w i t h i n t h e i r c l a s s , they answer that a l l of the g i r l s are t h e i r friends.  Only when asked to q u a l i f y , do they show any  preferences. solidarity.  Thus to o u t s i d e r s they show t h i s front of Only among themselves and i n t h e i r informal  a c t i v i t i e s i s i t dropped.  To o u t s i d e r s , however, they emphasize  the f a c t that they are equal and that they are a group.  This  i s shown by the way i n which they understand each other's d i f f i c u l t i e s and become i n s u l t e d and enraged when one of t h e i r members i s i n s u l t e d or enraged. P s y c h o l o g i c a l support i s derived from such s o l i d a r i t y . They exchange confidences about t h e i r f e e l i n g s towards others, about t h e i r inadequacies i n t h e i r work, as w e l l as about t h e i r personal problems outside o f the medical m i l i e u .  I n t h i s way  they understand each other without elaborate explanations and share burdens by " t a l k i n g shop."  Each member of the c l a s s i s  under the unspoken o b l i g a t i o n of l i s t e n i n g , o f f e r i n g support, and o f not repeating to o u t s i d e r s . This s o l i d a r i t y leads to the reinforcement of standards and of a t t i t u d e s .  The group r e g i s t e r s e i t h e r approval or  disapproval of an i n d i v i d u a l member's actions by g i v i n g or withholding  support.  A t t i t u d e s become so s t r o n g l y c o n t r o l l e d  that i f a student has deviated from expectations,  she does not  discuss t h i s d e v i a t i o n f o r she i s w e l l aware that the group would not approve.  Thus i f a student loses her temper towards  a patient and Is consequently apprehended by a u t h o r i t y , she not discuss i t .  may  She r e l i e v e s her g u i l t by withdrawing and  f o r g e t t i n g the s i t u a t i o n . I f , however, she f e e l s the punishment unjust, she complains to the group. The establishment and transmission of l o c a l myths are also the r e s u l t s of t h i s s o l i d a r i t y .  Hence the behaviour of a  head nurse or i n s t r u c t r e s s i s c r i t i c i z e d and passed from member to member, long before any contact has been made. group members are prepared f o r c e r t a i n experiences.  In t h i s  way  They are  able to p r e d i c t the behaviour of the head nurse involved,  and  to react i n the most d e s i r a b l e manner. L i s t e n to everything she says, but f o r goodness sake, don't argue w i t h her. Each c l a s s i n the residence  develops such s o l i d a r i t y .  I n t e l l e c t u a l and r e c r e a t i o n a l i n t e r e s t s do l e a d to c r o s s - c l a s s affiliations.  The i n i t i a l bonds, however, are not overcome,  the f e e l i n g s of "we"  are r e s t r i c t e d to one's own c l a s s , and  g e n e r a l l y i n times of s t r e s s , support i s sought among one's own  c l a s s members.  Regarding her c l a s s , one student commented:  You could go and t a l k t o anyone r e a l l y . I t h i n k our c l a s s i s quite c l o s e . And I t h i n k i t i s r e a l l y a good idea t o move a l l the classes together. Except that you don't get to know the other kids i n the other c l a s s e s . A c t u a l l y i t doesn't make too much d i f f e r e n c e because you have enough f r i e n d s i n your own c l a s s . Over and above the d i v i s i o n s among c l a s s e s , there i s a w e l l - d e f i n e d d i v i s i o n between students i n the u n i v e r s i t y degree course and the students i n the h o s p i t a l nursing course.  The  subjects o f t h i s study o f t e n complained that they were i d e n t i f i e d as " u n i v e r s i t y g i r l s " and were o f t e n scorned by the other students.  They f e l t that the a t t i t u d e s o f h o s p i t a l personnel  towards them changed when they discovered that they were "university g i r l s . "  Often they f e l t more was expected from  them i n the way of s k i l l s and knowledge. The u n i v e r s i t y students had varying explanations  f o r the f e e l i n g s that e x i s t e d between  themselves and the h o s p i t a l c l a s s .  They b e l i e v e d the others  thought them "stuck up." They o f t e n defined t h i s a t t i t u d e as u n j u s t , but on occasion they l a i d blame on a few of t h e i r members f o r engendering t h i s image. They o f t e n commented that the antagonism e x i s t e d because the h o s p i t a l students thought the u n i v e r s i t y students "had i t easy" and were required to spend l e s s time i n the residence and t o give l e s s s e r v i c e .  Or the  h o s p i t a l g i r l s believed they were "given favors," as they were allowed t o spend a two-month period at the p r o v i n c i a l mental h o s p i t a l as a part o f t h e i r t r a i n i n g , w h i l e the h o s p i t a l g i r l s were deprived o f t h i s .  U n i v e r s i t y g i r l s , furthermore, were  considered p r i v i l e g e d because of t h e i r a f f i l i a t i o n s w i t h the  u n i v e r s i t y and t h e i r opportunity t o partake of campus s o c i a l activities.  Generally, however, i t appears that both groups  l a i d the blame on the other.  The h o s p i t a l g i r l s were considered  unjust i n t h e i r antagonism, and the u n i v e r s i t y g i r l s were considered u n j u s t l y p r i v i l e g e d .  Sequences The nature of the t r a i n i n g p e r i o d can be c l a r i f i e d d i v i d i n g i t i n t o stages. one before.  by  Each stage i s an advancement on the  Instrumental s k i l l s and expressive knowledge become  increasingly internalized.  So that at the beginning of the f i r s t  stage the aspirant i s a layman, her only claim on the nursing r o l e being a desire to "become" a nurse.  At the end of the l a s t  stage, she i s a f u l l y accepted member o f the occupational group. The School of Nursing of the h o s p i t a l has declared formal phases to d i v i d e the r o l e - t a k i n g process.  They are named  the "probie," " j u n i o r , " "intermediate" and " s e n i o r " terms, each one s i g n i f y i n g an i n c r e a s i n g command of the instrumental and expressive knowledge of the r o l e . and more r e s p o n s i b i l i t y .  Each stage means more a u t h o r i t y  This i s v i s i b l y symbolized i n the dress  of the student, each of the four phases being c h a r a c t e r i z e d by a d i s t i n c t i v e uniform.  This way of i n d i c a t i n g the stage of a  student's knowledge functions to enable others i n the medical subc u l t u r e to expect from her, upon s i g h t , . a c e r t a i n amount of s k i l l and understanding.  1.  The  "Probie" Phase.  The probationary p e r i o d  begins w i t h the i s s u i n g of a uniform, c o n s i s t i n g of the "blues," the narrow b i b and apron, black shoes and s t o c k i n g s . w i t h "capping."  This o r i e n t a t i o n i n t o the medical  I t ends  sub-culture  c o n s i s t s mainly o f l e c t u r e s , w i t h short periods o f two to four hours on the ward.  The u n i v e r s i t y c l a s s has t h i s p r e l i m i n a r y  period f o r two months, the h o s p i t a l c l a s s f o r four months. A f t e r t h i s p e r i o d , there are exams and s u c c e s s f u l candidates are then e l i g i b l e f o r a cap, c u f f s and h o s p i t a l p i n . 2.  The  "Junior" Phase.  Capping i s a r i t e o f  i n i t i a t i o n marking acceptance by the nursing p r o f e s s i o n of another member.  I t presupposes that the i n i t i a t e has  fully  met the requirements of the p r o f e s s i o n and i s hence worthy of l e a r n i n g to p l a y the r o l e . begins.  With "capping," the j u n i o r term  This means a s i x month p e r i o d f o r u n i v e r s i t y g i r l s  and an eight month p e r i o d f o r the others.  They spend time on  the ward and become f a m i l i a r w i t h more complex procedures. are now  q u a l i f i e d to c a t h e t e r i z e , to give bladder  irrigations,  to chart doctor's orders, and to administer medications. begin to work s h i f t s .  They  They  Exams mark t h e i r entry i n t o the " j u n i o r  block" of l e c t u r e s where t h e y r e c e i v e i n s t r u c t i o n on j u n i o r specialties.  A f t e r classes t h e i r knowledge i s t e s t e d once more  before they are allowed to begin on t h e i r s p e c i a l t y t r a i n i n g . While j u n i o r s , the students work i n d i e t e t i c s , orthopedics, ophthalmology, on the ear, nose and throat ward, the genitou r i n a r y wards and i n the operating room.  Junior students are  considered to be "the ones that r e a l l y work, the intermediates and seniors s i t around answering the telephone and c h a r t i n g . " 3.  The "Intermediate" Phase.  Students graduate from  narrow to broad b i b s , and thereby enter onto the longest s i n g l e phase of the t r a i n i n g process. for twelve months.  They w i l l be "intermediates"  The l o c a l myth o f the monotony of the  intermediate phase has c i r c u l a t e d among the students and they have formed t h e i r expectations of what i t e n t a i l s .  They have  heard of the "intermediate slump," and expect to go through i t . Intermediate s p e c i a l t i e s are o b s t e t r i c s and p e d i a t r i c s , each department t a k i n g three months of the student's time.  Exams  terminate each p e r i o d , and f o r m a l l y s i g n i f y the student's a b i l i t y to progress to the next p e r i o d . J+.  The "Senior" Phase.  A f t e r "capping," a major  r i t u a l , entry i n t o the senior phase could be considered a minor r i t e de passage.  The fact that students are now c l o s e to  graduation i s symbolized by the wearing o f white shoes and stockings.  To prevent examination of shoes and s t o c k i n g s , the  t r a i n i n g stage that has been reached i s made immediately noticeable by a black band attached t o the cap. When the student graduates t h i s black band and the "blues" disappear and are replaced by an a l l - w h i t e uniform.  During t h i s period  of tvjelve months f o r the h o s p i t a l students and eight months f o r the u n i v e r s i t y students, instrumental s k i l l s are acquired i n the s p e c i a l t i e s o f gynaecology, and neurology.  i n f e c t i o u s diseases, p s y c h i a t r y  Exams f o l l o w each s p e c i a l t y .  The process of r o l e - t a k i n g , t h e r e f o r e , i s d i v i d e d into four w e l l - d e f i n e d phases.  Each phase s i g n i f i e s the d i d a c t i c  presentation of more d i f f i c u l t t e c h n i c a l and instrumental material.  With i n c r e a s i n g experience, however, i n t e r p e r s o n a l  r e l a t i o n s and expressive s k i l l s become more f a m i l i a r . A t t i t u d e s and norms, which are appropriate to the nursing r o l e , also are increasingly internalized.  This r e s u l t s i n the student r e a c t i n g  i n the required manner. The a c q u i s i t i o n of the m a t e r i a l presented i s measured at the conclusion of each phase. examinations.  This i s done o b j e c t i v e l y by  The manner In which t h i s knowledge i s a p p l i e d ,  as itfell as the nature of i n t e r p e r s o n a l r e l a t i o n s i s evaluated. T h i s , t h e r e f o r e , i s s u b j e c t i v e and i s presented i n the form of ward reports by head nurses.  A close check i s kept on the progress  of the student by these means. Ward reports and the r e s u l t s of examinations tend to check any deviance from the r e q u i r e d course of t r a i n i n g . The four phases serve s e v e r a l important f u n c t i o n s . Prom the point of view of others i n v o l v e d i n the medical subc u l t u r e , the extent of a student's knowledge can be immediately estimated by the nature of her apparel.  Therefore, no doctor  would approach a "probie" to give a medication, or any student, other than a s e n i o r , to i n s e r t a Irvine tube.  In a c u l t u r e of  such urgency as the medical sub-culture, t h i s device i s timesaving as i t avoids the arduous and time-consuming process of asking each student whether she i s able to perform the  procedure r e q u i r e d .  Prom the point of view of students  system serves a p s y c h o l o g i c a l f u n c t i o n .  The students  the  feel  secure i n knowing that they w i l l not be c a l l e d upon to perform services that they have not yet mastered. gives them greater confidence on the ward.  This undoubtedly They are also  equalized w i t h other students of equal a b i l i t i e s , not only i n knowledge, but also i n appearance.  The four phases, marked by  the v i s u a l means of apparel, f u n c t i o n also i n the d i s t r i b u t i o n of p r i v i l e g e s and s t a t u s .  CHAPTER V THE CHOICE OP NURSING AND ROLE-ANTICIPATION  This chapter i s based on the assumption that an occupational r o l e i n our s o c i e t y i s an acquired r o l e , being "taken on" because o f a wish t o enter the r o l e .  With t h i s wish  to take on the r o l e there goes a s e r i e s o f a n t i c i p a t i o n s and self-images, which w i l l be discussed i n the second s e c t i o n o f this  chapter. Student nurses were interviewed during t h e i r  u n i v e r s i t y t r a i n i n g w i t h questions on t h e i r choice o f nursing and t h e i r beginning a n t i c i p a t i o n s .  They were asked why they  took up nursing, what else they would consider as an occupation, what was t h e i r model occupational r o l e and what i n i t i a l s e l f images they had.  1.  Making the Choice  When considering " r o l e - t a k i n g " and'role-playing," i t does not s u f f i c e t o r e f l e c t on the process o f "how men become lawyers" o r "how women become nurses." s i g n i f i c a n t question:  This omits one  Why lawyers and not policemen?  nurses and not school teachers?  Why  There are, t h e r e f o r e , reasons  f o r choosing one occupational r o l e from numerous p o s s i b l e r o l e s .  Any enquiry i n t o why the subjects of t h i s study wished to  become nurses brought f o r t h a c e r t a i n type of information.  I t d i d not delve i n t o the complicated f a c t o r s that are involved i n m o t i v a t i o n , but r a t h e r showed the students' conceptions what turned them towards n u r s i n g . of t h e i r i n i t i a l  of  Their answers are i n d i c a t i v e  self-image and i t i s p o s s i b l e these answers  could change w i t h t h e i r changing self-images.  In other words,  before t a k i n g on the r o l e , they may give d e d i c a t i o n to h e l p i n g others as t h e i r reason f o r wanting to become nurses, but a f t e r having been student nurses f o r some time, they may  say that they  went i n t o nursing f o r reasons o f s e c u r i t y or personal satisfaction.  This chapter, t h e r e f o r e , s h a l l discuss the  images they had, at the beginning, of why they went i n t o n u r s i n g , and not what r e a l l y motivated them i n t o becoming nurses.  Types of Reasons Given When asked how they came to take up nursing, numerous reasons were given. . These reasons, however, f e l l Into two d i s t i n c t classes:  the "ascribed" and the "acquired" modes of  orientation.  1.  The Ascribed O r i e n t a t i o n These students see the nursing r o l e as a part of the  s e l f and as a m a n i f e s t a t i o n of one's inherent s e l f .  They b e l i e v e  they are meant to be nurses, and there i s no c o n f l i c t of having to choose an occupational r o l e .  Wo other r o l e would be s u i t a b l e  f o r them, and the t a k i n g and p l a y i n g of the nursing r o l e i s merely a c o n t i n u a t i o n o f the development o f t h e i r s e l v e s . There i s no stage of weighing the duties and p r i v i l e g e s o f occupational r o l e s and no evidence o f the n e c e s s i t y o f making an occupational choice.  These i n d i v i d u a l s d i d not consider other r o l e s , as the  nursing r o l e was i n h e r e n t l y s u i t a b l e and other r o l e s were not. In i n t e r a c t i o n w i t h these students I found that t h e i r "expressive" knowledge was well-developed and nursing norms and a t t i t u d e s had been i n t e r n a l i z e d and acted upon before they became nursing students.  They show that they have humanitarian,  a l t r u i s t i c ideas and t h a t they are eager to help others. are quiet and reserved and w i l l i n g to c a r r y out orders.  They Some  of these a t t r i b u t e s are evident before they take on the " p r a c t i c a l " aspects o f t h e i r work.  Hence f o r them the process  of becoming nurses i s g r e a t l y f a c i l i t a t e d . These i n d i v i d u a l s do not r e f e r to the rewards and p r i v i l e g e s of the p r o f e s s i o n , but r a t h e r to what they can do f o r others.  They show l i t t l e concern f o r remuneration, p r e s t i g e  and s e c u r i t y , and i f they are concerned w i t h these, they do not mention them.  In t h i s way they conform to the image of a  p r o f e s s i o n a l s e l f , namely, the image o f a l t r u i s m .  This does  not n e c e s s a r i l y mean, however, t h a t they are o b l i v i o u s of these rewards, but simply that they have adopted the occupational norm to such an extent t h a t they do not r e f e r to aspects of self-interest.  107  W i t h i n t h i s broad category o f those who consider themselves nurses because o f a s c r i b e d reasons, there are sub-types o f o r i e n t a t i o n :  Born a Nurse W e l l , a c t u a l l y , I never wanted to he anything e l s e . You know, when you're a l i t t l e g i r l you set an i d e a l f o r y o u r s e l f . Statements such as t h i s occurred w i t h marked frequency, and should, t h e r e f o r e , be considered as a d i s t i n c t category.  The i m p l i c a t i o n i n each case i s that the student i s  aware o f a w e l l - d e f i n e d g o a l , that i s , of wanting to be a nurse, from a r e l a t i v e l y e a r l y age, and i s , t h e r e f o r e , able to d i r e c t her energies towards t h a t g o a l . Where the i n i t i a l wish came from i s l o s t to the subject and cannot be discovered i n an interview s i t u a t i o n .  She b e l i e v e s , however, that the r o l e i s  i n h e r e n t l y appropriate t o her.  Therefore, she i s never placed  i n the c o n f l i c t i n g s i t u a t i o n o f having t o make a choice.  In Mother's Image —  Positive Identification  I decided that I would take up nursing simply because my mother had been a nurse and I always admired her . . . . Well n a t u r a l l y my mother i s i n t e r e s t e d . She's always t e l l i n g me what to do. She k i n d o f has the i n s i d e s t o r y . When I'm confused she's the person I go t o . The occupations o f parents and other f a m i l y members undoubtedly p o s i t i v e l y a f f e c t th.e occupational choice made by  108  children.  This could be explained i n terms of emotional  and  p h y s i c a l dependency, which are Involved i n c h i l d s o c i a l i z a t i o n . The c h i l d i s s e n s i t i v e to the i n f l u e n c e o f others, e s p e c i a l l y her parents.  Because of her f l e x i b i l i t y she i s molded through  the process of i n t e r a c t i o n w i t h these parents.  She  continuously  adopts the values and a t t i t u d e s of parents and these become parts o f her p e r s o n a l i t y . In t h i s way parents w i t h p e r s o n a l i t i e s r e s u l t i n g from the p l a y i n g of occupational r o l e s transmit t h e i r values and a t t i t u d e s to t h e i r c h i l d r e n . Thus mothers who were, or are, nurses are l i a b l e to have daughters who have c h a r a c t e r i s t i c s s i m i l a r to members o f that occupational group. I t i s s i g n i f i c a n t to note that the occupational group to which the l a r g e s t number o f mothers belonged was n u r s i n g . A, who  (Appendix  This does not take i n t o account other k i n s h i p members, are also nurses.  Subjects of t h i s sub-type have, t h e r e f o r e ,  adopted p e r s o n a l i t y f a c t o r s as a r e s u l t of i d e n t i f i c a t i o n w i t h the mother or other member o f the k i n s h i p group.  I n Mother's Image —  Negative  Identification  I t ' s funny . . . my mother and I know that she always a nurse, and I didn't want because I t h i n k she wanted so d i d f a t h e r .  was a nurse . . . wanted me to be to be, mainly me to be. And  Some of the students interviewed were i n f l u e n c e d towards nursing i n a negative manner.  In the case c i t e d above  i t seems l i k e l y that the values of the mother, as a nurse, have been transmitted to the c h i l d .  The c h i l d , however, i s not  conscious she has  o f a d e s i r e to take on the n u r s i n g r o l e .  The  values  i n t e r n a l i z e d , however, f i n a l l y i n f l u e n c e h e r t o choose  nursing. I t i s i n t e r e s t i n g to. note t h a t these i n d i v i d u a l s , have chosen the n u r s i n g r o l e at an e a r l y age, peers as h a v i n g nurse.  a l o n g e r and  their  a p r i o r c l a i m to the r o l e o f the  T h i s l e d to t h e i r o f t e n assuming an a u t h o r i t a t i v e  p o s i t i o n w i t h i n the group as having o f the s u b j e c t matter o f n u r s i n g . I n o t i c e d t h a t questions  p o s s e s s i o n o f the knowledge E a r l y i n the t r a i n i n g p e r i o d  on the nature  n u r s i n g were o f t e n d i r e c t e d at these  2.  are seen by  who  and s u b j e c t matter o f  students.  The A c q u i r e d O r i e n t a t i o n I n d i v i d u a l s o f t h i s type o f o r i e n t a t i o n see  n u r s i n g r o l e as something separate they must choose and then a c q u i r e .  the  from themselves, which I t i s a r o l e i n t o which  they must p l a c e or mould themselves, whereas i n d i v i d u a l s o f the a s c r i b e d type see the r o l e as a c o n t i n u a t i o n o f themselves. U n l i k e the f i r s t type, they go through a stage where they weigh the a t t r i b u t e s o f o c c u p a t i o n a l r o l e s , a stage o f i n d e c i s i o n which culminates  i n the making o f a c h o i c e .  C o n s i d e r a t i o n i s g i v e n to the demands made by r o l e and the rewards t h a t compensate f o r them.  the  On the one  they know t h a t nurses work on t h e i r f e e t and t h a t they have undesirable hours.  On the other hand, they are aware t h a t  hand,  nurses  have  prestige  rewarded for anywhere. they  their  They  f u l f i l l  within  the  community,  work and t h a t  are  aware  that  an a l t r u i s t i c  that  they  they  can  find  nurses  are  shown r e s p e c t  function.  Whereas  type  do n o t m e n t i o n t h e s e  rewards,  the  acquired  type  o u t w a r d l y show t h e i r  awareness  from the  professional  image  of  because  individuals  ascribed  deviate  well  employment  the  thereby  are  of  individuals of  lack  them  of  and  of  self-interest. The p r o f e s s i o n s , i n o t h e r w o r d s , a r e r e s p e c t a b l e b e c a u s e t h e y do n o t s t r i v e f o r money, but t h e y can o n l y remain r e s p e c t a b l e i f they succeed, i n spite of t h i s pecuniary i n d i f f e r e n c e , i n making quite a l o t of money, enough f o r t h e needs o f a g e n t l e m a n l y l i f e . ! There  are more  than there early  are  emotional There  in  this  Nursing  elements i n the  of  preceding  attachment are  rational  again  to  choice  i n these  reasons  group, which had developed  the  role.  several  modes  of  orientation  an  evident  group:  as  a  Means  I t o f f e r s e m p l o y m e n t , a n d i t w i l l be p r a c t i c a l i f you get m a r r i e d and i t o f f e r s a j o b . Say something happened to your husband you would h a v e a job . . . so i t s q u i t e u s e f u l . 1  1 M a r s h a l l , "Recent H i s t o r y o f P r o f e s s i o n a l i s m i n to S o c i a l S t r u c t u r e , " Canadian J o u r n a l of Economics P o l i t i c a l S c i e n c e . V o l . 5, 1939, p. 326.  Relation and  W e l l , I came Into i t f o r s e v e r a l reasons, mainly because I wanted a job to work w i t h people. And I wanted a job that afforded l o t s of opportunity when I f i n i s h e d . And one I could t r a v e l w i t h . The d e s i r e d end f o r t h i s sub-type of o r i e n t a t i o n i s not being a nurse, but r a t h e r what nursing o f f e r s as a means to  a d e s i r e d end.  Whereas the f i r s t types mentioned above give  other-oriented reasons, t h i s type gives s e l f - o r i e n t e d reasons. Nursing i s a form of s e c u r i t y and a way o f a c q u i r i n g a t t r a c t i v e goals.  An occupational r o l e f o r these i n d i v i d u a l s i s only a  means, and the nursing r o l e i s the most appropriate one available.  Nursing as a means i s p o s s i b l y a c o n s i d e r a t i o n i n  a l l cases, but only i n a few i s i t given as the prime reason f o r the choice of the r o l e .  Traumatic  Experiences W e l l , when I was very l i t t l e — I t h i n k i t i s a l l personal experience. W e l l , when I was very l i t t l e , I had very serious ear t r o u b l e . And through the doctors and the nurses they f i x e d i t up O.K. and I'm a l l f o r d i f f e r e n t operations. And I found out l a t e r t h a t i f they hadn't f i x e d i t , I would have been deaf, and I f i g u r e d that I owed so much to i t , I would l i k e to help other people. Being l i t t l e and being i n h o s p i t a l , the whole t h i n g i n t r i g u e d me . . . the whole atmosphere o f the p l a c e . Here nursing i s chosen because of a personal  experience i n v o l v i n g high e m o t i o n a l i t y . Besides being harmful to the organism i n the p h y s i c a l sense, i l l n e s s i s s o c i a l l y i s o l a t i n g and u n d e s i r a b l e .  Others, who help the p a t i e n t to  112  leave t h i s unpleasant s t a t e , are defined as "good," "necessary" and "important." They are afforded p r e s t i g e on t h i s b a s i s . dependency between the p a t i e n t and the nurse develops.  A  This i s  s i m i l a r to the m o t h e r - c h i l d r e l a t i o n s h i p where emotional attachment i s i n v o l v e d .  In the above case, and i n s i m i l a r cases  of sickness or death i n a f a m i l y , the student had developed an attachment and i d e n t i f i e d w i t h an admired and s o c i a l l y d e s i r e d model. role.  Therefore, they choose nursing as t h e i r occupational Thereby they also can be "good," "necessary" and  "important."  Crystallization A f t e r I graduated I came to u n i v e r s i t y . W e l l , a f t e r I graduated from h i g h school, I thought that I would go i n t o n u r s i n g then, before that . . . I hadn't r e a l l y thought about i t from my childhood or anything l i k e t h a t . I t sort o f grew upon me.  I went into n u r s i n g . . . w e l l , because medicine i s i n t e r e s t i n g and people are i n t e r e s t i n g and you l e a r n at the same time as caring f o r people . . . oh, I don't know. Just people .... These statements are vague and show that the student i s not r e a l l y aware o f a c l e a r cut reason why she went i n t o nursing.  C e r t a i n values and norms are part of the p e r s o n a l i t y .  They are also compatible w i t h those n a t i v e to the nursing r o l e . The student, however, i s not aware o f t h i s and i s placed i n a p o s i t i o n of f r u s t r a t i o n when she i s expected t o i n d i c a t e a  113  preference f o r some occupational r o l e . F i n a l l y i n such a s i t u a t i o n o f c r i s i s , when pressure i s a p p l i e d t o decide on an appropriate occupational r o l e , the existence o f these values and norms i s f o r c e d i n t o awareness. She f i n d s that the nursing r o l e i s most s u i t e d t o her, although she may not be able t o i d e n t i f y reasons why t h i s i s so. I found that they have values of " l i k i n g people," o f "helping o t h e r s " and of "being of s e r v i c e , " but had never thought of e x e r c i s i n g these I n the r o l e o f a nurse. I t ' s not something I wanted to do a l l my l i f e . . . . I decided i n one afternoon that I wanted t o take i t . . . I was going through f o r a l a b t e c h n i c i a n . And I wanted to major i n Chemistry. I was studying A r t s l a s t year, you see . . . and I didn't l i k e i t at a l l . . . and I decided that t h i s wasn't f o r me, so I decided to t r y n u r s i n g . This quotation shows the existence o f a value system which i s s i m i l a r to that found i n n u r s i n g . Yet the student was not aware o f the s i m i l a r i t y and made another occupational choice. The r o l e which had been chosen d i d not provide the necessary s a t i s f a c t i o n s and was, t h e r e f o r e , abandoned.  A Way Out —  and Into Nursing  I t ' s something d i f f e r e n t from t a k i n g a B. A. and I wanted to be a doctor before. . . and then I decided that i t was too long and too i n v o l v e d , and nursing was the next best t h i n g . . Many students i m p l i e d that they d i d not i n i t i a l l y want to be nurses, but as t h e i r f i r s t preferences had to be  Ilij.  c a n c e l l e d f o r one reason or another, they had to r e s o r t to nursing as an a l t e r n a t i v e choice.  I t would be safe to assume  that the t a k i n g and p l a y i n g of the nursing r o l e would prove a greater s t r a i n to students o f t h i s group than i t would to students who  "always wanted to be a nurse," or who became nurses " i n  mother's image."  They have become nursing students  simply  because they could not take on another occupational r o l e that they p r e f e r r e d .  I t seemed to me l a t e r i n the study that these  g i r l s were more d i s s a t i s f i e d w i t h t h e i r r o l e than the others, and entertained more doubts about whether they were i n the r i g h t p r o f e s s i o n or not.  I f e l t that nursing to them was  something  "they had to take." These modes o f o r i e n t a t i o n show the kinds o f reasons given and i n d i c a t e the nature o f the i n i t i a l self-image.  They  are o n l y valuable i n showing that my  reasons,  subjects gave these  and i n suggesting that p o s s i b l y a l l nursing students could be seen i n terms o f these o r i e n t a t i o n s .  Strength of Wish f o r Nursing In order to discover the strength of t h e i r wish to become nurses, the students were asked what other  occupation  they would consider, what was t h e i r i d e a l occupation and what opinions were h e l d about nursing by parents and f r i e n d s . During the i n t e r v i e w the students were presented w i t h the problem o f what occupational choice they would make i f f o r  115  some reason they d i d not go through w i t h n u r s i n g . w i t h two p o s s i b l e a l t e r n a t i v e s .  Some answered  Laboratory technicians and  s o c i a l workers were the most frequent choices, followed by school teachers, p h y s i o t h e r a p i s t s , d i e t i t i a n s , s e c r e t a r i e s , doctor's nurses, a i r stewardesses and academic p r o f e s s i o n s , i n that order. These answers i n d i c a t e a marked preference f o r what could be t r a d i t i o n a l l y termed "women's p r o f e s s i o n s . "  They a l s o show a  continuing i n t e r e s t i n the medical sub-culture, and i n occupations i n v o l v i n g "dealing w i t h people." Some respondents had a d i f f i c u l t time, on the whole, to t h i n k o f a p o s s i b l e a l t e r n a t i v e .  As one student put i t :  I don't r e a l l y know. That's the t r o u b l e w i t h having one idea i n mind, you just sort o f a u t o m a t i c a l l y exclude everything e l s e . I t i s i n t e r e s t i n g to note that t h i s student would be c l a s s i f i e d i n the "mother's image" type o f o r i e n t a t i o n .  She had not  considered other occupational r o l e s and could not conceive of h e r s e l f as not being a nurse.  On the other hand a student who  sees nursing as "a way out," gives t h i s answer: Well r i g h t now t h a t was what I was wondering about, because I don't l i k e n u r s i n g . I was t h i n k i n g o f Med, but . . . . Of those who had no c l e a r l y defined a l t e r n a t i v e , two were o r i e n t e d to nursing " i n mother's image," one was o f the "horn to be a nurse" sub-type, one wanted t o he a nurse because o f traumatic experiences and one saw nursing as a means as w e l l as a c r y s t a l l i z a t i o n o f her values.  lib  The nature o f the a l t e r n a t i v e s mentioned i n d i c a t e s , g e n e r a l l y , that nursing was chosen i n i t i a l l y because of i t s humanitarian values, because i t i s t r a d i t i o n a l l y a woman's p r o f e s s i o n and because o f i t s demands on a l t r u i s m and s e r v i c e . I t i s also apparent by a l t e r n a t i v e choices that the medical subc u l t u r e holds a f a s c i n a t i o n f o r the students.  I t should be  remembered, however, that these are i n i t i a l self-images and are l i a b l e to change w i t h r o l e - t a k i n g . To f i n d out i f the students had any hidden desires for  any other occupational r o l e they were asked t o imagine that  they could change anything about themselves that they wished. They were then asked what occupational r o l e they would choose. T h i s , I assumed, would a l l o w them to i n d i c a t e t h e i r i d e a l or t h e i r model occupation.  Their answers were:  I d e a l occupational choice  %  Medicine Nursing Creative occupations, e.g. p a i n t i n g , designing  choosing i t ij.0 ij.0 10  Also mentioned were the f i e l d o f philosophy, o f commercial occupations and a i r l i n e p i l o t i n g .  Thus there i s an overwhelming  m a j o r i t y i n favour o f the medical p r o f e s s i o n s . I t i n d i c a t e s that many nurses would have i d e a l l y p r e f e r r e d to have been doctors, i f circumstances had been more favourable.  It is  i n t e r e s t i n g t h a t lj.0 per cent o f the students would s t i l l choose nursing, thus showing t h a t these i n d i v i d u a l s had been able to "take on" t h e i r model occupational r o l e .  I'd s t i l l do nursing. I f I could change my sex I t h i n k I would he a doctor . . . I don't know, i t ' s just the only t h i n g that appeals to me, and I can't r e a l l y t h i n k of anything i n the world happening that would r e a l l y change my i d e a l s . Students were asked what t h e i r parents and f r i e n d s thought o f t h e i r choice o f occupation.  The answers showed that  85 per cent o f the students b e l i e v e d that both parents were pleased w i t h the choice, and 15 per cent i n d i c a t e d that there had been an i n i t i a l d i s l i k e or d e s i r e t o r e d i r e c t t h e i r preference.  A m a j o r i t y o f the students claimed that e i t h e r  t h e i r feminine f r i e n d s approved o f t h e i r choice o f r o l e , or were nurses themselves.  A few mentioned that t h e i r g i r l f r i e n d s  were o f the opinion that "anyone can he a nurse," o r could not "see why I wanted t o be a nurse," o r considered the pay too low and the work too hard.  When t h e i r ideas on the opinions o f men  were asked, the answers were more v a r i e d .  The m a j o r i t y believed  that t h e i r male f r i e n d s approved o f the choice.  Some i n d i c a t e d  that t h e i r f r i e n d s expressed no o p i n i o n , thought nursing a waste of a b i l i t y , d i d not show p a r t i a l i t y , or thought that nurses were c o l d , too s p e c i a l i z e d and l i m i t e d i n a b i l i t i e s .  One student  seemed somewhat u n c e r t a i n o f the a t t i t u d e s o f men: I t seems to have quite an e f f e c t on boys. They seem t o p r e f e r t o take out nurses. When you say that you're going i n f o r n u r s i n g , they s o r t o f perk up. On the whole, t h e r e f o r e , most students seem t o have the support o f f r i e n d s and parents.  Such approval undoubtedly  110  influences them to express stronger d e s i r e s i n becoming a nurse. 2.  Role A n t i c i p a t i o n  I suggest that the choice o f an occupational r o l e i s accompanied by some k i n d of image o f the future r o l e and of oneself p l a y i n g that r o l e .  Thus i f an i n d i v i d u a l desires to  take on a s p e c i f i c r o l e , I assume that she has a p a t t e r n o f thoughts as t o what the p l a y i n g o f the r o l e would mean.  That  i s to say, I expect t h a t student nurses, before embarking on t h e i r p e r i o d o f t r a i n i n g , have some conception of what the functions o f a nurse are, what kinds o f behaviour would be expected from her, how they would f i t i n t o the h o s p i t a l , and what kinds of rewards they could expect.  I assume that they have some  conception, however vague, o f what the r o l e - p l a y i n g would involve.  I t i s p o s s i b l e that they conjure up a p i c t u r e o f  themselves as they would appear during d i f f e r e n t phases of the l e a r n i n g of the r e q u i r e d s k i l l s and techniques, and as they would appear once they are f u l l y accepted members o f the group.  I t seems l i k e l y that they have fears and doubts about  some o f these phases and look forward eagerly t o o t h e r s . I t has been pointed out how a s p i r a n t s dreaded the t r a i n i n g p e r i o d b e l i e v i n g t h a t i t was d i f f i c u l t .  They found i t much easier  2  than they had expected.  2 Morrison and Breed, "Some Interviewer's Impressions o f Student Nurses," 1955, P« 6 .  119  The f u n c t i o n o f p u b l i c images i n r o l e - a n t i c i p a t i o n are pointed out by Morrison and Breed i n other f i n d i n g s .  They  discovered that freshmen seem to a n t i c i p a t e w i t h i n t e r e s t t h e i r work I n the operating room, while at the same time they expressed doubts as t o whether they would be capable and quick enough f o r the r e q u i r e d t a s k s .  The i n i t i a l i n t e r e s t  could a r i s e out o f a p u b l i c image which conceives o f the operating room nurse as the "glamour g i r l " o f the p r o f e s s i o n , and hence as a d e s i r a b l e r o l e .  The extent by which r o l e -  a n t i c i p a t i o n s are a f f e c t e d by p u b l i c images, however, i s a matter f o r future research. As students become more f a m i l i a r w i t h the  various  d e t a i l s o f t h e i r future p r o f e s s i o n , these a n t i c i p a t i o n s may change.  The images t h a t the students had o f themselves i n the  desired r o l e when they made t h e i r choice o f occupation, would d i f f e r from the self-images  that would a r i s e once they were  i n v o l v e d i n the t a k i n g and the p l a y i n g o f the r o l e .  They would  become more f a m i l i a r w i t h the patterns o f behaviour and the values o f t h e i r r o l e , and these would be g r a d u a l l y accepted and f i t t e d i n t o t h e i r p e r s o n a l i t y .  I t could be s a i d that the  d i f f e r e n c e l i e s i n the d e f i n i t i o n s o f the two images.  One  could be termed " a n t i c i p a t i o n , " and the other " i n t e r p r e t a t i o n s of r e a l i t y . "  Obviously there i s a d i f f e r e n c e i n the  self-image  3 Morrison and Breed, "Some Interviewer's Impressions o f Student Nurses," 1 9 5 5 , p. 2 .  where, on the one hand, a student p i c t u r e s h e r s e l f proudly standing at the elbow of a surgeon, s k i l f u l l y and d e f t l y handing him the c o r r e c t instruments even before he has expressed h i s needs i n words, and on the other hand the self-image o f the g i r l that a c t u a l l y stands at h i s s i d e , nervous, d i s t r a u g h t , fumbling w i t h the instruments and aware of the i n c r e a s i n g impatience o f the surgeon and the i n t e n s e , accusing gaze o f the i n s t r u c t r e s s .  Of course i t i s also p o s s i b l e that the  student may have a p e s s i m i s t i c i n i t i a l self-image, and l a t e r become an e f f i c i e n t , s k i l f u l operating room nurse. Leaving aside the .problem of the d e r i v a t i o n o f i n i t i a l images, i t should be pointed out that there i s a d i f f e r e n c e between " a n t i c i p a t i o n s " and " r e a l i t y , " as there i s between the thoughts of handling an instrument and the a c t u a l handling of it.  The former i s i n terras of a b s t r a c t , immaterial concepts,  the l a t t e r i n terms of very concrete a c t i o n s . The former i s subject to c o n t r o l by the i n d i v i d u a l , who can, i f he so pleases, change an unpleasant image to a pleasant one.  The l a t t e r ,  however, i s i n a context where the image i s c o n t r o l l e d t o a large extent by actors and objects outside of the i n d i v i d u a l . The i n d i v i d u a l has l i t t l e c o n t r o l over " r e a l i t y " over and above the c o n t r o l they have over t h e i r own behaviour i n the context of t h i s " r e a l i t y . "  One i s simple, i n that the awareness o f  d e t a i l that a r i s e s w i t h experience i s absent; the other i s complex i n that the i n d i v i d u a l becomes i n c r e a s i n g l y i n v o l v e d w i t h both the aspects of the work that he had a n t i c i p a t e d and  w i t h the d e t a i l s , o f which he was not aware. This chapter s h a l l present the i n i t i a l r o l e a n t i c i p a t i o n s and self-images as they were revealed through questionnaire and through i n t e r v i e w .  Images o f the Role Students were questioned e a r l y i n t h e i r u n i v e r s i t y t r a i n i n g p e r i o d about what they considered t o be the c h a r a c t e r i s t i c s 'of an i d e a l nurse.  Above a l l they b e l i e v e d  that a nurse should have the a b i l i t y t o get along w i t h people. She should enjoy her work, have a p l e a s i n g p e r s o n a l i t y , a neat appearance and the a b i l i t y t o f o l l o w orders and to have a command o f the t e c h n i c a l s k i l l s o f the occupation.  Of the  q u a l i t i e s l i s t e d , they considered i t l e a s t important that a nurse have s c i e n t i f i c c u r i o s i t y and a high l e v e l o f i n t e l l i g e n c e To be s u c c e s s f u l , they thought, a nurse should devote h e r s e l f to the welfare o f the p a t i e n t without over-concern f o r the r u l e s The p a t i e n t should be,the centre o f the nurse's i n t e r e s t .  They  b e l i e v e that they, as nurses, should be overwhelmingly p a t i e n t o r i e n t e d and not i l l n e s s - o r i e n t e d .  That i s , they thought that  they should concern themselves w i t h the p a t i e n t , r a t h e r than with his i l l n e s s .  They were g r e a t l y i n favour of a human  r e l a t i o n s approach, as opposed to an e f f i c i e n t , mechanical one. When, however, a problem o f personal attachment to a p a t i e n t was posed against her o b l i g a t i o n towards other p a t i e n t s , the  students showed that they were faced w i t h a c o n f l i c t i n g situation.  They were asked how they would behave i f t h e i r  mother was one o f t h e i r p a t i e n t s and whether they would spend more time w i t h her than w i t h the others.  They suggested t h a t ,  although during t h e i r working hours they would not devote more time to her, they would spend time w i t h her during o f f - d u t y hours.  Some thought that they would e x p l a i n the s i t u a t i o n to  the mother.  Others would not l i k e to have t h e i r mother as a  patient at a l l and would ask to change wards or would l e t another nurse tend to her. Students were aware of c e r t a i n expectations d i r e c t e d towards them by others i n the medical c u l t u r e and by the public.  As f a r as p a t i e n t s were concerned, a l l the subjects  thought that p a t i e n t s expected them to have a sympathetic, personal a t t i t u d e towards them, and to have feminine, almost motherly c h a r a c t e r i s t i c s .  Mechanical s k i l l and e f f i c i e n c y was  next i n importance, followed by p r o f e s s i o n a l c h a r a c t e r i s t i c s such as t r u s t w o r t h i n e s s , r e l i a b i l i t y and a u t h o r i t y . I n t e l l i g e n c e and an a b i l i t y to converse were also mentioned but were not considered as important. A large m a j o r i t y o f the subjects thought that the prime expectation of doctors was t h a t nurses f i l l a subordinate status p o s i t i o n , and hence he able to take and f u l f i l l o r d e r s . Nurses should show deference, and g e n e r a l l y be there f o r the doctors' convenience and to f u r t h e r t h e i r work w i t h the p a t i e n t .  123  Secondly they expect a nurse to be a t e c h n i c i a n and to have mechanical and nursing s k i l l s .  A few thought that the doctor  saw the nurse as a person, a co-worker, and placed importance on her p e r s o n a l i t y and appearance.  S t i l l fewer students  mentioned that the doctor expected the nurse to have p r o f e s s i o n a l characteristics.  On the other hand they showed, i n a great  m a j o r i t y , that they b e l i e v e d the doctor saw them o n l y as instruments f o r c a r r y i n g out o r d e r s . Their co-workers, other nurses i n the h o s p i t a l , they b e l i e v e d would, above a l l , expect them to he cooperative and to place emphasis on human r e l a t i o n s h i p s .  They would expect them  to show a humanistic approach to the p a t i e n t and to he independent, to have i n i t i a t i v e and to be endowed w i t h p r o f e s s i o n a l c h a r a c t e r i s t i c s such as trustworthiness and reliability.  In other words, other nurses would expect them  i n future to stand on t h e i r own f e e t and to cooperate w i t h them. E f f i c i e n c y and the a b i l i t y to perform mechanical feats were mentioned as being expected, but were not deemed as important as the other f a c t o r s . Before any contact w i t h the h o s p i t a l m i l i e u , students thought t h a t the h o s p i t a l expected the nurse t o have a t e c h n i c a l , instrumental and e f f i c i e n t approach to the patient and to h i s illness.  They wanted s k i l l , neatness, c l e a n l i n e s s , an a b i l i t y  to give good nursing care w i t h thoroughness, speed, and a f u l l knowledge o f what she was doing and why.  I t would also expect  them to maintain the structure and function of the organization by appropriate behaviour.  They would have to be obedient and  l o y a l ; to know and follow the rules; to uphold the hospital's reputation o f high standards; and to show pride i n being a member of the i n s t i t u t i o n .  They would have to cooperate with  others, to be dependable, r e s p e c t f u l , and pleasant. The non-medical community would also direct expectations towards them and have images o f what a nursing role should be. I n i t i a l anticipations o f students showed that they thought  their  family and friends placed the greatest emphasis on a personal, humanistic type o f nursing care.  S k i l l s and e f f i c i e n c y were  also thought important, followed by t h e i r expectation f o r the nursing student to r e t a i n i n d i v i d u a l q u a l i t i e s of f r i e n d l i n e s s , cheerfulness, and good grooming.  At the same time they would  be expected to assume the a i r of a professional being.  Parents  and friends would expect them to be responsible, i n t e l l i g e n t , respected and to have high i d e a l s .  In t h i s way the students  thought they would be expected to advise, help and guide, not only patients, but their family as w e l l . Nursing i n i t i a t e s see the public as demanding a personal, human touch with patients, but, at the same time, the a b i l i t y to give good, e f f i c i e n t care.  They believe the public  sees nurses as leaders i n the community and as people who have a "good education."  They are seen as being w i l l i n g to serve  others and as doing i t i n a s k i l f u l , r e l i a b l e way.  They want  a nurse to be sympathetic, pleasant and m o r a l l y beyond reproach.  Character of O b l i g a t i o n s The f i r s t o b l i g a t i o n o f a nurse, as conceived by students at the beginning of t h e i r t r a i n i n g p e r i o d , i s to give kindness and understanding to her p a t i e n t s . s k i l f u l i n her work.  Next she must be  Less emphasis i s placed on obedience to  the head nurse, to h o s p i t a l r u l e s and to the expectations of the p u b l i c .  T h e i r most important t a s k , they b e l i e v e , w i l l be  to give good, e f f i c i e n t p h y s i c a l care to the p a t i e n t , and secondly to e s t a b l i s h good r e l a t i o n s h i p s w i t h him or her. When asked what they thought was l e a s t important, many answered that they thought everything was important, w h i l e others answered that r o u t i n e jobs, which they would have to do, would he the l e a s t important.  They expected to enjoy most t h e i r  contacts w i t h the p a t i e n t and the "working w i t h people" aspect of t h e i r r o l e .  Also they thought t h a t they would enjoy making  people comfortable, watching them recover, working w i t h c h e e r f u l people and w i t h c h i l d r e n .  In other words they expect to enjoy  t h e i r work i f t h e i r p a t i e n t s showed r e c i p r o c i t y .  They also  mentioned that they would enjoy l e a r n i n g new techniques and specialties.  Least of a l l they would enjoy " d i r t y work," such  as r o u t i n e jobs and bedpans.  This i s o b v i o u s l y status-lowering  and thus can e a s i l y be explained as not being enjoyable.  They  also p o i n t out that they would not expect to l i k e p a t i e n t s who  do not r e c i p r o c a t e and hence give the nurse no s a t i s f a c t i o n . In t h i s context they mention p a t i e n t s w i t h chronic complaints and p a t i e n t s w i t h annoying h a b i t s . They a l s o f e e l t h a t they w i l l not enjoy bookwork. They have developed c e r t a i n views o f i l l n e s s .  They  consider i t a t h i n g of bad l u c k , and a few see i t as a t h i n g of negligence. possible.  I t i s above a l l to be cured as q u i c k l y as  I t i s a t h i n g which they should accept without fuss  and from which they can l e a r n .  The greatest misfortune i n  i l l n e s s they t h i n k would be shown i n a case o f nervous breakdown, cancer, t u b e r c u l o s i s , s k i n disease, and venereal disease, i n that order.  They a l l t h i n k p a t i e n t s are ashamed  more of venereal disease than of any other complaint.  This i s  followed to a l e s s e r degree by t h e i r b e l i e f that p a t i e n t s are ashamed of s k i n disease and nervous breakdowns.  Venereal  disease, s k i n disease and stomach u l c e r s are, i n that order, considered to be r e s u l t s of negligence.  The most r e p u l s i v e  i l l n e s s e s are, i n the f o l l o w i n g order, s k i n diseases, venereal disease, cancer and asthma.  I t should be noted that students  g e n e r a l l y d i d not l i k e to show d i s c r i m i n a t i o n among the i l l n e s s e s l i s t e d , but were forced to do so by being asked to answer a l l the questions on the paper. In t h e i r tasks they were also concerned w i t h what they, as nurses, would be able to c o n t r i b u t e to the welfare o f the p a t i e n t that the doctor could not.  In the i n i t i a l  127  self-image they thought that they would be able t o contribute nursing s k i l l s and e x p e r t i s e , and other comforts  resulting  from t h e i r c l o s e r contact w i t h the p a t i e n t . They could administer to small p h y s i c a l needs and give " t o t a l nursing care."  They f e e l that they, as nurses, would be able to give  a more personal touch.  Many mentioned that they thought t h i s  would be p o s s i b l e as they were women.  On the other hand, they  thought that the doctor, as a r e s u l t o f greater education and s k i l l , could contribute h i s broader knowledge o f medicine.  He  i s i n a p o s i t i o n o f a u t h o r i t y , and the nurse i s r e a l l y a subordinate.  When asked t o estimate the i n d i s p e n s a b i l i t y o f  the other r o l e s t o the medical sub-culture, they thought that the doctors would be the most v a l u a b l e , followed by nurses, d i e t i t i a n s , i n s t r u c t r e s s e s and student nurses.  The l e a s t  valuable were v i s i t o r s and nurses' a i d e s .  Rewards When asked what they thought other nurses found most a t t r a c t i v e about the p r o f e s s i o n , they mentioned s e c u r i t y f i r s t , followed by the thought o f being able to help others, and the idea that nursing i s a p r o f e s s i o n s u i t e d t o women. They were overwhelmingly i n favour o f the thought that other nurses were a t t r a c t e d by s e c u r i t y . They themselves, however, thought that they had been a t t r a c t e d , f i r s t l y , by the opportunity to be a l t r u i s t i c and only secondly, by s e c u r i t y . They p r o j e c t s e c u r i t y on others, a l t r u i s m on themselves.  Nevertheless they t h i n k  that people are f i r s t a t t r a c t e d to nursing by the glamour o f the work, the drama and the emergency.  The m o t i v a t i o n o f  service to others i s also considered important, but by fewer students.  S t i l l fewer students t h i n k u t i l i t a r i a n reasons such  as s e c u r i t y and a p r a c t i c a l preparation f o r marriage are considered as important. On the other hand, however, they t h i n k nursing i s a good p r o f e s s i o n f o r women because above a l l , i t o f f e r s s e c u r i t y and tenure.  I t has s i m i l a r i t i e s to the r o l e o f a mother, and  hence i s p r a c t i c a l f o r women, and a good preparation f o r marriage.  "A woman can give good care and love t o a p a t i e n t —  she may approach 'motherliness ," wrote one student. 1  Other  reasons such as personal s a t i s f a c t i o n , the opportunity t o l e a r n and to see r e a l i t y , the chance to work w i t h people, and the v a r i e t y o f the work were also g i v e n .  Some suggested that  women were " n a t u r a l l y " good nurses. The c h i e f reward o f the r o l e they thought would be personal s a t i s f a c t i o n , chosen by a l a r g e m a j o r i t y over and above s e c u r i t y , income and p r e s t i g e .  Income and p r e s t i g e were  not mentioned at a l l , w h i l e s e c u r i t y was i n d i c a t e d i n only three instances out o f the p o s s i b l e f o r t y . Nursing, they thought, was not a very d i f f i c u l t p r o f e s s i o n t o get i n t o , and many thought i t was " f a i r l y easy." Most o f the students thought that nurses were paid too l i t t l e , or just enough.  They f e l t that they were "not too w e l l  129  prepared" f o r h o s p i t a l experiences,  or just " f a i r l y w e l l  prepared." Most g i r l s showed a preference a career as p u b l i c h e a l t h nurses.  f o r nursing leading to  The next r o l e chosen was  that o f a "nurse," c l o s e l y followed by the r o l e o f "mother." Status and p r e s t i g e i s also an occupational reward. The g i r l s grouped themselves w i t h the medical team, w i t h women's p r o f e s s i o n s , w i t h t r a d i t i o n a l professions l i k e medicine and law and w i t h professions which work w i t h people.  Thereby  they saw themselves i n groups o f occupations that enjoy p r e s t i g e i n the community.  Strains Students were asked t o w r i t e o f what aspects of nursing they thought the general p u b l i c was ignorant.  They  thought that the p u b l i c d i d not see the side of nursing that lacked glamour and drama and that was hard work and monotony. They thought that t h e p u b l i c was not aware of the t r a i n i n g and education of a nurse and thereby tended t o underestimate her.  Some thought that the p u b l i c was ignorant o f the  psychological care and the human approach given the p a t i e n t . Nursing, some maintained, was not merely a d i r t y job.  There  was more to i t . They thought that the p u b l i c d i d not see the nurse as a part o f the h o s p i t a l , and thereby was ignorant o f some aspects o f her r e s p o n s i b i l i t i e s and work.  When asked what professions they admired, the  students  answered, w i t h the exception of only three people, that they admired medicine.  This was  followed by the mention of  t r a d i t i o n a l professions l i k e law and the c l e r g y by fourteen people, and nursing by t e n .  Eleven students r e f e r r e d t o the  professions o f t h e i r parents and the same number to educational p r o f e s s i o n s , such as school and college teaching.  R e l a t i o n to Others W i t h i n the occupational world, prospective nurses grouped themselves most f r e q u e n t l y w i t h s o c i a l workers. was  This  followed by doctors, p s y c h o l o g i s t s , l a b o r a t o r y t e c h n i c i a n s ,  school teachers, engineers, lawyers and a r c h i t e c t s , i n that order.  Their reasons f o r these choices were given as being  the s i m i l a r i t y of the work, education and i n t e r e s t s , as w e l l as t h e i r p r o f e s s i o n a l status and t h e i r r o l e i n h e l p i n g and working w i t h people. W i t h i n the medical sub-culture they e s p e c i a l l y looked forward to t h e i r work w i t h other nurses. p l e a s a n t l y t h e i r work w i t h doctors.  They also a n t i c i p a t e d  They thought that l e a s t of  a l l they would l i k e t h e i r work w i t h medical i n t e r n s , head nurses and o r d e r l i e s .  Many showed no a n t i c i p a t e d d i s l i k e s .  They i n d i c a t e d that they would l i k e t o nurse i n a semi-private ward, followed c l o s e l y by a s t a f f ward. showed a preference f o r a p r i v a t e ward.  Very few  There was also a  marked preference f o r the emergency u n i t , the operating room and p e d i a t r i c s .  Least o f a l l they would l i k e a mental h o s p i t a l .  I l l n e s s e s t h a t they would p r e f e r to nurse a r e : s u r g i c a l cases, c h i l d r e n ' s diseases, i l l n e s s e s where the p a t i e n t recovers and i s not s u f f e r i n g extremely,  obstetrical  cases and heart diseases. Among p a t i e n t s they thought that they would p r e f e r children.  They would l i k e t o nurse c h e e r f u l p a t i e n t s , p a t i e n t s  who are g r a t e f u l and who f o l l o w orders.  They d i s l i k e people  who swear, who are obviously economically p r i v i l e g e d and p a t i e n t s who cannot express themselves i n E n g l i s h .  They would  f i n d p a t i e n t s who c o n s t a n t l y complain, and who t e l l them what to do, very disagreeable. They mention that they had not given too much thought, on the whole, t o the problem o f g e t t i n g too attached to p a t i e n t s , but they were f a i r l y sure that they could deal w i t h i t .  They  had given no thought to the p o s s i b i l i t y of p a t i e n t s g e t t i n g attached to them.  They b e l i e v e d , however, that they could deal  w i t h the problem, but they d i d not show as great a degree o f confidence at t h e i r a b i l i t y to deal w i t h t h i s problem as they d i d w i t h the f i r s t .  On the other hand, they had given quite a  l o t o f thought t o the question o f f e e l i n g the r i g h t amount o f concern f o r p a t i e n t s and thought that they could deal w i t h i t .  Conclusions  and Implications  The answers given by nursing i n i t i a t e s show a marked "other-oriented" i n t e r e s t .  They are e n t i r e l y  patient-centered,  and place the welfare of the p a t i e n t above a l l t h e i r future responsibilities.  This a b i l i t y to help others they f e e l to be  the greatest a t t r a c t i o n o f the nursing r o l e .  They imply that  they, as women, are able to do t h i s more e f f e c t i v e l y and to give the human, personal touch that i s so important.  Thus  personal s a t i s f a c t i o n i n being " a l t r u i s t i c " or "other-oriented" i s t h e i r greatest reward. They show a disregard f o r rewards of the monetary and p r e s t i g e type,, but f e e l that they are not paid s u f f i c i e n t l y f o r their obligations.  In t h i s way they conform t o the norms of a l l  p r o f e s s i o n s , e s p e c i a l l y as professions claim a " s e r v i c e " i d e a l . Their reward comes through the status of a s s o c i a t i o n w i t h the medical p r o f e s s i o n , a high-status p o s i t i o n , and w i t h t h e i r " a l t r u i s t i c " motives. They expect to be rewarded by the r e c i p r o c i t y of patients.  They l i k e p a t i e n t s who depend on them; thus they  l i k e children,  and p a t i e n t s who give them s a t i s f a c t i o n by  showing improvement and recovery.  They want to be able to  communicate w i t h t h e i r p a t i e n t s , t h i s being one form of s a t i s f a c t i o n that they w i l l expect. Although they f e e l that they have p u b l i c respect,  133  one s t r a i n of the r o l e i s that they believe the public i s not aware of the f u l l extent of t h e i r a b i l i t i e s and r e s p o n s i b i l i t i e s . Hence they show a d i s l i k e f o r status-lowering tasks, such as bedpans, and bookwork.  CHAPTER VI PROM PROBIE TO GRAD — PROCESSES  Between the time when the student begins her probationary term and the time when she graduates, s o c i a l i z a t i o n i n t o the nursing r o l e occurs.  P r i m a r i l y t h i s i s concerned w i t h  the i n t e r n a l i z a t i o n o f new norms.  These are the norms  c h a r a c t e r i s t i c o f the n u r s i n g r o l e ; the sum t o t a l and o r g a n i z a t i o n o f these norms d i s t i n g u i s h nurses from other occupational groups.  The Norms o f Nursing Nursing o f f e r s a set o f norms, both instrumental and expressive, which become part o f the o b l i g a t i o n o f each student. These norms cover areas o f performance and conduct. 1.  Norms o f P h y s i c a l Performance.  Nurses l e a r n the  techniques and procedures o f nursing such as the g i v i n g o f hypodermics  and treatments, the correct way t o change dressings  and so on. How these are performed, i n other words the expressive norms, are governed by values o f optimum s k i l l , accuracy and a t t e n t i o n t o minute d e t a i l s .  For example i n  g i v i n g s t e r i l e dressings great care i s given to the p o s s i b l e existence o f germs and e x t r a tasks are performed f o r the sake o f  these i n v i s i b l e t h r e a t s .  Here s k i l l , accuracy and a t t e n t i o n  to d e t a i l are emphasized as o b l i g a t i o n s , even though the need f o r them i s understood, but not 2.  visible.  Norms of I n s t i t u t i o n a l Behaviour.  The nurse i s  expected to be obedient towards s u p e r i o r s , h e l p f u l w i t h her equals and understanding towards her subordinates. times, a norm of cooperation  governs her a c t i o n s .  At a l l Once i n the  h o s p i t a l , she i s introduced also to norms of l o y a l t y towards those of the in-group, i n other words the h o s p i t a l  personnel,  and a norm of d i s c r e t i o n about her knowledge o f techniques and p a t i e n t s i s enforced.  Generally, the norm i s that each i n d i v i d u a l  nurse should f e e l i t her r e s p o n s i b i l i t y to f o s t e r the good reputation of the h o s p i t a l . 3 . Norms of Behaviour towards P a t i e n t s .  The  chief  o b l i g a t i o n of the nurse i s to t r a n s f e r a p a t i e n t once more i n t o a person.  I t i s emphasized that she nurse the patient and  the sickness.  not  She i s expected to comprehend the p a t i e n t ' s needs  and to understand h i s point of view. t o l d not to get  At the same time she i s  involved.  I t i s important that she f e e l f o r her p a t i e n t , not w i t h him. Important she accept h i s c o n d i t i o n despite her r e a c t i o n . . . . I f she f e e l s w i t h him, she would be exhausted at the end of the day. Instrumentally her behaviour towards the p a t i e n t must be o r i e n t e d e n t i r e l y towards the s a f e t y of the p a t i e n t , and e x p r e s s i v e l y her norm i s to place the patient before a l l other i n t e r e s t s .  ij..  Norms o f Behaviour towards Colleagues.  Once again,  i n her i n t e r a c t i o n w i t h her equals, the norm of cooperation i s stressed.  She i s expected to l i v e harmoniously w i t h others, to  understand t h e i r problems, and to help them whenever p o s s i b l e . The norm i s that any one i n d i v i d u a l i s not to expect e x t r a p r i v i l e g e s or to he subjected to e x t r a d u t i e s . In other words, they are to f e e l equal to t h e i r n u r s i n g colleagues, at l e a s t once they have become accepted members of the group.  I n t e r n a l i z i n g Nursing Norms The norms of nursing are i n t e r n a l i z e d through s e v e r a l processes.  Some o f these processes f u n c t i o n m a n i f e s t l y , others  function l a t e n t l y .  Thus d i s c i p l i n e i s a process which i s  consciously imposed on students by the t r a i n i n g s c h o o l , w h i l e the f u n c t i o n of r i t u a l s i s of a more l a t e n t nature.  This chapter  s h a l l deal w i t h the processes by which instrumental and expressive knowledge i s adopted and i n t e g r a t e d .  I n t e r n a l i z i n g of Instrumental Norms The student i s taught b a s i c nursing techniques at the beginning.  Emphasis i s placed on s a f e t y and accuracy as being  the main c r i t e r i o n of worth i n these instrumental aspects of her work.  The anxiety t h a t she appears to f e e l at the beginning  about these u n f a m i l i a r tasks i s r e i n f o r c e d by the t e l l i n g of anecdotes by i n s t r u c t r e s s e s and other students o f what could  f o l l o w i f a nurse does not give a t t e n t i o n to s k i l l and accuracy. Her i n i t i a l  anxiety when she comes i n contact w i t h p a t i e n t s  takes the form of doubting whether she can give bedbaths and whether she has the a b i l i t y to rub a back c o r r e c t l y .  By  observing students, I n o t i c e d that t h i s anxiety i s lessened when her a b i l i t y t o perform these tasks i s ensured by constant successful repetitions.  When t h i s knowledge i s thus e s t a b l i s h e d  by continuous r e p e t i t i o n , accompanied by i n c r e a s i n g confidence, anxiety and doubt are attached to newer and more d i f f i c u l t techniques.  The end r e s u l t i s that nurses show l i t t l e  r e c o l l e c t i o n o f t h e i r i n i t i a l doubt and anxiety and t h e i r tasks become part o f t h e i r everyday a c t i o n s , performed w i t h the same self-assurance as cleaning t h e i r t e e t h . The functions o f anxiety could be seen i n two ways — p o s i t i v e and negative.  Anxiety functions i n a p o s i t i v e manner  to give e x t r a impetus t o processes o f l e a r n i n g . The student devotes more energy towards being accurate and s k i l f u l i f she f e e l s anxious about her work.  I f , however, anxiety becomes too  great, i t s functions become negative and the student may be i n h i b i t e d i n her l e a r n i n g .  On the other hand, i f anxiety  disappears altogether, the student may become over-confident and thereby i n e f f i c i e n t .  Therefore, f o r anxiety to f u n c t i o n  e f f i c i e n t l y i t i s maintained at a s a t i s f a c t o r y  level.  I n t e r n a l i z i n g of Expressive Norms At f i r s t the expressive expectations  of the nursing  r o l e are l e a r n t i n the same manner as the instrumental ones. They are transmitted as l e c t u r e - m a t e r i a l or i n f o r m a l l y by i n s t r u c t r e s s e s and s u p e r i o r s . intellectually,  These norms appear to be l e a r n t  but they do not become s o l i d i f i e d as the norms  of behaviour u n t i l t h e i r meaning becomes apparent i n student nurse contacts w i t h p a t i e n t s .  Students may be taught the  expectation that they d i r e c t a l l t h e i r a c t i v i t i e s  towards the  welfare of the p a t i e n t , but they are not f u l l y aware of what t h i s i m p l i e s u n t i l they begin t h e i r ward experiences and f i n d that everything i s o r i e n t e d towards the p a t i e n t . Before long, students become aware o f c o n t r a d i c t i o n s between the expressive aspects of t h e i r work and  the  instrumental requirements.  On the one hand, they must carry out  the p r e s c r i b e d techniques.  These may  pain.  o f t e n involve i n f l i c t i n g  On the other hand a prominent norm i s the o r i e n t a t i o n  towards curing p a i n .  In other words, i n s t r u m e n t a l l y they must  cause p a i n , but e x p r e s s i v e l y they must at a l l times t r y to alleviate pain.  This c o n f l i c t i s overcome by r a t i o n a l i z i n g  p a i n - g i v i n g as "medical treatment" and d e f i n i n g i t as l e g i t i m a t e and necessary.  At the same time they begin to ease t h e i r  anxiety at i n f l i c t i n g p a i n , which they should i n s t e a d be easing, by d e f i n i n g p a t i e n t s as cases rather than people.  You hear people t a l k i n g about nurses being c a l l o u s . W e l l , I f i n d myself becoming l i k e t h a t . And I have to f i g h t against i t . There i s , t h e r e f o r e , a change i n t h e i r expressive norms.  In  the beginning they saw patients as people and i n d i v i d u a l s , and t h e i r outlook was was  therefore " p a r t i c u l a r i s t i c . "  Each patient  defined as an i n d i v i d u a l , as d i f f e r e n t from the patient i n  the next bed, and not to be t r e a t e d by the nurse i n a manner used f o r a l l p a t i e n t s .  The problems of each patient were seen  as s p e c i a l and as r e q u i r i n g the personal a t t e n t i o n of the nurse. The  students'  continuing i n t e r a c t i o n w i t h p a t i e n t s , however,  begins to resemble an o r i e n t a t i o n to " p a t i e n t s " rather than to "people."  They are l e s s able to see the d i f f e r e n c e s between  p a t i e n t s and to define each one's problems as s p e c i a l . They become i n c r e a s i n g l y more " u n i v e r s a l i s t i c . "  The Assessment of Learning The l e a r n i n g of norms i s evaluated o b j e c t i v e l y by examinations and s u b j e c t i v e l y by ward administrators i n the form of ward r e p o r t s .  High marks are on occasions rewarded by  p r i z e s , and "good" ward reports b r i n g p r a i s e . supposedly strengthens the wish to l e a r n .  In theory t h i s  E l e v a t i o n to higher  a u t h o r i t y i s another way by which l e a r n i n g i s encouraged.  If  a j u n i o r passes her examinations she i s rewarded by a promotion to the new  status of intermediate.  Probies perform subordinate  tasks, such as c a r r y i n g t r a y s and running errands, w i t h the promise that i f they p e r s i s t and perform w e l l , both i n the  14-0  instrumental  and expressive  be rewarded by a new  aspects of t h e i r tasks, they w i l l  status.  Maintaining Student I n t e r e s t T r a i n i n g i s a combination of r o u t i n e , s p e c i a l events and changes to new  s p e c i a l t i e s . M a n i f e s t l y s p e c i a l .events and  changes to new wards are defined as the l e a r n i n g of material. routine.  new  L a t e n t l y they f u n c t i o n to break the monotony of With changes students show new  i n t e r e s t . Thus a t r i p  to the operating room i s morale-boosting to students, r e l i e v i n g them from the r o u t i n e of ward d u t i e s .  At the same time i t  implies to the student that there are future areas of i n t e r e s t to which she i s e l i g i b l e i f she learns the required m a t e r i a l and endures the sameness of r o u t i n e .  S p e c i a l t y t r a i n i n g , such  as p e d i a t r i c s and o b s t e t r i c s a l t e r n a t e between periods ordinary medical or s u r g i c a l ward experiences.  In t h i s  of way  l e a r n i n g i s encouraged and i n t e r e s t i s r e i n f o r c e d .  The Nature and Function of R i t u a l i n T r a i n i n g R i t u a l s and ceremonies t r a d i t i o n a l l y mark the passage from one stage of t r a i n i n g to another.  L a t e n t l y , they also  f u n c t i o n to confirm a t t i t u d e s and to stimulate i n t e r e s t and l e a r n i n g i n students.  Oaths, vows, and ceremonies appeal, not  as much to the i n t e l l e c t , as to the emotions.  Capping  ceremonies, performed w i t h l i g h t e d candles h e l d high to the  ±41  s i n g i n g o f hymns such as "Take my L i f e and l e t i t be, consecrated Lord to Thee . . . " f u n c t i o n not only to imply that students • have s u c c e s s f u l l y passed t h e i r p e r i o d o f probation.  They  imply t o students and t o other p a r t i c i p a n t s t h a t nursing i s a sacred, devoted p r o f e s s i o n . Any doubts about nursing that may p r e v i o u s l y have occurred to students are d i s p e l l e d .  My subjects  sometimes i m p l i e d t h a t they were very s i m i l a r t o maids or cleaning women, hut during and a f t e r the ceremony the a t t i t u d e was that the work o f the nurse was somehow sacred and important. I t was a solemn crowd . . , but then capping i s r a t h e r a sad occasion — a l l those young g i r l s dedicating t h e i r l i v e s . When students saw t h e i r p r o f e s s i o n i n a l i g h t where i t had greater p r e s t i g e , i t seemed to me that a greater s e c u r i t y was gained, and o r i g i n a l motivations to become nurses were renewed or strengthened. Each r i t e de passage, whether i t i s capping, graduation or merely the change i n uniform s i g n i f y i n g an increased s t a t u s , functions to confirm the students' a b i l i t i e s to perform more d i f f i c u l t t a s k s .  They symbolize a t r a n s i t i o n  to a higher s t a t u s . They imply that t r a i n i n g i s not an evenly continuous process, hut a d i s j o i n t e d one, where each stage i s marked by abrupt beginnings and endings.  One day, t h e r e f o r e ,  a student wears "blues" and a b l a c k band and i s not permitted to i n s e r t l a v i n e tubes.  The next day she wears a white .uniform  and i s allowed to i n s e r t l a v i n e tubes.  Ceremonies f u n c t i o n also as expressions of group solidarity.  Graduation ceremonies, f o r i n s t a n c e , are attended  by a l l the students i n the school who i s defined as a requirement.  are not "on duty."  This  Under dramatic circumstances they  are able to observe a l a r g e group o f white-uniformed g i r l s , to smell the scent o f bunches o f roses, to hear the Florence Nightingale pledge (see Appendix B) and to l i s t e n to the compliments  and p r a i s e given to the graduates by o u t s i d e r s .  A f t e r such a ceremony the subjects of t h i s t h e s i s implied that they were " i n s p i r e d to go s t r a i g h t home and study."  The  importance and the d e s i r a b i l i t y o f the nursing r o l e i s r e i n f o r c e d .  The Abnormal becomes the Normal The medical s u b - c u l t u r e , c h a r a c t e r i z e d by urgency, concerns i t s e l f w i t h l i f e and death.  These matters, i n our  s o c i e t y , are d e f i n e d as somewhat abnormal, and matters about which the m a j o r i t y o f i n d i v i d u a l s f e e l l i t t l e r e s p o n s i b i l i t y . From the beginning students are taught to develop h a b i t s that are adapted to p o t e n t i a l emergencies.  Tours of the operating  room are conducted on Sunday, implying that the importance of t h i s emergency transcends even the sacredness o f Sunday.  Facts  such as t h i s p l a y a s i g n i f i c a n t part i n i n d o c t r i n a t i n g the a t t i t u d e towards emergency. develop,.however, with i t .  As t h e i r instrumental s k i l l s  students become more competent i n d e a l i n g  They become more aware that emergency i s permanent  and something could go wrong at any time.  They begin to expect  emergencies as the normal course of events.  Students cease  running w i l d l y down the c o r r i d o r when Mrs. Smith turns blue or Mrs. Brown has a n a t u r a l a b o r t i o n .  Alarm, which accompanies  s i t u a t i o n s where i n d i v i d u a l s do not know how gradually.  to r e a c t , disappears  Students begin to l e a r n that prompt, quiet a c t i o n i s  the desired norm.  Therefore, what i s abnormal f o r s o c i e t y at  large becomes normal f o r nurses.  A Process of Growing Up We've become a l o t more serious about things . . . you're q u i e t e r and I t h i n k you're a l i t t l e o l d e r , and you t h i n k things through more c l e a r l y . Students o f t e n claim that nursing has given them more self-confidence and a d i f f e r e n t outlook on l i f e .  They  f e e l that they have an i n c r e a s i n g l y greater knowledge of l i f e and, at the h o s p i t a l , they are "closer to the very essence of life."  Intermediate  and senior students define the probies  "innocent l i t t l e t h i n g s " and reminisce how  inadequate they  themselves were and how  They claim that  l i t t l e they knew.  as  t h e i r knowledge of people has increased, together w i t h t h e i r understanding of the i l l n e s s e s which they are t r e a t i n g . They consider non-nursing students as immature and l i g h t - h e a r t e d i n comparison.  In t h i s way they f e e l that nursing has helped them  to "grow up." This process of "growing up" could be understood i n terms of the process of i n c r e a s i n g r e s p o n s i b i l i t y .  Students  are beginning to i n t e r n a l i z e norms where they subject what the s e l f wants to do, to what the s e l f must do. They have passed from stages where they, as c h i l d r e n and adolescents, were protected to stages where they are responsible f o r g i v i n g i n c r e a s i n g l y greater degrees of p r o t e c t i o n to others.  I t seems  l i k e l y that t h e i r a s s o c i a t i o n o f nursing w i t h a process of "growing up" stems from an i n t e r n a l i z e d norm o f r e s p o n s i b i l i t y towards o t h e r s , which i s part o f t h e i r occupational r o l e .  The Process o f D i s c i p l i n i n g The i n t e r n a l i z i n g o f the new norms depends also on the d i s c i p l i n a r y nature o f the b u r e a u c r a t i c structure o f the training setting.  The r e q u i r e d mode o f behaviour, whether i t  i s the correct procedure f o r dry dressings or the a b i l i t y to t o l e r a t e a l l p a t i e n t s , i s enforced.  This i s done u n t i l the  students act i n the r e q u i r e d manner and u n t i l such behaviour has been accepted to the extent that d e v i a t i o n s from i t become matters of g u i l t .  There i s a d i s t i n c t process of methodical  t r a i n i n g I n obedience and the s u b j e c t i o n of a student's i n d i v i d u a l i t y t o h o s p i t a l and n u r s i n g requirements.  In this  way they are taught the boundaries o f t h e i r r e s p o n s i b i l i t i e s , what they are allowed to do and what work must be l e f t f o r the doctor.  I n d i v i d u a l a c t i o n and d e c i s i o n are d e f i n i t e l y  discouraged.  This type of t r a i n i n g i s r a t i o n a l i z e d by the  nursing occupation as being "necessary" f o r the s t r u c t u r e and f u n c t i o n o f the h o s p i t a l .  They ask: what would happen i n an  emergency i f a nurse stopped to query a doctor's d e c i s i o n and to suggest a l t e r n a t i v e s ? as "duty."  Conformity to d i s c i p l i n e i s defined  Nonconformity, t h e r e f o r e , i s defined as "not doing  one's duty" and i s subject to d i s a p p r o v a l by superiors and by peers who have been s u c c e s s f u l l y d i s c i p l i n e d .  Hence a student  who has not f o l l o w e d orders i s seen by her peers as "not doing her duty."  Duty i s , needless to say, a strong norm of the  nursing group. D i s c i p l i n i n g , as I observed i t , appeared militaristic.  Obedience was emphasized.  on h i s own a t t i t u d e s :  almost  One l e c t u r e r commented  "I never ask why, I j u s t do i t . "  The  a t t i t u d e Is that students should not e x e r c i s e personal c r i t i c i s m s or d e v i a t i o n s . You copy e x a c t l y what the doctor w r i t e s . . . you do not i n t e r p r e t h i s a b b r e v i a t i o n s , but copy them e x a c t l y . . . I know sometimes they are d i f f i c u l t to read, but you copy as close as you can to what i t looks l i k e . At the beginning of t h e i r p r a c t i c a l experiences, a l l t h e i r paper-work i s checked.  Each new procedure i s f i r s t observed  by the student, then she performs i t under s u p e r v i s i o n , and only i f she can do t h i s a p p r o p r i a t e l y , i s she permitted to perform i t alone. There i s an e q u a l i z i n g process which i s s i m i l a r to military discipline.  The behaviour of students on a p a r t i c u l a r  l e v e l o f competence i s expected to be p r e d i c t a b l e , and s i m i l a r to that of other students on that l e v e l .  Their r e s p o n s i b i l i t i e s  are w e l l - d e f i n e d . by uniforms.  Furthermore, t h e i r i n d i v i d u a l i t y i s concealed  Any d e v i a t i o n , such as h a i r on the c o l l a r , i s  immediately brought to the student's n o t i c e . U n l i k e the army, however, nursing does not r e j e c t c e r t a i n c u l t u r a l norms.  In other words, where the army  encourages aggression, n u r s i n g r e t a i n s the norms of gentleness, sympathy and h e l p f u l n e s s a t t r i b u t e d to middle-class womanhood. There tends to be a c o n t r a d i c t i o n of norms.  On the  one hand, norms i n s t i l l e d by a process of m i l i t a r i s t i c d i s c i p l i n e serve to emphasize such m i l i t a r i s t i c q u a l i t i e s as methodical performance of d u t i e s , heightened e f f i c i e n c y , and h o s t i l i t y between ranks.  Thus nurses o f t e n r e f e r to each other by  surnames, show d i s l i k e f o r superiors and f a l l e a s i l y into a routine.  This functions to increase e f f i c i e n c y and  impersonality.  On the other hand, t h e i r a b i l i t y to give  personal, i n d i v i d u a l i s t i c care i s l i m i t e d by t h i s very process. Thus i f they have i n t e r n a l i z e d the norm of " t r e a t i n g p a t i e n t s as i n d i v i d u a l s " and g i v i n g p s y c h o l o g i c a l care, they are l i a b l e to experience a c o n f l i c t . D i s c i p l i n e begins at the probie p e r i o d . f e e l , i n comparison to more, advanced students and  1  Probies graduate  nurses, that they are the "scum of the p l a c e , " or "the lowest of the low."  T h e o r e t i c a l l y , t h i s makes them submit e a s i l y to  d i s c i p l i n a r y measures.  They f e e l subordinated and i n t i m i d a t e d  s u f f i c i e n t l y to r e f r a i n from a s s e r t i n g t h e i r charismatic q u a l i t i e s and t h e i r i n d i v i d u a l i t y .  The Process o f I m i t a t i o n and I d e n t i f i c a t i o n Each student has been taught the c r i t e r i o n of worth i n nurses.  She i s thus able to evaluate the worth o f each  nurse w i t h whom she comes i n contact.  Students admitted that  they admired some nurse whom they considered to be a "good nurse."  They commented on how she performed her t a s k s , her  manner towards the patients and "how n i c e she i s . " They showed a desire t o become and to act l i k e her. Empathy, as i t occurs i n i d e n t i f i c a t i o n and i m i t a t i o n , plays a major r o l e i n the i n c u l c a t i o n o f s o c i a l values.  Students are aware o f values i n n u r s i n g , but these  values become s o l i d i f i e d when they are able t o observe and i n t e r a c t w i t h those that have i n t e r n a l i z e d these values and are defined as "good nurses." Gee, d i d you see that t a l l g i r l ? see how f a s t she was?  Did you  On the other hand, "bad" nurses also f u n c t i o n t o r e i n f o r c e p o s i t i v e l y the norms o f n u r s i n g . They are a l l graduates on that f l o o r . No students. But everything i s so sloppy, you don't f e e l proud o f being a nurse. The p a t i e n t s c a l l the head nurse "mother" and o f f e r a l c o h o l i c refreshments to the nurses at the nursing s t a t i o n i n the middle o f the afternoon.  li|8  Students begin to i d e n t i f y w i t h those nurses that they admire and attempt to a c t as they do.  Role-taking and  conformity t o nursing norms and values i s thereby s t i m u l a t e d . I n d i v i d u a l deviations are somewhat c o n t r o l l e d .  A similarity  and e q u a l i t y among nurses i s also strengthened.  Unlearning the Old Norms New norms are sometimes i n t e r n a l i z e d at the expense of o l d ones.  The o l d norms, i f i n disagreement w i t h the new,  are e i t h e r suspended or changed.  Nursing has i t s own norms  and values, and o f t e n the p e r s i s t e n c e of o l d norms and learned h a b i t s can lead to s t r a i n s i n the nursing r o l e .  Consequently,  i f an i n d i v i d u a l i s motivated t o take on the n u r s i n g r o l e , she must i n t e g r a t e or supplant her o l d norms w i t h the new. example of t h i s i s the two norms concerning death.  An  The c u l t u r a l  d e f i n i t i o n i s where death i s regarded as sacred and condoned w i t h the reverence given to the supernatural. Respect i s shown f o r the dead and f o r the bodies o f the dead.  The medical sub-  c u l t u r e , however, defines death as a " n a t u r a l " t h i n g and nurses are expected t o behave i n accordance w i t h t h i s and to perform such tasks as washing the corpse i n p r e p a r a t i o n f o r the morgue. I n such a case, the o l d norm would have to be unlearned and replaced w i t h the new. Another example i s the norm concerning p a i n .  1  1 Mark Zborowski, " C u l t u r a l Components i n Responses to Pain," Journal o f S o c i a l Issues, 8:16-30, 19^2.  C u l t u r a l l y , p a i n i s defined as undesirable and i n f l i c t i n g p a i n i s considered a symptom of an abnormal p e r s o n a l i t y .  I n the  course of performing t h e i r t a s k s , nursing students are o f t e n expected to i n f l i c t p a i n . Thus they must l e a r n to define t h i s abnormal symptom not only as normal, but even as d e s i r a b l e . The change was n o t i c e a b l e among the subjects of t h i s t h e s i s . "When I f i r s t met them they were gasping i n anxiety when other students, merely a c t i n g as p a t i e n t s i n p r a c t i c e l a b o r a t o r y period, were r o l l e d over i n bed.  Toward the end they were  moving p a t i e n t s i n great p a i n , g i v i n g hypodermics dressings on gaping wounds — necessary, f o r the p a t i e n t .  and doing  a l l of which were p a i n f u l , yet One student described her  reactions: My f i r s t colostomy'. I thought that I was going t o pass out . . . I've never been squeamish i n my l i f e . . . hut I f i n d that when you have to do i t y o u r s e l f i t i s not as bad as standing and watching. Students, f o r t h e i r own comfort, t h e r e f o r e have to l e a r n to overcome t h e i r previous a t t i t u d e s and to be able "to take i t . " At the beginning they r a t i o n a l i z e f o r themselves that these unpleasant steps have to be taken f o r the b e n e f i t of the patient.  The need to r a t i o n a l i z e appeared to decrease w i t h  the i n c r e a s i n g i n t e r n a l i z a t i o n of values that define "medical care" as important, necessary and the only way by which a cure can be a t t a i n e d .  The o l d norm regarding the i n f l i c t i n g of p a i n  i s therefore unlearned.  C u l t u r a l l y l e a r n t norms regarding knowledge of the body have also to be disregarded. be modified.  Taboos on s e x u a l i t y have t o  Students have to l e a r n to care f o r the bodies o f  others, both male and female, without f e e l i n g the s o c i a l norm which governs s e x u a l i t y .  New norms i n which knowledge of the  body i s accompanied by d i s i n t e r e s t have to be l e a r n t .  A student  who had just begun to work i n the urology operating room s t a t e d : W e l l , i f you had any modesty, you wouldn't have any once you get out of t h e r e . S o c i a l secrecy on the processes of e l i m i n a t i o n and on the g e n i t o - u r i n a r y t r a c t have to be unlearnt i n a sub-culture where u r i n e a n a l y s i s and the recording of excretions are emphasized.  Probies f e e l the embarrassment of l i s t e n i n g to  nursing conversations on such matters.  They commented w i t h  some s u r p r i s e that nurses stop to t a l k , while s t i l l h o l d i n g a bed pan i n t h e i r hand.  Before very l o n g , however, probies  begin to discuss enemas at the breakfast t a b l e and stop to converse i n the c o r r i d o r s themselves, when on t h e i r way to the hopper room. These r e j e c t i o n s o f s o c i a l norms i n favour o f nursing norms go through a p e r i o d of c o n f l i c t , where the i n d i v i d u a l i s s t i l l guided by the persistence of learned h a b i t s .  As nursing  norms begin to win out, however, and become accepted and i n c r e a s i n g l y defined as t h e d e s i r e d norms, nursing students f i n d i t i n c r e a s i n g l y more d i f f i c u l t to i d e n t i f y w i t h o u t s i d e r s and there i s a widening gap of common experience between them.  151  Increasing Group S o l i d a r i t y —  Peer Group Pressures and C o n f l i c t s  The processes i n v o l v e d i n the i n t e r n a l i z a t i o n of norms, such as the r i t u a l s , the i d e n t i f i c a t i o n , the d i s c i p l i n e and the l o s s of s o c i a l norms f o r nursing norms serve another function.  The a b i l i t y of students to i d e n t i f y w i t h outsiders  diminishes.  The t r a i n i n g s e t t i n g , the residence l i f e and the  s u b - c u l t u r a l i s o l a t i o n a i d t h i s process and strengthen the s o l i d a r i t y of the nursing group.  I found that my  subjects  became aware o f the existence of common experiences, problems and understanding.  Each member of the group i d e n t i f i e d h e r s e l f  w i t h the others and was able to empathize w i t h them. I s o l a t e d as they are by the p r e s c r i b e d method o f t r a i n i n g , they i d e n t i f y w i t h the people w i t h whom they i n t e r a c t . This undoubtedly makes the i n t e r n a l i z a t i o n of the  necessary  norms much e a s i e r . This i d e n t i f i c a t i o n w i t h each other i s s i m p l i f i e d by the f a c t t h a t most students admit that the m a j o r i t y of t h e i r f r i e n d s are a l s o nursing students or are i n t h e i r nursing c l a s s .  Frequent close contacts f u r t h e r stimulate  these f r i e n d s h i p s , and encourage the making of more f r i e n d s i n the nursing c l a s s .  Thus not only frequent i n t e r a c t i o n and peer  group pressures, but also f r i e n d s h i p s , l e a d to the and transmission of a t t i t u d e s .  reinforcement  Nursing Group " E t h n o c e n t r i c i t y " The nursing c l a s s develops an "ethnocentric" a t t i t u d e I n d i v i d u a l s outside the group are r e f e r r e d t o as "they," and t h i s extends to non-medical people, to personnel i n the h o s p i t a l , t o other nurses and even t o other student E f f o r t s are made t o keep o u t s i d e r s out.  nurses.  I n the c l a s s studied  t h i s was done by t u r n i n g the conversation t o common experiences such as u n i v e r s i t y l i f e , i n which other nursing classes could not p a r t i c i p a t e .  Intra-group antagonism develops.  This i s  e s p e c i a l l y evident between the university-program nurses and the h o s p i t a l program nurses.  The extent o f t h i s h o s t i l i t y has  been mentioned. There i s some f r i c t i o n . You have t o go more than 50 per cent o f the way t o be f r i e n d l y . They t h i n k you are u n i v e r s i t y g i r l s , you know, r i c h , snobbish and so on . . . . Yet although nursing norms demand f r i e n d s h i p between the two groups, few close f r i e n d s are made w i t h students i n other classes.  R o l e - t a k i n g , t h e r e f o r e , i s enforced by both i n t e r -  group i n t e r a c t i o n and intra-group c o n f l i c t . Each group develops i t s own system of sanctions and norms, and t h i s system o f m o r a l i t y i s defined as "good." U n i v e r s i t y students valued i n i t i a t i v e and complained more about t h e i r l o s s o f i n d i v i d u a l i t y , than d i d the h o s p i t a l nursing students.  They also value the nature o f u n i v e r s i t y l e c t u r e s  and consider the h o s p i t a l l e c t u r e s t o he somewhat simpler.  Each group has i t s own myths.  Foreknowledge o f a  matron or i n s t r u c t r e s s i s the property o f a student before she comes i n t o personal contact w i t h h e r .  One student, f o l l o w i n g  a s i t u a t i o n o f c o n f l i c t w i t h an i n s t r u c t r e s s , transmits to the others that t h i s i n s t r u c t r e s s has a l i t t l e animosity f o r u n i v e r s i t y t r a i n e d nurses.  Members o f the group now know how  to react w i t h the i n s t r u c t r e s s i n question and what to expect from h e r . S i m i l a r l y each group has i t s own cues and s i g n s . They have warnings f o r the approach o f matrons; they cast meaningful glances at each other during s i g n i f i c a n t s i t u a t i o n s they cease t a l k i n g or q u i c k l y change the t o p i c of conversation on the approach o f an o u t s i d e r .  These are a l l cues and signs  to keep o u t s i d e r s out. There are also signs used w i t h i n the group i n r e l a t i o n t o each other.  Thus open doorways  signify  that the student desires others t o come i n and converse, whereas closed doors i n d i c a t e a desire f o r p r i v a c y . Acceptance as a member o f a s o c i a l group i m p l i e s , that the i n d i v i d u a l has p s y c h o l o g i c a l support.  Tension i s  released by complaining t o members o f the group, who are considered to understand because o f t h e i r a b i l i t y to i d e n t i f y and empathize.  The group also attempts controls i n that i t  reacts n e g a t i v e l y against departure from in-group ways.  Thus  group members who do not help others on the ward s i t u a t i o n become outcasts and subject to group d i s f a v o u r .  The Secret Cult o f Nursing Once they become nursing students, g i r l s become aware of two d i s t i n c t groups: outsiders.  the members o f the nursing group and  W i t h i n the nursing group students also become  members o f smaller groups, such as the group o f student  nurses,  the group of degree-program nurses and f i n a l l y the p a r t i c u l a r nursing c l a s s .  This nursing c l a s s could i n i t s t u r n be d i v i d e d  i n t o f r i e n d s h i p groups. The nursing group has many o f the c h a r a c t e r i s t i c s o f a secret c u l t .  Prospective members are selected or r e j e c t e d  on the basis o f a set o f c r i t e r i a c o n t r o l l e d by the group, and a l t e r a b l e only by members o f the group.  Their progress,  p e r s o n a l i t y r e p o r t s , medical examinations, l e t t e r s are f i l e d f o r f u t u r e reference.  exam marks, and  Interviews w i t h the  student are recorded and t h e i r p e r s o n a l i t i e s are evaluated. Thus the occupational group i s i n possession o f complete knowledge regarding a s p i r a n t s .  I t keeps a constant watch on  those that are accepted and r e j e c t s those that do not q u a l i f y f o r p r o f e s s i o n a l standards.  Language Students begin g r a d u a l l y t o acquire the c h a r a c t e r i s t i c s o f the "secret c u l t . "  They begin to use the  d i s t i n c t language that i s assigned to t h e i r group. of colostomies, trichyotomies and g a s t r o - i n t e s t i n a l  They t a l k  155  nourishments.  They r e f e r to the operating room as the "0.  R.,"  to the p e d i a t r i c department as "Peds" and to temperature, pulse and r e s p i r a t i o n as "T. P. R."  These words s i g n i f y t h e i r  acquired l e v e l of knowledge and of competence. f u n c t i o n to keep outsiders out.  They also  At the same time they stimulate  subordinates who have as yet not l e a r n t c e r t a i n aspects of the language and cannot p a r t i c i p a t e i n conversation, to l e a r n the language more f u l l y . also  stimulates  the  The use of a common language, t h e r e f o r e , internalization  of group  norms.  Acceptance through R i t e s de Passage A p r o b i e , when accepted as an aspirant and as worthy of assuming the status o f a member o f the " c u l t , " assumes the status of "nurse" to outsiders w h i l e to the occupational group she i s s t i l l on t r i a l , and defined as "student."  P r i o r to  acceptance i n the group she has to perform a p p r o p r i a t e l y and to pass the t e s t s set by the members. Then a f t e r r i t e s de passage and r i t u a l s of i n i t i a t i o n , such as capping and graduation, she becomes a f u l l y - f l e d g e d member of the group. U n t i l that time she maintains a subordinate status and shows respect to accepted members, by obeying t h e i r orders. Once accepted they guard t h e i r knowledge and g a i n p r e s t i g e by being i n possession of mysterious methods of c o n t r o l l i n g l i f e and death.  They f e e l moral i n d i g n a t i o n  towards u n q u a l i f i e d people performing nursing d u t i e s .  They  keep a b a r r i e r between themselves and those u n q u a l i f i e d .  Widening Gap from Outsiders Accompanying i n c r e a s i n g group s o l i d a r i t y and i n c r e a s i n g acceptance Into the occupational group, there i s a decreasing a b i l i t y to partake i n the experiences of o u t s i d e r s . Many of the c u l t u r a l norms have been r e j e c t e d and o u t s i d e r i n t e r a c t i o n , because of l a c k of time or i n t e r e s t , has come to a minimum. The students' knowledge becomes more s p e c i a l i z e d and there i s a widening distance between a student nurse and her p a t i e n t i n knowledge o f what can he done f o r the w e l f a r e o f the p a t i e n t .  There i s an i n a b i l i t y to f e e l comfortable i n  the presence of oufts-iders; t h i s leads to f e e l i n g s of inadequacy when w i t h these o u t s i d e r s . Once you get past the stage of " H i i How are you? What's new?" you're stuck, because you've got nothing to t a l k about. Therefore nurses f i n d that they are both more knowledgeable than outsiders and yet l e s s knowledgeable.  I n other words  they l e g i t i m a t e l y claim a greater knowledge of the subject matter of n u r s i n g ; to t h i s they add t h e i r varying contacts "with a l l kinds of people."  On the other hand, however, they  complain that t h e i r knowledge of non-nursing matters i s meagre and causes them to f e e l i s o l a t e d i n noii-nursing groups.  Increasing I n s t i t u t i o n a l i z a t i o n Mention should be made of the context w i t h i n which these processes occur.  The context i s the h o s p i t a l , an  i n s t i t u t i o n , c o n s i s t i n g of r o l e s i n t e r a c t i n g f o r a w e l l defined purpose —  the curing o f i l l n e s s .  This i n s t i t u t i o n  has a l l the aspects o f the medical sub-culture, such as the norms, the values, the techniques, the personnel and so on. The h o s p i t a l could be considered to be the main s o c i a l i z e r , and i n t h i s m i l i e u the student i s s l o w l y converted i n t o the r e q u i r e d image of a nurse.  Communication w i t h t h i s  i n s t i t u t i o n a l s o c i a l i z e r , together w i t h the processes of d i s c i p l i n e , i m i t a t i o n , i n c r e a s i n g group s o l i d a r i t y and norm i n t e r n a l i z a t i o n , which a l l operate w i t h i n t h i s context, b r i n g t h i s image i n t o e f f e c t .  The manifest f u n c t i o n o f being i n the  i n s t i t u t i o n a l m i l i e u i s the development of nurses from students The l a t e n t f u n c t i o n i s that the development of nurses, as w e l l as other i n s t i t u t i o n a l processes, serves to perpetuate the e x i s t i n g nature of the i n s t i t u t i o n . I n i t i a l entrance i n t o the h o s p i t a l plays a l a r g e p a r t i n changing the self-images of students.  I found that at the  u n i v e r s i t y the self-images of student nurses i n v o l v e d the i n t e r a c t i o n between doctors, p a t i e n t s , and themselves as nurses Once i n the h o s p i t a l , however, they become aware of h o s p i t a l costs, of the need f o r s e r v i c e , the importance of knowing r u l e s  and of the f a c t that the h o s p i t a l i s also concerned with numerous r o l e s above those of doctors, nurses and p a t i e n t s . The s i m p l i f i e d image which they had at u n i v e r s i t y becomes enlarged by contact w i t h the " r e a l i t y " of the context. I would say that you don't l e a r n anything r e a l l y u n t i l you're i n the h o s p i t a l and faced w i t h the p r a c t i c a l s i t u a t i o n . They become i n v o l v e d w i t h norms of which they were only vaguely aware.  F i r s t l y the norm of f i l l i n g a p o s i t i o n  on a h i e r a r c h y , where obedience i s the major expectation. They become aware o f the waning o f i n d i v i d u a l importance, the discouragement o f i n i t i a t i v e and the growth of quick obedience. Obedience i s uniform and i s achieved by appeals to nursing norms and e t h i c s w i t h regard to f u l f i l l m e n t of duty.  Duty  comes to include s t r i c t obedience and the d i s p l a y of respect f o r those higher on the h i e r a r c h y .  The i n d i v i d u a l i s t i s a  deviant, not only i n the i n s t i t u t i o n a l sense, but also a v i o l a t o r of nursing norms.  I n s t i t u t i o n a l expectations and nursing norms,  t h e r e f o r e , support each other. We have to do i t , the doctor ordered We are going to do i t .  it.  This comment was made xvith regard to the g i v i n g of a s k i n preparation to a p a t i e n t , who needed an operation, but  was  quite s t r o n g l y against both the operation and the " s k i n prep." Obedience i s defined as duty, and i n t h i s case, t h i s i n s t i t u t i o n a l norm of obedience replaces l o y a l t y to people as i n d i v i d u a l s .  Secondly, they become aware o f a process o f depersonalization. not condoned.  Their personal f e e l i n g s and opinions are  This i m p e r s o n a l i t y i s maintained, on the  s u p e r f i c i a l l e v e l , by the i n s i s t e n c e on the formal, impersonal form o f address:  Miss Brown.  Boundaries are placed on the  nature of the personal objects permitted i n residence rooms. Matrons, t h e r e f o r e , r e g u l a r l y check rooms f o r i n d i c a t i o n s o f such a r t i c l e s ; and magazine racks and potted plants are removed.  Students are not encouraged to v i s i t p a t i e n t s ,  e s p e c i a l l y never i n v i s i t i n g hours.  Emphasis i s placed on  the maintenance of h o s p i t a l s u p p l i e s , t h a t the corners o f the bed are neat, that the casters are turned i n and that the thermometer water i s changed.  They are taught to use the  word "appears" i n r e p o r t s , because "who are you to know" whether t h i s i s f a c t or merely hypothesis.  Students i n  r e p o r t s , t h e r e f o r e , w r i t e statements l i k e the f o l l o w i n g : "The p a t i e n t appears to be d i s o r i e n t e d . "  Individual  deviations from these i n s t i t u t i o n a l r u l e s are open to reprimand.  A l l o f these undoubtedly serve to perpetuate the  state o f the h o s p i t a l that i s i n existence.  There appears to  be a tendency that w h i l e becoming more i n s t i t u t i o n a l i z e d , more p r o f e s s i o n a l and more f a m i l i a r w i t h the r o l e o f the nurse, there seems to be an i n c r e a s i n g i n d i c a t i o n that nurses become l e s s i n d i v i d u a l i s t i c , l e s s personal and l e s s c r e a t i v e . The t h i r d norm i s the engendering o f a f e e l i n g o f e q u a l i t y that accompanies the l o s s of i d e n t i t y and the t a k i n g  of a p o s i t i o n on the h i e r a r c h y . T h e i r d i s l i k e o f a u t h o r i t y i s eased by the support r e c e i v e d from t h e i r equals.  This f e e l i n g  of sameness i s generated by a system o f i n s t i t u t i o n a l i s o l a t i o n where a l l a s s o c i a t i o n s are l i m i t e d t o one's peers.  The p r i v a t e  l i f e o f a l l student nurses becomes an i n s t i t u t i o n a l responsibility.  Their f r e e time i s d i v i d e d by the i n s t i t u t i o n  into what must be spent i n the residence and what can be spent outside.  A head nurse at any time can telephone the residence  and enquire from a student why she i s l a t e f o r work.  Students,  even on time o f f , can be reached at any time, as they leave the telephone numbers of the places where they "sleep out." Students have a common bond i n sharing the image o f being "confined." Students become g r a d u a l l y accustomed to these norms i n the same way as they become accustomed to the p h y s i c a l structure o f the h o s p i t a l .  For i n s t a n c e , they f i n d i t hard  to sleep when they f i r s t enter the h o s p i t a l . and c r y i n g c h i l d r e n keep them awake. these cease t o a f f e c t them.  Ambulance s i r e n s  Before l o n g , however,  I n a s i m i l a r way they become  accustomed to norms of obedience, i m p e r s o n a l i t y , e q u a l i t y and subjection to a u t h o r i t y .  CHAPTER V I I PROM PROBIE TO GRAD  PHASES, CHANGES AND TYPOLOGY  This chapter s h a l l f o l l o w the process by which a probationary student changes i n t o a graduate.  I t could be  seen from three p e r s p e c t i v e s . 1) C e r t a i n changes, whether i n the t r a i n i n g s e t t i n g or i n student a t t i t u d e , permitted the d i v i s i o n o f the whole continuous process i n t o e a s i l y definable phases.  2) Questionnaires and Interviews provided data on  concrete changes t h a t occurred i n the a t t i t u d e s o f students. These w i l l be discussed and i l l u s t r a t e d by the use o f t a b l e s . 3) During the s o c i a l i z a t i o n process c e r t a i n d i s t i n c t i v e types of nurses seemed to evolve. w i l l be suggested.  Therefore, a typology o f nurses  I t should be s t a t e d that because o f the  l i m i t a t i o n s o f my data i n t h i s area, the typology w i l l be merely a p r o p o s i t i o n .  Phases There are two ways o f d i v i d i n g the process o f r o l e taking i n t o phases:  f i r s t l y , as i t i s seen by the subjects o f  the study and secondly, as I see i t . The students studied were asked how they v i s u a l i z e d t h e i r t r a i n i n g p e r i o d , and whether they would suggest any d i v i d i n g l i n e s o r stages.  A l l the students made c l e a r  d i s t i n c t i o n s between the t h e o r e t i c a l and the p r a c t i c a l parts their learning. I guess.  One  stated simply:  "Just d i v i d e i t i n t o  two,  The theory at u n i v e r s i t y and the p r a c t i c a l here."  should also be considered s i g n i f i c a n t that not one mentioned the h o s p i t a l d i v i s i o n s of "probie," intermediate and s e n i o r .  of  It  student  junior,  The phases of theory and  practice  were the most d i s t i n g u i s h a b l e . On the other hand, I see the process of r o l e - t a k i n g i n four phases:  1) the t h e o r e t i c a l preparation, which occurs  at the u n i v e r s i t y and i n e a r l y h o s p i t a l l e c t u r e s ;  2) the  first  p r a c t i c a l experiences, where students have t h e i r p r e l i m i n a r y contacts w i t h h o s p i t a l and p a t i e n t s ;  3) a r e a l i t y shock,  where students f i n d that r o l e - a n t i c i p a t i o n , and previous r o l e - p l a y i n g , does not always correspond to the new  role-playing;  a pattern o f r o u t i n e , s e t t i n g i n a f t e r the period of i n i t i a l disillusionment.  The two phases r e f e r r e d to by the students  correspond to phases one and two of my scheme.  1.  Theoretical The  Preparation  t h e o r e t i c a l u n i v e r s i t y period i s  by teaching and d i s c u s s i o n . presentation  The  characterized  subject matter i s the  of an i d e a l i z e d view of the medical  Instrumental knowledge i s transmitted  sub-culture.  as t h e o r e t i c a l m a t e r i a l ,  and the a p p l i c a t i o n of t h i s knowledge i s taught by asking the students to "pretend."  Enemas are given to Mrs.  Chase w i t h  the use o f a beer b o t t l e , o r a mustard p l a s t e r i s a p p l i e d to her arm. Students themselves pose as p a t i e n t s and thereby have some i n d i c a t i o n o f how i t f e e l s t o be a p a t i e n t . knowledge i s a l s o taught.  Expressive  They are made aware o f the  c u l t u r a l l y p r e s c r i b e d behaviour, and are placed under the o b l i g a t i o n to adopt i t . During t h e i r i n i t i a l p r e p a r a t i o n students are i n the u n i v e r s i t y c u l t u r e and subject to i t s norms. to be c h a r i s m a t i c , and to show i n i t i a t i v e .  They are I n s p i r e d  They are expected  to evaluate and c r i t i c i z e a l l the m a t e r i a l that i s presented to them, and questioning and d i s c u s s i o n are encouraged. Emphasis i s placed on each as being an i n d i v i d u a l , and nonconformity i s approved and considered c r e a t i v e .  Within this  environment they have t h e i r i n t r o d u c t i o n t o n u r s i n g . A source o f s t r a i n to the students at t h i s stage i s the l a c k o f a means t o apply t h i s p u r e l y t h e o r e t i c a l type o f knowledge.  They f e e l t h a t being members o f an occupation,  which i s c h a r a c t e r i z e d by a c t i o n , they should have more " p r a c t i c e " and thus prepare themselves f o r the d i f f e r e n t c a l i b r e o f t r a i n i n g t h a t they know they w i l l he given a t the hospital.  There i s a general impatience w i t h theory and a  f a i l u r e to see i t s connection t o the work they w i l l be doing. They f e e l that they are "not doing anything" and query how the t h e o r e t i c a l t r a i n i n g they are having i s concerned w i t h "doing n u r s i n g . "  I don't t h i n k we have enough p r a c t i c a l work. I t h i n k we have too much theory. There i s too much to absorb and you cannot put i t t o use a l l at once. And I t just seems as i f what you are l e a r n i n g I s going to waste. I f you could p r a c t i c e the procedures and the p r i n c i p l e s as you go along a b i t more . . . l i k e i f you had more t r i p s down to the h o s p i t a l . I know that would be d i f f i c u l t to arrange. We j u s t go down twice t o work w i t h a c t u a l p a t i e n t s . I f you could go down more times, i t would be b e t t e r . They i n d i c a t e a f e a r that they w i l l come to the p r a c t i c a l phase and not have the a b i l i t y to carry out t h e i r t a s k s . They complain that as they are nursing students they should be l e a r n i n g "nursing." They f e e l that i n t h e i r p o s i t i o n they are n e i t h e r u n i v e r s i t y students, as they f e e l i s o l a t e d both p h y s i c a l l y and academically from other students, nor nursing students, as t h e i r work i n v o l v e s academic courses and not nursing.  2.  F i r s t P r a c t i c a l Experiences The second phase begins w i t h the students' entry i n t o  the h o s p i t a l , and i n t o residence l i f e .  They move i n t o the  context I n which they w i l l p l a y t h e i r future r o l e . the " r e a l " s i t u a t i o n as they see i t .  This i s  They are now i n a  p o s i t i o n , they are t o l d , t o apply the t h e o r e t i c a l knowledge that they acquired I n the f i r s t phase.  What was taught t o  them at the u n i v e r s i t y i s r e i n f o r c e d i n h o s p i t a l l e c t u r e s .  Whereas i n the f i r s t phase much emphasis was put on instrumental norms, expressive norms are now more f o r c e f u l l y confirmed through r i t u a l and d i s c i p l i n e .  They p a r t i c i p a t e i n  and observe ceremonies performed i n c a n d l e l i g h t .  They take  vows and oaths of d e d i c a t i o n . They are emotionally impressed w i t h the sacredness o f these acts, and w i t h belonging to the group.  The meaning of nursing becomes more s i g n i f i c a n t and i s  f i l l e d w i t h added importance. d e s i r e to be l i k e other nurses.  They begin to f e e l a greater Thereby the commitment to  nursing norms becomes e a s i e r , and the students begin to f i t i n t o the medical s u b - c u l t u r e . For the f i r s t time, n u r s i n g s e r v i c e s are r e q u i r e d from them, and they begin to be defined, not o n l y as students, but also as workers. duties —  They are no longer l e a r n i n g about ward  they are performing them.  A new set o f expectations,  t h e r e f o r e , i s imposed on them. They now have to contend w i t h the i n s t i t u t i o n and w i t h other r o l e s t h e r e i n .  There i s an eagerness to l e a r n new  duties and to progress to a higher l e v e l on the h i e r a r c h y . They f e e l t h a t they are the l e a s t knowledgeable of a l l the students and t r y to conceal t h e i r ignorance.  They have an  anxiety about wasting h o s p i t a l equipment, and f e e l i n g s of g u i l t about t a k i n g coffee breaks when the ward i s busy.  They  are u n c e r t a i n of how to behave i n the presence of superiors and of o l d e r students.  166  Their major concern i n the new phase i s t h e i r i n t e r a c t i o n w i t h the p a t i e n t .  They begin by showing great  concern f o r the p a t i e n t ' s c o n d i t i o n and by i d e n t i f y i n g w i t h him i n h i s discomfort.  They show preferences  f o r p a t i e n t s who  are improving, or who are w e l l enough to respond t o them. There i s much concern a t f i r s t f o r the p a t i e n t ' s p r i v a c y and a tendency t o define t h e i r o b l i g a t i o n s towards him i n terms of his  r o l e o f " p a t i e n t " i n the medical sub-culture.  They f i n d  they are not prepared to perform many o f the unexpected duties that f a l l to t h e i r l o t . One i n s t r u c t r e s s commented:  "Doing  l i t t l e things f o r the p a t i e n t i s the hardest t h i n g to put across at f i r s t . " The a t t i t u d e s o f the students a t t h i s stage o f t h e i r t r a i n i n g could be looked at i n terms o f Parsons' "pattern variables."  He analysed the p r o f e s s i o n a l r o l e as achievement-  oriented, u n i v e r s a l i s t i c , functionally s p e c i f i c , a f f e c t i v e l y n e u t r a l and c o l l e c t i v i t y - o r i e n t e d .  1  that a p r o f e s s i o n a l r o l e i s achieved,  I n other words he suggests as opposed to ascribed;  .that i t i s o r i e n t e d towards a c l i e n t or a p a t i e n t i n terms o f t h e i r s p e c i f i c r o l e as such, rather than i n terms o f the o r g a n i z a t i o n o f the many r o l e s that they play; that the duties of the p r o f e s s i o n a l are confined to the s p e c i f i c area o f h i s p r o f e s s i o n ; that the p r o f e s s i o n a l does not develop an emotional attachment to h i s c l i e n t or p a t i e n t , but remains a f f e c t i v e l y 1 Parsons, The S o c i a l System, p. 1+54.  167  n e u t r a l ; and f i n a l l y , t h a t a p r o f e s s i o n a l person i s a l t r u i s t i c and i n t e r e s t e d i n a c o l l e c t i v i t y r a t h e r than i n s e l f gratification.  (These suggestions o f Parsons have been  paraphrased more f u l l y and w i t h reference to the r o l e of a p  doctor i n a preceding chapter.)  With t h i s scheme i n mind, i t  could be s a i d that at the time o f phase two, the student i s a f f e c t i v e l y - o r i e n t e d , f o r she tends to develop a personal concern f o r her p a t i e n t . She i s p a r t i c u l a r i s t i c as she "••; i n t e r e s t s h e r s e l f i n as many aspects o f the p a t i e n t as p o s s i b l e , and not merely i n h i s i l l n e s s .  She i s f u n c t i o n a l l y s p e c i f i c  i n that she Is too inexperienced and unsure o f her tasks and the boundaries o f these tasks t o perform small d u t i e s such as "doing l i t t l e things f o r the p a t i e n t . " Operating simultaneously, or immediately a f t e r t h e i r f i r s t p r a c t i c a l experience, the students f e e l some a n x i e t y . The gap between phases one and two i s so great that t h i s anxiety occurs.  I n other words, r o l e - a n t i c i p a t i o n d i f f e r s  from a c t u a l r o l e - p l a y i n g .  This could be c a l l e d a " r e a l i t y  shock."  3.  R e a l i t y Shock I remember t h i n k i n g you go r i g h t i n and everything's r i g h t t h e r e . An i d e a l s i t u a t i o n . And you f i n d out i t i s n ' t .  2 Cf. ante pp. 21-23.  168  R e a l i t y i s something outside of the s e l f to which the s e l f must a d j u s t .  P r i o r to coming into contact w i t h r e a l i t y  the s e l f e n t e r t a i n s images o f what r e a l i t y would be l i k e .  The  e f f e c t i s d i s i l l u s i o n i n g when i n i t i a l expectations are f r u s t r a t e d or d i s s o l v e d on meeting the demands of the r e a l s i t u a t i o n .  The  r e a l i t y shock, t h e r e f o r e , i s the r e s u l t of a discrepancy between phase one and phase two.  I t i s also the r e s u l t of a discrepancy  between previous r o l e - p l a y i n g and the new r o l e - p l a y i n g .  Reality  shocks are Incurred i n the f o l l o w i n g :  Overcoming Old Norms When students come i n t o contact w i t h the p r a c t i c a l aspects of t h e i r t r a i n i n g , some of t h e i r o l d norms have to be unlearned or m o d i f i e d .  Whereas the u n i v e r s i t y f o s t e r e d charisma  and i n d i v i d u a l i t y , the h o s p i t a l tends to frown on these and to consider them d y s f u n c t i o n a l .  Instead p r e c i s e obedience i s  rewarded, and e q u a l i z i n g , depersonalizing processes are instigated.  Students begin to f e e l the i n f l u e n c e o f these  processes, together w i t h the growing knowledge that they are unable to do anything about t h i s .  This change from one extreme  to another takes the form o f a shock. As I have already pointed out, they have to overcome such s o c i a l norms as the norm governing a t t i t u d e s towards death, towards I n f l i c t i n g p a i n and towards contacts w i t h the human body.  They have also been unprepared f o r such f a c t o r s  as o b j e c t i o n a b l e s m e l l s , t o which they are forced t o accustom themselves.  A l s o , they were not aware o f the s t r a i n s that  would occur during o p e r a t i o n s , when a person i s converted i n t o a nondescript combination o f a r t e r i e s , muscles, f l e s h and bone. They experience great anxiety when i n contact w i t h amputated limbs.  These remind them of previous s o c i a l norms where such  a limb i s "part o f a person," and any separation from the t o t a l i t y i s a matter o f h o r r o r . There i s , t h e r e f o r e , a sensation of shock when a student has t o overcome p r e v i o u s l y i n t e r n a l i z e d s o c i a l norms.  Imperfections of I n s t i t u t i o n a l L i f e As f a r as the h o s p i t a l Is concerned, students are d i s i l l u s i o n e d i n f i n d i n g that o f t e n i n s t i t u t i o n a l r u l e s do not make sense.  They query why i n the case o f an emergency they  should phone the s u p e r v i s o r who w i l l then summon the i n t e r n . They ask why both could not be summoned at once, thereby saving time.  They are s u r p r i s e d at f i n d i n g that r o u t i n e , which has  long become t r a d i t i o n a l , i s s t i l l maintained, even though i t has become d y s f u n c t i o n a l .  For i n s t a n c e , they do not see why  they should use a clamp i n g i v i n g enemas, when they can do i t j u s t as w e l l without. Because o f the constant reference t h a t was made t o them, I gather that students were not prepared f o r what they began to define as shortcomings on the part o f the h o s p i t a l .  170  They were in  the  has  shocked to  hospital,  to  be  permit  the  the  find  time,  a shortage  They are not  they  also  of  are  a lack of  to  be  they  n u r s i n g norms patients, or  a shortage  on the  not  forced to  able to  table not  leave  to duty  coffee-breaks  e x t r a demands u p o n t h e m . many g r a d u a t e  and p e r f o r m a c t s are  supplies  Contrary  do w i t h o u t  that  of  operating  performed.  are  find  is  b l o o d s u p p l y does  personnel places  unprepared to  conform to  indifference  that  or  there  an i n d i v i d u a l  required operation to  correct  because  and t h a t  "sewed u p " because  expectations, at  discover that  Inefficient  of  nurses  do  unkindness,of  i n nursing  techniques.  Contradictions  to  Previous Learning i n  Students one  of  their  example, aureus in  that what they were  training is  they were t o l d  boils  s h o u l d be  has  to  be  object. bath,  they  They may f i n d  Students  take  their  would not  be  problems to  afraid of  with  yet  them,  they  told,  they  are  yet  their  they  but are  phase  two.  For  them w a n d e r i n g  that they as  forced to  from them.  instructresses, that  find  patient,  during  expected  and f e e l  in  staphylococcus  were taught  individual  that  when t h e y h a d been this  patients  segregated,  the  taught  d i s r e g a r d e d i n phase  should always rub h a r d ,  adapted to  that  often that  the ward c o r r i d o r s .  back r u b s ,  be  find  Nursing  when  giving  find that often  finish  this  patients a  theoretical  man's training,  They were t o l d  to  i n r e a l i t y t h e y may not  able  to  please  them w i t h t h e i r work.  Hence, they are discouraged from  approaching them w i t h problems.  Such c o n t r a d i c t i o n s place them  i n a p o s i t i o n of c o n f l i c t , where they do not know which course to adopt. I n a d d i t i o n t o such obvious c o n t r a d i c t i o n s i n technique and the performance o f nursing d u t i e s , there i s a f e e l i n g t h a t p r e v a i l s that there i s l i t t l e connection between the t h e o r e t i c a l t r a i n i n g and i t s p r a c t i c a l counterpart.  Students  o f t e n mentioned that they were unable to apply the theory that they l e a r n t , and i n f a c t gave no thought to i t during the various aspects o f t h e i r work.  At the same time they f e l t they  should be u s i n g t h i s theory i n t h e i r work.  One student  emphasized: There's no s i m i l a r i t y between what we l e a r n t at V a r s i t y and what we're doing here. I t ' s a completely d i f f e r e n t stage.  Peelings o f Inadequacy At one time o r another a l l my subjects i n d i c a t e d the presence o f f e e l i n g s o f Inadequacy, whether they are the r e s u l t o f f r u s t r a t e d self-images, which had c o n s i s t e d o f images of the student ably and promptly c a r r y i n g out her d u t i e s , or whether they are the r e s u l t o f mistakes o r the l a c k of knowledge.  They c l a i m , f o r example, t h a t although they knew  the work o f a nurse was "hard," they had not been able to r e a l i z e just how "hard."  They complain o f aching arms, t i r e d  feet and backs, and "housework" hands. They f i n d that bedmaking i s not as easy as they had thought, e s p e c i a l l y when there i s a " l i v e " p a t i e n t i n i t .  They f i n d that on g i v i n g  the wrong thermometer to a p a t i e n t , they are faced w i t h the h u m i l i a t i o n o f being corrected by the p a t i e n t .  They had not  been prepared f o r the p o s s i b i l i t y o f w e l l - i n f o rmed p a t i e n t s , and the c o n t r o l s that could be exercised from t h i s area. They f i n d t h a t o f t e n t h e i r knowledge i s inadequate. They begin work i n P e d i a t r i c s and r e a l i z e that they are not able to change diapers, and, i n f a c t , f i n d that they are not able to perform many o f the basic duties that non-nursing people can perform.  Or, during t h e i r f i r s t weeks i n the  h o s p i t a l they are faced with the emergency o f a n a t u r a l a b o r t i o n , and are asked t o take charge.  They have never,  however, l e a r n t or observed the c o r r e c t procedure. Not only do they f e e l inadequate w i t h i n the context of the h o s p i t a l , but there i s an i n c r e a s i n g f e e l i n g o f inadequacy w i t h the non-medical c u l t u r e .  They f i n d that they  are i s o l a t e d and are not able to t a l k o f anything but nursing Consequently, they complain that they o f t e n f e e l ousted i n non-nursing groups.  Routine Replaces Drama and Glamour Changes i n self-images: o f t e n l e a d t o r e a l i t y shocks Many students imply that they had seen the nursing r o l e as  s o c i a l l y d e s i r a b l e f o r i t was  i d e a l l y feminine, somewhat  glamourous, mysterious and s e l f - s a c r i f i c i n g .  They f i n d ,  however, that many symbols of f e m i n i n i t y are disguised behind such e q u a l i z i n g , m i l i t a r i s t i c f r o n t s as uniforms and short h a i r . They i n v a r i a b l y i n d i c a t e d that they p i c t u r e d themselves, glamourously a t t i r e d i n white, bending over a i l i n g p a t i e n t s . They r e a l i z e , however, that they perform t h i s task seldom, but most of t h e i r time goes i n t o tasks that i n v o l v e t r e a t i n g the p a t i e n t , often i n an unpleasant manner, cleaning up "messes" and c h a r t i n g .  They even f i n d that o f t e n t h e i r work i s o f such  a nature that i t has l i t t l e relevance to nursing and seems unnecessary. The DK i s f i n e f o r one week, but a f t e r f i v e , i t ' s t e r r i b l e . . . I don't t h i n k we should go down to the DK. That's one part o f the t r a i n i n g that i s n ' t necessary. They f e e l they are v i o l a t i n g the image that defines t h e i r occupation as "important."  This f e e l i n g a r i s e s very s t r o n g l y  when they are i n the d i e t k i t c h e n p u t t i n g butter and s p r i g s of parsley on the potatoes on p a t i e n t s ' p l a t e s . Therefore, what was  once dramatic, glamourous and  a t t r a c t i v e because o f i t s abnormality, becomes normal and a part of every day's work.  The monotony of r o u t i n e , which had  not been part of the r o l e - a n t i c i p a t i o n , sets i n and a p e r s i s t e n t f e e l i n g of d i s i l l u s i o n m e n t occurs.  Peeling of Depersonalization Students i n d i c a t e t h a t they f e e l a l o s s of freedom, a l o s s of r e s p o n s i b i l i t y f o r d i r e c t i n g t h e i r own l i v e s and a l o s s o f a b i l i t y to c o n t r o l t h e i r development i n t o an image which i s o f t e n d i s t a s t e f u l to them.  They f e e l r e s t r i c t e d i n  t h e i r behaviour i n not being able to partake o f outside a c t i v i t i e s , i n being i s o l a t e d i n t o the company o f other nurses and i n l i v i n g i n residence; they begin to f e e l e x p l o i t e d as i n s t i t u t i o n a l scapegoats, when they t h i n k both superiors and p a t i e n t s o f t e n "take i t out on them"; they t h i n k that working i n the d i e t k i t c h e n serves the f u n c t i o n o f removing them from what i s "important" and what i s the work o f a nurse; they have heard o f c a l l o u s nurses and have intended t o prevent  themselves  from becoming so, yet they f e e l that they are becoming i n c r e a s i n g l y so, and are unable to c o n t r o l the process.  This  process o f d e p e r s o n a l i z a t i o n i s met w i t h d e f e a t i s t a t t i t u d e s on the part o f the students.  They recognize i t s presence, hut can  do nothing t o stop i t . R e a l i t y shocks, t h e r e f o r e , a r i s e from two sources: 1) the discrepancy between what students expected and r o l e p l a y i n g as i t a c t u a l l y e x i s t s ; role-playing.  2)  c o n t r a d i c t i o n s t o previous  Reference t o r e a l i t y shocks i s not meant t o  imply that I have r e s o r t e d to the hypothesis t h a t " r e a l i t y " i s unpleasant.  Future chapters w i l l i n d i c a t e that contact w i t h  " r e a l i t y " can also be an experience o f s a t i s f a c t i o n , as w e l l  as an experience of s t r a i n .  i i . Acceptance and Routine Phase four i s the r e s u l t of the adjustment between phase one, two and t h r e e .  This adjustment, I observed,  took  the form of a l t e r n a t i n g between s i n c e r i t y and cynicism, between s a t i s f a c t i o n and depression.  The tenseness and anxiety which  a r i s e s when the students come i n contact w i t h the p r a c t i c a l s i t u a t i o n i s q u e l l e d by acceptance of the circumstances as they exist.  The r e s u l t i s the formation o f appropriate h a b i t s of  conduct to cope w i t h the e x i s t i n g s t a t e of r o l e - p l a y i n g . F i n a l l y , routine i s established. In the beginning, the o n l y reason that students gave f o r t h e i r l e a v i n g nursing was f a i l u r e to meet the r e q u i r e d standards.  This changes to a question of "do I r e a l l y want  t h i s ? " and the doubt whether some other r o l e would have been more appropriate. to withdraw.  They i n d i c a t e , however, that i t i s too l a t e  The i n i t i a l desire of students to be s u c c e s s f u l  nurses i s r e p l a c e d by a r e s i g n a t i o n to the e x i s t i n g state of performance. I t h i n k I'm l o s i n g my i n i t i a t i v e . I never r e a l l y exert myself to do anything. You get to the point where you can't be bothered to do anything. There seems to he a decreasing a b i l i t y to experience contentment w i t h t h e i r work, and there i s l i t t l e evidence of the f e e l i n g s of optimism t h a t occurred i n the beginning.  The c u r i o s i t y f o r the abnormality of i l l n e s s passed through p r a c t i c a l experience  has  and r e a l i t y shocks to where  i t becomes normal, everyday and r o u t i n e .  "Probies," when they  f i r s t went to the h o s p i t a l , had serious a t t i t u d e s towards t h e i r d u t i e s ; t h i s changes to the l e s s serious a t t i t u d e s of intermediates, who  are able to joke about t h e i r work.  An  example of t h i s d i f f e r e n c e In a t t i t u d e occurred at the party given by intermediates f o r the"probies " A s k i t , r i d i c u l i n g h o s p i t a l personnel, nursing techniques  and p a t i e n t s , was  created f o r the "probies" by the o l d e r students.  The  latter  were o f t e n amused by the dialogue or a c t i o n s o f the a c t r e s s e s , while the former remained unmoved and somewhat s u r p r i s e d at the a t t i t u d e presented to them.  "Probies" also regard nursing  as f a s c i n a t i n g and boast about i t being "hard work."  Aching  limbs are r e f e r r e d to as i f they were i n d i c a t i o n s o f s e l f sacrifice.  This changes to complaints about genuine f a t i g u e ,  w i t h no i n d i c a t i o n s o f p r i d e .  Work proves to be, not the  reward that they estimated i n phase one, but rather a punishment.  They no longer f e e l g u i l t y about t a k i n g coffee  breaks, but grumble when t h i s I s not p o s s i b l e . They become more competent i n organizing time and i n performing procedures.  They manipulate prescribed methods  of performance by adapting them to t h e i r own  use.  I t h i n k t h a t most o f b a s i c procedure w i l l that a c e r t a i n 1, 2, w r i t t e n i n the book, 3, 5> because i t f i t s  us a f t e r we know the go ahead. We know 3, k, 5A 7 it's but we do i t 1, 2, ij., better. S  t t l e  w a  Students g r a d u a l l y begin t o l o s e t h e i r a b i l i t y t o i d e n t i f y w i t h p a t i e n t s , and t h i s they o f t e n i n t e r p r e t as a process o f becoming c a l l o u s . They are becoming more affectively neutral.  They become l e s s concerned w i t h the  p a t i e n t ' s i n d i v i d u a l i t y , and more concerned w i t h d e f i n i n g them as " p a t i e n t s , " and i n converting them i n t o "people." When a p a t i e n t begins to respond to treatment and t o improve they refuse to perform tasks t h a t they would f o r " p a t i e n t s . " One student remarked:  "I see no e a r t h l y reason why she  cannot wash her own back . . . i f she complains once more I ' l l scream."  Thus they are becoming more u n i v e r s a l i s t i c .  Their tasks also are becoming more d i f f u s e , because they become aware that they are expected t o perform such duties as buying c i g a r e t t e s and candy or l i s t e n i n g to personal problems Students then become a f f e c t i v e l y - n e u t r a l , p a r t i c u l a r i s t i c and f u n c t i o n a l l y d i f f u s e , a l l o f which, w i t h the exception of the l a s t , correspond t o Parsons' c r i t e r i a f o r p r o f e s s i o n a l i s m . Therefore, phase four could also be r e f e r r e d t o as the phase where r o l e - p l a y i n g takes on p r o f e s s i o n a l c h a r a c t e r i s t i c s .  Changes The students s t u d i e d were given a questionnaire p r i o r to t h e i r e n t r y i n t o the h o s p i t a l as p r o b i e s , the r e s u l t s o f t h i s questionnaire being designed t o i n d i c a t e beginning self-images and r o l e - a n t i c i p a t i o n s .  They were questioned again a f t e r they  had experienced phases two and three o f t h e i r t r a i n i n g .  The  d i f f e r e n c e s between the two questionnaires i s an i n d i c a t i o n o f the change that had occurred.  I n order to give a systematic  view o f the r e s u l t s , I s h a l l use my f i v e - v a r i a b l e scheme f o r occupational analysis.-'  Images o f the Role Students were asked what they thought people t o n u r s i n g .  attracted  At f i r s t they thought that people were  a t t r a c t e d p r i m a r i l y by the drama, the glamour and the urgency of the p r o f e s s i o n . This was f o l l o w e d by a d e s i r e to help others, and then by u t i l i t a r i a n reasons such as s e c u r i t y and an a b i l i t y t o prepare f o r marriage.  At the second time, when  they were asked they i m p l i e d t h a t h e l p i n g others was the most important, followed by the glamourous aspects o f the work. The importance o f a favourable p u b l i c image and the f u n c t i o n  3 These r e s u l t s s h a l l be examined i n more d e t a i l i n the j o i n t report w r i t t e n w i t h Dr. K. D. Naegele, f o r the Koerner Foundation.  179  of c u r i o s i t y have taken a r i s e i n importance, w h i l e u t i l i t a r i a n reasons have diminished. C h a r a c t e r i s t i c s Which Became More Important °/o Who Considered I t Important (Time 1) (Time 2) Favourable p u b l i c image, p r e s t i g e 13 26 Curiosity £ If? Role C h a r a c t e r i s t i c  C h a r a c t e r i s t i c s Which Became Less Important Role C h a r a c t e r i s t i c Drama, glamour, urgency Being able t o h e l p others U t i l i t a r i a n , security etc.  %  Who  Considered I t Important (Time 1) (Time 2) h f>l 36 4.6 38 38 21  This s h i f t from images which show the students as being a t t r a c t e d by egocentric reasons such as glamour and s e c u r i t y are d i m i n i s h i n g and being r e p l a c e d by other-oriented reasons.  This leads to the  suggestion that nursing norms o f devoting one's energies and l o y a l t i e s to the p a t i e n t are being i n c r e a s i n g l y i n t e r n a l i z e d . Increasing commitment to h o s p i t a l norms becomes apparent when students were asked what they thought the p u b l i c expected from a nurse.  Emphasis on s k i l l and e f f i c i e n c y increased,  w h i l e a t t r i b u t e s o f i n d i v i d u a l i t y and f e m i n i n i t y decrease. The prime e x p e c t a t i o n o f p e r s o n a l i z e d , humanitarian care r e t a i n s i t s importance. the  I n s t i t u t i o n a l demands were a l s o brought out, i n  second instance, to a g r e a t e r degree when students were  asked what they thought t h e i r f a m i l y and f r i e n d s expected from nurses.  P r o f e s s i o n a l a t t i t u d e s became more important. On the  other hand, however, they thought that t h e i r f a m i l y would also expect them to r e t a i n t h e i r i n d i v i d u a l i t y .  This became more  emphasized at the time of the second questionnaire, when contact w i t h the medical sub-culture  occurred.  C h a r a c t e r i s t i c s Expected , - % ' ' Personal, humanitarian care Mechanical s k i l l & e f f i c i e n c y Nurse as I n d i v i d u a l Professional attitudes A b i l i t y to help own f a m i l y Desirable i n s t i t u t i o n a l q u a l i t i e s This suggests that students may  Who  Considered I t Important (Time 1) (Time 2) 66 72 62 66 ' lj.9 66 ijl $1 . 21 18 18 31  i n d i c a t e t h e i r family's d e s i r e  f o r t h e i r i n d i v i d u a l i t y as a r e s u l t of t h e i r own f e e l i n g s o f s t r a i n , o c c u r r i n g as a r e s u l t of the depersonalizing process of r o l e - t a k i n g .  Character of Obligations I n answer to a question which asks what a nurse can contribute to the welfare o f a p a t i e n t t h a t a doctor cannot, there was  an overwhelming m a j o r i t y i n favour of e f f i c i e n t ,  s c i e n t i f i c nursing care i n the f i r s t i n s t a n c e .  This was  not  considered so important i n the second i n s t a n c e . E x c l u s i v e Contributions o f Nurse Technical nursing s k i l l s Psychological care  °/6 Who  Considered I t Important (Time 1) (Time 2) 80 59  62 62  This decline i n the importance o f the t e c h n i c a l care given by  the nurse i n d i c a t e s a source o f s t r a i n when the nurse f e e l s marginal t o the doctor. I t also i m p l i e s a tendency on the part o f probies before entrance to the h o s p i t a l to define i l l n e s s i n terms o f p h y s i c a l and not mental abnormality. Students were asked f o r t h e i r o p i n i o n o f what made a s u c c e s s f u l nurse.  The answers were as f o l l o w s :  Form o f Behaviour  % Who Considered I t Important (Time 1) (Time 2)  Devoting o n e s e l f t o the w e l f a r e of the p a t i e n t without overconcern f o r the r u l e s Carrying out the orders o f superiors at a l l events Obeying s t r i c t l y the r u l e s o f the h o s p i t a l  77  66  10  23  10  10  These f i g u r e s show a d i s t i n c t awareness o f the i n s t i t u t i o n and i t s expectations i n the second instance, and t h e l o y a l t y that a s u c c e s s f u l nurse should show.  Nursing norms, on the other  hand, put nurses under the o b l i g a t i o n t o devote themselves e n t i r e l y to patients.  Therefore, i n s t i t u t i o n a l norms seem to  gain i n importance over nursing norms. When asked t o mention the c h a r a c t e r i s t i c s that the h o s p i t a l would expect from nurses, the answers were the following:  C h a r a c t e r i s t i c s Which Became More Important C h a r a c t e r i s t i c Expected  °/> Who  Technical approach to p a t i e n t s Adoption of i n s t i t u t i o n a l norms Econoray  Considered I t Important (Time 1) (Time 2) 82 95> 33 &4 23 1|1  C h a r a c t e r i s t i c s Which Became Less Important C h a r a c t e r i s t i c Expected  %  Smooth i n t e r a c t i o n w i t h other r o l e s Humanitarian approach to p a t i e n t s Independence, charisma  Who  Considered I t Important (Time 1) (Time 2) 77 26 l£  69 18 £  The suggestion i s t h a t students become i n c r e a s i n g l y aware that the h o s p i t a l r e q u i r e s them to f i t i n t o the i n s t i t u t i o n a l context and to help to m a i n t a i n I t i n i t s r e q u i r e d s t a t e .  Individuality  and humanitarian a t t i t u d e s are not considered as being important. On the other hand when asked where t h e i r l o y a l t i e s belonged, students answered t h a t they belonged, f i r s t l y , i n kindness and understanding to the p a t i e n t , and, secondly, i n the s k i l l i n v o l v e d i n work.  A f t e r p r a c t i c a l experiences,  kindness and understanding towards the p a t i e n t became more important and the s k i l l diminished somewhat i n s i g n i f i c a n c e . The i m p l i c a t i o n i s that r e l a t i o n s h i p s w i t h p a t i e n t s showed the importance of p s y c h o l o g i c a l care. aspect o f t h e i r work.  This was the most important  The l e a s t important was r o u t i n e work,  and t h i s continued to decrease i n importance, w i t h experience. Routine tasks were a l s o i n d i c a t e d , together w i t h " d i r t y work,"  183  as being the l e a s t enjoyable.  The most enjoyable t a s k was  the  s o c i a l contact w i t h the p a t i e n t . Most Enjoyable Tasks S o c i a l contacts w i t h p a t i e n t s Nursing p a t i e n t s who r e c i p r o c a t e A b i l i t y to acquire knowledge  %  Who  Considered I t Enjoyable (Time 1) (Time 2) I4J4.  6I4.  33 10  23 10  This i m p l i e s that before p r a c t i c a l experiences, students thought they would enjoy p a t i e n t s who r e c i p r o c a t e d , and thereby derive s a t i s f a c t i o n s i n t h e i r r o l e .  On the second i n s t a n c e ,  t h i s d e c l i n e d as being an enjoyable aspect of t h e i r work, implying that they gained greater i n s i g h t Into the p s y c h o l o g i c a l conditions of p a t i e n t s and why they were unable to respond. When asked to mention the c h a r a c t e r i s t i c s of i d e a l nurses, the f o l l o w i n g were the changes that were of any significance: Characteristics  °/6 Who Mentioned I t As Important (Time 1) (Time 2) ~~~~ A b i l i t y to get along w i t h people 77 77 Enjoying one's work 1+-9 6J4. A b i l i t y to f o l l o w orders 38 lj.6 Neat appearance 36 lj.6 Technical s k i l l 36 15 Recognition o f own l i m i t a t i o n s 31 1+9 This suggests t h a t i d e a l nurses have an a b i l i t y to commit themselves to i n s t i t u t i o n a l requirements and p r o f e s s i o n a l role-images. t h e i r work.  They f o l l o w orders and appear neat.  They enjoy  They work w e l l w i t h i n the h o s p i t a l context by  r e c o g n i z i n g t h e i r l i m i t a t i o n s and by being able to get along  w i t h people.  Technical s k i l l , which c a r r i e s w i t h i t the stigma  of i m p e r s o n a l i t y and c a l l o u s n e s s , i s not as important and becomes l e s s important* a f t e r experience.  Rewards Students were asked what they thought most people l i k e d about nursing as a future p r o f e s s i o n . Before t h e i r p r a c t i c a l experiences, s e c u r i t y and being able t o help others were both considered important.  A f t e r t h e i r experiences,  however, s e c u r i t y grew i n importance.  This i n d i c a t e s that  t h e i r f e e l i n g s o f being able t o help others were no longer considered as s i g n i f i c a n t a f t e r they- had experienced the p r a c t i c a l situation.  I n a d d i t i o n , when asked why nursing was a good  p r o f e s s i o n f o r women, students answered that i t was such because o f the s e c u r i t y i t o f f e r e d , and also because i t was practical i n later l i f e .  Personal s a t i s f a c t i o n became more  important a f t e r experiences.  When they were asked f o r t h e i r ,  c h i e f rewards, however, over 90 per cent i n both instances f e l t that personal s a t i s f a c t i o n was t h e i r c h i e f reward.  Strains A f t e r ward experiences students show that they b e l i e v e t h a t nurses are paid f a r too l i t t l e .  This was not  as n o t i c e a b l e before they had p r a c t i c a l experiences.  This  i n d i c a t e s t h a t , t o some extent, students discovered that p l a y i n g the r o l e o f a nurse was more d i f f i c u l t than they had thought.  Students were asked whether they thought they were prepared f o r p r a c t i c a l h o s p i t a l experiences.  These were the  answers: Degree of Preparedness Very w e l l prepared F a i r l y w e l l prepared Not too w e l l prepared Not at a l l w e l l prepared  % Who Mentioned I t (Time 1) (Time 2) 5 18 38 66 lj-9 l£ 8  These f i g u r e s i n d i c a t e a g e n e r a l l y i n c r e a s i n g s a t i s f a c t i o n w i t h university training.  They also show the strength of t h e i r  i n i t i a l discontent i n being i s o l a t e d from t h e i r prospective work as nurses and "having o n l y theory."  L a t e r , however, they  show t h e i r preferences f o r u n i v e r s i t y t r a i n i n g i n n u r s i n g , r a t h e r than h o s p i t a l t r a i n i n g .  Thus does t h e i r  initial  discontent become diminished w i t h time. When the i s s u e of unfavourable p u b l i c images was r a i s e d , students thought that the p u b l i c was ignorant o f : Nursing C h a r a c t e r i s t i c s Lack o f glamour T r a i n i n g and education P s y c h o l o g i c a l care given More than just a d i r t y job D i f f u s e nature o f work Part played i n h o s p i t a l l i f e Emotional s t r a i n  °/fc Who Mentioned I t (Time 1) (Time 2) 33 28 26 33 23 13 21 18 1$ 8 13 28 13 13  Increasing awareness o f the h o s p i t a l i s i n d i c a t e d here.  R e l a t i o n to Others Students were asked what r o l e s they considered indispensable t o the f u n c t i o n i n g o f the h o s p i t a l .  They  answered i n the f o l l o w i n g manner: Role  % Who Considered I t A b s o l u t e l y Indispensable (Time 1) (Time 2) 97 100 85 85 51 31 33 31 ' 23 36 13 36  Doctors Nurses Dietitians Instructresses Student nurses Visitors  Therefore, i n the students' eyes, student nurses and v i s i t o r s became more important t o the f u n c t i o n i n g o f the h o s p i t a l . D i e t i t i a n s and i n s t r u c t r e s s e s became l e s s important.  Thus,  before h o s p i t a l experiences, students were not aware o f the amount o f service they would be asked t o g i v e . of s t r a i n f o r them. service."  This i s a form  "We're supposed to l e a r n and not give  The i n c r e a s i n g importance o f v i s i t o r s suggests that  students begin to r e a l i z e the s i g n i f i c a n c e of p s y c h o l o g i c a l care given to the p a t i e n t , and accept the r o l e o f the v i s i t o r i n giving t h i s .  D i e t i t i a n s , i n t h e i r o p i n i o n , decrease i n  importance, because o f t h e i r i n a b i l i t y to p a r t i c i p a t e i n the emergency o f the s u b - c u l t u r e . They were asked what they thought a doctor expected from a nurse.  A f t e r p r a c t i c a l experiences they placed more  importance on occupational q u a l i t i e s , and l e s s on i n d i v i d u a l  18?  qualities.  They were also asked what they thought that other  nurses would expect from them.  Mechanical s k i l l s and e f f i c i e n c y ,  p r o f e s s i o n a l a t t i t u d e s and awareness of the h o s p i t a l as an i n s t i t u t i o n became more important. Several questions were asked about the kinds o f p a t i e n t s that students would l i k e to nurse.  When asked about  the sex o f t h e i r p a t i e n t s , students commented that they would l i k e to nurse °/6 Who P r e f e r r e d Them (Time 1) (Time 2)  Children Men Women  90 28 18  80 66  51  Their preference f o r men and women seemed t o r i s e .  This could  be the r e s u l t o f t h e i r having, at the time that the question was posed, only experienced the nursing of adult p a t i e n t s . I t could also suggest a commitment to nursing norms which expect nurses to show no d i s c r i m i n a t i o n among p a t i e n t s . A l s o , the order o f preferences, c h i l d r e n , men and women, i n d i c a t e s that an absence o f c r i t i c a l a b i l i t i e s i n a p a t i e n t are important.  They l i k e to nurse c h e e r f u l p a t i e n t s , and t h i s  desire becomes i n t e n s i f i e d a f t e r h o s p i t a l experiences. p a t i e n t s are also important.  Grateful  They d i s l i k e p a t i e n t s who swear,  who demand more a t t e n t i o n than they need, who cannot express themselves, who act s u p e r i o r , o r who do not care what happens to them.  They show an i n i t i a l d i s l i k e f o r economically  188  privileged patients.  This diminished markedly a f t e r  experience.  These r e s u l t s i n d i c a t e that students l i k e p a t i e n t s who  reciprocate  and that t h e i r g i v i n g must be complemented by r e c e i v i n g .  In  a d d i t i o n t h e i r decreasing d i s l i k e of economically p r i v i l e g e d p a t i e n t s suggests that they p r e f e r p a t i e n t s who  conform most  c l o s e l y to t h e i r own middle-class way of l i f e . When asked about where they would l i k e to nurse and where they would not l i k e to nurse, they answer i n the f o l l o w i n g manner: Ward  %  Semi-private Staff Private  Who P r e f e r to Nurse There (Time 1) (Time 2 ) 4° 5% 38 kk18 5  These answers i n d i c a t e a c o n f l i c t .  They p r e f e r to nurse the  middle-class p a t i e n t that i s i n f e r r e d by the  semi-private  ward, yet nursing values of c h a r i t y and helping those who i t , i n d i c a t e that they should nurse s t a f f p a t i e n t s who  need  come  from the lower socio-economic l e v e l .  The p r i v a t e ward p a t i e n t ,  who  and also does not p l a y  i s above them socio-economically,  such a prominent part i n n u r s i n g norms, i s not p r e f e r r e d . They were asked what s p e c i a l t y they p r e f e r r e d .  The  answers i n d i c a t e d that before h o s p i t a l experiences they p r e f e r r e d the emergency u n i t . but was  This dropped s i g n i f i c a n t l y ,  s t i l l p r e f e r r e d , a f t e r students had encountered the  practical situation.  Preferences  f o r other u n i t s were not  189  significant.  The suggestion here i s that the drama and the  urgency o f the medical sub-culture may have played an important part i n i n i t i a l m o t i v a t i o n . When asked where they would d i s l i k e to nurse, the mental h o s p i t a l maintained i t s unpleasant connotations. unit.  A change occurred w i t h regard to the contagious  Only f i v e students i n d i c a t e d a d i s l i k e f o r t h i s before  p r a c t i c a l experiences, but seventeen showed a d i s l i k e a f t e r the h o s p i t a l experience.  This suggests t h a t the monotony of the  i n f e c t i o u s diseases technique i s f u l l y r e a l i z e d a f t e r thep r a c t i c a l contact w i t h i t . Students were asked what i l l n e s s they would l i k e to nurse, and a f t e r t h e i r experience i n the r e a l s i t u a t i o n , they were asked what i l l n e s s e s they l i k e d n u r s i n g . They answered as f o l l o w s : %  Illness Surgical Children's i l l n e s s e s Where p a t i e n t recovers and does not s u f f e r extremely Mental  Who Would L i k e to Nurse I t (Time 1) (Time 2) 28 26  kk.  18 15  33 2  10  This supports the previous suggestions that students p r e f e r contacts w i t h p a t i e n t s who recover and r e c i p r o c a t e .  Recovery  of a p a t i e n t i s a source o f s a t i s f a c t i o n to the nurse. Furthermore the transference of a p a t i e n t to a person, and hence to one who  can r e c i p r o c a t e , i s also an i n d i c a t i o n of  nursing s a t i s f a c t i o n .  S u r g i c a l p a t i e n t s on the whole, a f t e r  they have f i r s t become worse through an operation, begin to  190  improve.  Very few r e f e r r e d t o medical p a t i e n t s i n t h i s  question.  Students were asked w i t h whom they thought they would l i k e to work.  A f t e r p r a c t i c a l contacts, they were again asked  w i t h whom they l i k e d to work.  They e s p e c i a l l y looked forward  to t h e i r work w i t h other nurses, and found that they s t i l l l i k e d i t above other r e l a t i o n s h i p s . Many looked forward t o t h e i r work w i t h doctors, but discovered that they d i d not l i k e I t as much as they had expected.  This i n d i c a t e s that they had not  a n t i c i p a t e d t h e i r p o s i t i o n o f subordination t o doctors, and that often they were ignored or t r e a t e d impersonally.  Their  d i s l i k e o f head nurses increased, and the suggestion i s that t h i s may have increased f o r the same reason, namely, t h e i r subordination to a u t h o r i t y and punishment i n case o f d e v i a t i o n . Students a t both times were overwhelmingly personoriented instead o f i l l n e s s oriented.  A f t e r p r a c t i c a l contacts,  however, they elaborated t h e i r answers i n some cases t o show that an a b i l i t y to combine the two would be p r e f e r a b l e .  They  were also more human r e l a t i o n s o r i e n t e d than e f f i c i e n c y o r i e n t e d , but a f t e r working i n the h o s p i t a l , they showed a greater d e s i r e to f i n d a balance between the two. These answers i n d i c a t e that t h e i r I d e a l i s t i c view o f nursing values, where the humane approach i s emphasized, i s replaced by a greater c o n s i d e r a t i o n f o r i n s t i t u t i o n a l requirements, such as e f f i c i e n c y , s k i l l , knowledge and a t t e n t i o n to i l l n e s s .  Suggested Typology During the course of t h i s study, I began to n o t i c e emerging s i m i l a r i t i e s and d i s s i m i l a r i t i e s among the studied.  students  I t seemed that c e r t a i n groups, or types of nurses  were i n the process o f emerging i n the r o l e - t a k i n g process. These groups appeared on the b a s i s of a general o r i e n t a t i o n to nursing and i n behaviour.  The i n s u f f i c i e n c y of my data forces  me merely to suggest the existence of a typology and to leave the discovery of i t s exact nature to future research.  I have  c a l l e d my three elementary types "the p r a c t i t i o n e r , " "the t h e o r e t i c i a n " and "the i n d i v i d u a l i s t " ; and I s h a l l r e s o r t to merely a d e s c r i p t i o n of ,each.  The  Practitioner These students see nursing as an end i n i t s e l f ; they  are very i n t e r e s t e d i n what they can do f o r nursing, as opposed to the " t h e o r e t i c i a n s " who  see nursing as a means and whose  main i n t e r e s t i s i n what nursing can do f o r them.  They are  eager to adjust to the i n s t i t u t i o n a l way of l i f e , and place great Importance on the part they play i n the f u n c t i o n o f the hospital.  They also conform more r e a d i l y to the  i n s t i t u t i o n a l i z i n g processes of d e p e r s o n a l i z a t i o n and discipline. They f e e l t h e i r greatest s a t i s f a c t i o n i s i n g i v i n g bedside care, and i n "being able t o help the p a t i e n t . " They  192  refuse t o d i s c r i m i n a t e i n showing personal preferences or d i s l i k e s and o f t e n declare that they l i k e a l l t h e i r p a t i e n t s ; o n l y on probing do they admit t h a t some p a t i e n t s are more pleasant than others.  They accept t h e i r r o l e s as i n s t i t u t i o n a l  scapegoats and do not hear grudges against s u p e r i o r s . I n short, they do not seem t o experience the " r e a l i t y shock" as much as do the other types. Q u a l i t i e s o f motherliness and f e m i n i n i t y are prominent i n t h i s type o f nurse.  They conform to the nursing  values o f s e r v i c e and profess d e d i c a t i o n to t h e i r work.  They  have the sympathy and understanding, which i s o f t e n a t t r i b u t e d to women and which i s r e q u i r e d i n n u r s i n g .  One of t h i s type  commented on a nurse o f the " t h e o r e t i c i a n " type: She»s very masculine . . .I'm s u r p r i s e d she even went i n f o r nursing . . . she would seem t o be more i n place as a t a x i d r i v e r . . . can't you just see her i n a cap w i t h a union badge. They may recognize the drudgery and the monotony of many o f t h e i r t a s k s , but they perform them without complaints. they take on many o f the q u a l i t i e s o f martyrdom.  Thus  In many ways  t h i s type tends to i n t e r n a l i z e nursing values and norms to a greater extent than do the other types.  They r e l y on the  ideology o f an oppressed group and g a i n p r e s t i g e by conforming to the c u l t u r a l l y d e s i r a b l e q u a l i t y o f a l t r u i s m . This typology could he c o r r e l a t e d w i t h the o r i g i n a l o r i e n t a t i o n - t y p o l o g y suggested f o r the students before t h e i r  entry i n t o n u r s i n g .  The hypothesis suggested by the data I  have d o l l e c t e d i s that the p r a c t i t i o n e r c o r r e l a t e s w i t h those students who expressed t h e i r wish f o r nursing, because they believed they were "born a nurse," or were taking on the r o l e i n "mother's image."  The  Theoretician To the t h e o r e t i c i a n , nursing i s a means to something  else.  They are more i n t e r e s t e d i n what nursing can do f o r  them, than i n what they can contribute be seen as f a l l i n g i n t o two sub-types:  as nurses.  They could  l ) the i n d i v i d u a l who  sees the p r a c t i c e o f nursing as a means t o a p r i v a t e end, and 2) the i n d i v i d u a l who sees nursing as a way i n t o the p r o f e s s i o n a l world and therefore i s i n t e r e s t e d i n reforming the occupation and i n e l e v a t i n g i t s s t a t u s . These i n d i v i d u a l s f i t t e d w e l l i n t o the u n i v e r s i t y culture.  Consequently they are not eager t o adapt themselves  to the h o s p i t a l , but rather i n d i c a t e a wish f o r the h o s p i t a l to adapt to them.  They accept residence l i f e and i n c r e a s i n g  i n s t i t u t i o n a l commitments only because they are defined as necessary. Students of t h i s v a r i e t y d i s p l a y a m o t i v a t i o n to l e a r n , to "get ahead" and to become p r o f e s s i o n a l .  They  correspond more to the concept o f the modern emancipated woman, who plays a p r o f e s s i o n a l r o l e i n the occupational  sub-system, who shows i n i t i a t i v e and charisma, and who f e e l s uncomfortable i n a subordinate  role.  They show l i t t l e i n t e r e s t i n bedside care and do not show the same evidence o f d e d i c a t i o n as the " p r a c t i t i o n e r s . They f e e l that they have adequately met t h e i r o b l i g a t i o n s when they have done t h e i r day's work and have done i t competently. However, where the " p r a c t i t i o n e r ' s " i n t e r e s t ends w i t h the day's work, the " t h e o r e t i c i a n " c a r r i e s hers f u r t h e r .  They  tend to be c r i t i c a l o f a l l f a c e t s o f nursing, from l e c t u r e s t o hospital administration.  They d e f i n e many aspects o f nursing  as "menial" and complain about the status-lowering f u n c t i o n of these aspects.  They seek r e c o g n i t i o n and show future  authoritarian t r a i t s .  This suggests t h a t whereas the  " p r a c t i t i o n e r s " are l i a b l e to p l a y the r o l e o f bedside nurses, " t h e o r e t i c i a n s " are l i a b l e to become administrators or supervisors.  On the whole these students seem t o emerge from  groups who gave t h e i r reasons f o r e n t e r i n g nursing as "nursing as a means," or "a way out —  and i n t o nursing."  They do not  conform so much to the t r a d i t i o n a l values o f n u r s i n g , such as the r e q u i r e d sympathy, understanding and d e d i c a t i o n , but show a tendency to he more concerned with p r o f e s s i o n a l values and attitudes.  The I n d i v i d u a l i s t The  " i n d i v i d u a l i s t " i s the deviant and the r e b e l of  the nursing r o l e .  She does not conform to nursing or to  i n s t i t u t i o n a l expectations.  Often i t i s f i r s t  discernible i n  i n i t i a l self-images, i n agreements w i t h adverse p u b l i c images, or as the r e s u l t of excessive demands of the s u b j e c t i o n of the i n d i v i d u a l p e r s o n a l i t y to the occupational group.  As w i t h  many r e b e l s who  oppose a u t h o r i t y , they earn the admiration  of  their fellows.  They openly defy i n s t i t u t i o n a l s u b j e c t i o n  and  d i s c i p l i n e , and r e t a i n t h e i r i n i t i a l i n d i v i d u a l i t y or develop a new type o f i n d i v i d u a l i t y . Their behaviour does not conform to occupational norms or to I n s t i t u t i o n a l requirements.  They are c y n i c a l and  show l i t t l e eagerness to l e a r n or to perform t h e i r t a s k s .  They  are f l i p p a n t w i t h superiors and defy the h o s p i t a l h i e r a r c h i c a l s t r u c t u r e by t a k i n g t h e i r problems to the highest a u t h o r i t y without f o l l o w i n g the p r e s c r i b e d channel.  They do not f e e l  responsible f o r f o s t e r i n g f a v o u r i t e p u b l i c images, and admit t h e i r shortcomings i n the nursing r o l e to o u t s i d e r s . may  They  even accept unfavourable p u b l i c images and so o f t e n they  agree that nurses are "scrubwomen" or that "anyone can be a nurse." not  They admit that the l e a r n i n g of the nursing r o l e i s  difficult.  They want t o do something, they don't want t o get married and they just don't want t o work, because that lowers t h e i r s o c i a l s t a t u s . Just l i k e a person without any s k i l l . A l o t of them don't want to be s e c r e t a r i e s . They don't f e e l they have the b r a i n s o r can't a f f o r d to go to c o l l e g e . So they go i n t o n u r s i n g . That's respected and not too hard, although they l i k e t o make you t h i n k i t ' s hard. You know, "Well, I didn't go to c o l l e g e , but I went through nursing and t h a t ' s hard enough." I t r e a l l y i s n ' t , you know. Thus they v i o l a t e the common norm o f a l l occupational groups where each s o c i a l i z e d member attempts t o maintain the p r e s t i g e and status o f the group. D i v i s i o n i n t o the three types o f " p r a c t i t i o n e r , " " t h e o r e t i c i a n " and " i n d i v i d u a l i s t " does not eradicate the p o s s i b i l i t y that other types also may e x i s t .  This typology  i s merely based on the three d i s t i n c t types o f r o l e - o r i e n t a t i o n that I n o t i c e d to be emerging i n the group studied f o r t h i s thesis.  CHAPTER V I I I PLAYING THE ROLE -- BEING A NURSE  P l a y i n g the r o l e o f a nurse can be understood by asking the question:  what does i t mean to he a nurse?  In  other words, i t i s important to ask what a nurse does, what images are h e l d o f nurses, what i s expected from her, how she i s repaid f o r these expectations, what c o n f l i c t s she has and how she i s r e l a t e d t o others.  One answer l i e s i n analysing  the r o l e by the use o f s p e c i f i c and r e l a t e d v a r i a b l e s .  I  suggested i n Chapter I I that t h i s can be done by the use of five variables:  the images o f the r o l e , the character o f the  o b l i g a t i o n s , the rewards, the s t r a i n s and the r e l a t i o n o f the r o l e to other r o l e s . nature o f these  The meaning o f the r o l e hinges on the  variables.  Therefore when the f u n c t i o n s , the expectations, o r the rewards o f the r o l e change, t h e meaning o f "being a nurse" should also change.  H i s t o r i c a l l y , the r o l e o f a nurse has had  a v a r i e t y o f d i f f e r e n t meanings.  To i l l u s t r a t e t h i s p o i n t ,  some c o n s i d e r a t i o n w i l l be given, on the basis o f my reading and i n f e r e n c e s , to the h i s t o r i c a l development o f nursing before examining the p l a y i n g o f the r o l e a t t h e present time.  The  m a t e r i a l on which t h i s chapter i s based has been c o l l e c t e d through observation, i n t e r v i e w i n g , reading and the r e s u l t i n g interpretations.  198  Nursing through H i s t o r y Those who nursed i n ' . c l a s s i c a l Greece were much d i f f e r e n t from those who nursed i n the eighteenth century, and those who nurse today.  I n Greek times, the i l l took up residence  i n temples and returned t o h e a l t h under r e l i g i o u s i n s t r u c t i o n . Nursing was a r o l e devoted t o s p i r i t u a l w e l l - b e i n g , l i t t l e thought being given t o p h y s i c a l cure.  The next d i s t i n c t i v e  stage was when n u r s i n g became a s s o c i a t e d w i t h C h r i s t i a n monasteries and the C h r i s t i a n v i r t u e s o f c h a r i t y and mercy. For the f i r s t time i n h i s t o r y n u r s i n g became a separate and recognized r o l e , and moreover a r o l e played by women.  Then,  i t was the task o f the wealthy and the a r i s t o c r a t i c , who became nurses i n penance f o r s i n s ; and hence nursing was defined as an unpleasant duty meant to t e s t one's C h r i s t i a n b e l i e f s .  Another  change took place when the i l l l e f t the p r o t e c t i o n o f the m i l i t a r y and r e l i g i o u s orders w i t h which nursing was connected i n medieval times and came i n t o the care o f tax-supported h o s p i t a l s , s t a f f e d by p a i d personnel. Nurses a t t h a t time were e n t i r e l y u n t r a i n e d and many were Inmates o f penal and w e l f a r e institutions.  Then came the wet nurse, the medical discovery  of the eighteenth century, and f o l l o w i n g her, the woman o f Florence N i g h t i n g a l e ' s e r a .  "Every woman i s a n u r s e "  1  wrote  Florence N i g h t i n g a l e , and i t was she who fashioned the  1 Florence N i g h t i n g a l e , Notes on Nursing. New York, Appleton,  i860, p. 3.  199  beginnings o f the s e c u l a r , p r o f e s s i o n a l nurse.  Images o f the Role Through the years, the p u b l i c and s e l f images o f nurses have d i f f e r e d q u i t e markedly.  At f i r s t , a nurse was a r e l i g i o u s  f i g u r e , n u r s i n g p a t i e n t s i n a Greek temple.  The i d e a was that  r e l i g i o u s concepts could be t r a n s m i t t e d , and a t the same time a cure could be e f f e c t e d .  Next, a nurse was a s e l f - s a c r i f i c i n g  nun, o r a devoted monk o f the Middle Ages, considering i t C h r i s t i a n duty t o l i v e a l o w l y l i f e and help the s i c k . a reward i n heaven could be a t t a i n e d .  By t h i s  Nursing tasks were a l s o ,  at one time, sought by those who had t o do penance f o r t h e i r sins.  The drudgery o f such work was considered adequate  punishment f o r inmates from prisons and poorhouses.  At the  next stage, a nurse was the lowest p a i d o f a l l servants, having no t r a i n i n g , or l i k i n g , f o r her work. the  From t h i s , she passed t o  stage where she became the s e l f - s a c r i f i c i n g "lady w i t h the  lamp."  Now she i s considered a p r o f e s s i o n a l person, and  although some o f h e r tasks are s o c i a l l y defined as unpleasant, she i s rewarded by the h i g h p r e s t i g e given t o those who devote t h e i r time t o " s e r v i c e . "  Her self-image has at each stage been  governed by the p u b l i c image.  Therefore i t i s d i f f e r e n t today  from what i t was when nurses were c r i m i n a l s or paupers.  200  Character o f the Obligations The o b l i g a t i o n s o f a nurse have also d i f f e r e d .  They  have been to give r e l i g i o u s teachings, to serve a r e l i g i o u s d e i t y , to seek forgiveness by doing work d i s t a s t e f u l to others, or to earn l i v e l i h o o d i n an occupational c a p a c i t y .  The  tasks  o f a nurse have been to say the appropriate prayers when disease was  a struggle between good and e v i l , to r e s t r a i n a  screaming p a t i e n t w h i l e an eighteenth century surgeon amputated a l e g , or to administer the l a t e s t wonder-drug.  With each t a s k  and w i t h each type o f "nurse," standards, both i n s t i t u t i o n a l and p u b l i c , have been imposed.  I n s t i t u t i o n a l standards must  have d i f f e r e d markedly between the era o f the Protestant Reformation and the twentieth century.  For example, the  former p e r i o d saw a h o s p i t a l i n which one bed was occupied a f e v e r i s h c h i l d , a woman dying from t u b e r c u l o s i s and  by  an  e p i l e p t i c ; the l a t t e r sees such changes as p r i v a t e wards, f o s t e r beds and s t e r i l e , d a z z l i n g l y white operating t h e a t r e s . There i s a d i f f e r e n c e also between the "nurse" who  considered  sickness as an i n d i c a t i o n o f e v i l , and the one who  sees i t as  a normal f u n c t i o n , the a c t i o n o f b a c i l l i on the body.  Rewards To balance o b l i g a t i o n s , there have always been rewards.  The modern nurse i s p a i d , hut at one time the c h i e f  reward was the forgiveness of s i n s , or the knowledge that one  had conformed to the C h r i s t i a n i d e a l of mercy and that the u l t i m a t e reward would be bestowed i n heaven.  Twentieth century  nurses are rewarded by a monetary income, by a r e l a t i v e l y high status among women's occupations,  and by s e c u r i t y .  U n t i l the  time o f Florence N i g h t i n g a l e , nursing status was a matter o f s t r a i n , rather than a reward.  Nurses were paupers, s i n n e r s ,  c r i m i n a l s or servants o f the lowest order.  During monastic  nursing, however, status was higher, but i t i s to be noted that t h i s status accrued as a r e s u l t o f nurses being, p r i m a r i l y , monks or nuns.  As examples o f good C h r i s t i a n l i v i n g and s e l f -  s a c r i f i c e , t h e i r p r e s t i g e was h i g h .  Strains R o l e - p l a y i n g , at any time, cannot be discussed e f f e c t t i v e l y without mention o f s t r a i n s .  The values associated w i t h  the p l a y i n g o f one r o l e could be incompatible w i t h the values associated w i t h the p l a y i n g o f another.  I t "seems that n u r s i n g ,  i n v o l v i n g the care o f the human body, has always been connected with sexuality.  What s t r a i n s t h i s produced i n nurses during  monasticism, during the s e m i - r e l i g i o u s m i l i t a r y p e r i o d when the f u n c t i o n was f u l f i l l e d by the wealthy and the a r i s t o c r a t i c , or p r i o r to the advent o f Florence N i g h t i n g a l e , can only be speculated.  C e r t a i n l y , student nurses experience  conflicts  when they are forced to overcome those i n h i b i t i o n s about the body which they have adopted as members o f our s o c i e t y . s t r a i n s , o f course, occur and are o f t e n more p r e s s i n g .  Other They  are, however, too numerous to be mentioned here.  R e l a t i o n to Others The f i f t h v a r i a b l e —  r e l a t i o n s h i p to other r o l e s  i s also too v a r i e d to be f o l l o w e d t o i t s l i m i t s .  —  Perhaps i t  should s u f f i c e to speculate on the r e l a t i o n s h i p o f the "nurse" to the p a t i e n t .  He has been d e f i n e d , i n t u r n , as an e v i l  i n d i v i d u a l , i n league w i t h the d e v i l and consequently i n need of s p i r i t u a l guidance; as an instrument upon which one could work i n order t o have one's s i n s f o r g i v e n ; and as an unfortunate to be cured. Thus, the p l a y i n g o f the n u r s i n g r o l e has changed through h i s t o r y .  This change can be c l e a r l y described by the  use of the f i v e - v a r i a b l e system, f o r the meaning of the r o l e depends on the meaning and nature of the chosen v a r i a b l e s . The same a n a l y t i c a l f ramework w i l l be used to look at the nurse,' as she plays her r o l e today.  As nurses o f d i f f e r e n t c u l t u r e s  perform d i f f e r e n t r o l e s , t h i s i n v e s t i g a t i o n i n t o the r o l e s h a l l be r e s t r i c t e d to n u r s i n g In Anglo-American  c u l t u r e , and to  nurses encountered during the course of t h i s study. Role-playing i n f e r s , on the whole, that a r o l e has been "taken," and should, t h e r e f o r e , concern i t s e l f w i t h graduate nurses.  On the other  hand, i n n u r s i n g , students are taught by an i n - s e r v i c e t r a i n i n g method.  Therefore, they l e a r n and "take on" t h e i r r o l e , by  seeing i t played, and by p l a y i n g i t themselves.  The m a t e r i a l  used i n t h i s chapter, t h e r e f o r e , s h a l l come from three  sources:  1) from q u a n t i t a t i v e and q u a l i t a t i v e information c o l l e c t e d from the c l a s s of student nurses studied; 2) from p a r t i c i p a t i o n w i t h and observation of graduate nurses made during f i e l d work; and 3) from speculations and impressions derived from reading and from my own  experiences.  1.  Images of the Role  The images h e l d of a s i n g l e r o l e can be numerous. The nature o f each image depends on the group or i n d i v i d u a l by whom i t i s h e l d .  So as not to go too f a r i n t o the realm  of s p e c u l a t i o n , t h i s t h e s i s s h a l l focus on o n l y two Images of the nursing r o l e —  that h e l d by the p u b l i c , w i t h a l l i t s  d i v e r s i t y , and that held by the occupational group and by the nurse h e r s e l f . I suggest that the p u b l i c sees nurses, to some extent, i n terms of how others to see i t .  the nursing group sees i t s e l f and wishes  S i m i l a r l y the nursing group forms conceptions  p a r t l y on the b a s i s o f the p u b l i c image, whether i t be to adopt p u b l i c views, or to c o r r e c t them.  P u b l i c Images P u b l i c images of the nursing r o l e are numerous and often c o n f l i c t i n g .  They could be described as stereotypes,  o b j e c t i v e l y communicated by mass media.  Once possessed by the  p u b l i c , they f u n c t i o n to form the a t t i t u d e s h e l d towards nurses,  204  and consequently p l a y a major r o l e i n m o t i v a t i n g some i n d i v i d u a l s to become nurses, or not to become nurses, whatever the case may be.  I t i s important to note, however,  that a l l images are not c u l t u r a l l y defined, but are based to some extent on i n t e r a c t i o n w i t h nurses.  These, i n t h e i r t u r n ,  could he t r a n s m i t t e d and become p u b l i c images.  Thus a l l images,  at t h e i r beginning stage, are constructed on the b a s i s of i n t e r a c t i o n w i t h the r o l e of the nurse. P u b l i c images, i t has been shown, are dependent on > such f a c t o r s as age, sex and socio-economic s t a t u s .  For example,  lower status i n d i v i d u a l s have a more favourable o p i n i o n of 2  nurses than do i n d i v i d u a l s i n a higher socio-economic bracket. S i m i l a r l y , they can be expected to vary between p a t i e n t s and farmers, between doctors and lawyers, between high school students and u n i v e r s i t y students. I n recent times I have observed a greater concentration on the medical s u b - c u l t u r e . One index of t h i s i s the nature of the mass media which has made i t s appearance i n recent times. Paper-hack l i t e r a t u r e on doctors and nurses i s f l o o d i n g the stands and the needs o f the p u b l i c are catered to by the p r o v i s i o n o f separate stands f o r "medical f i c t i o n . "  The past  few years have seen many s t o r i e s on s u c c e s s f u l nurses, devoted 2 Community Studies Inc., P u b l i c Images of the Nurse. Part I I , A Study of the Registered Nurse i n a M e t r o p o l i t a n Community, Kansas C i t y , M i s s o u r i , 1955, p. 71.  to duty, misunderstood by crabby s u p e r i o r s ; they always manage, however, "to get t h e i r man."  T i t l e s such as Nurses are People  and Doctors are D i f f e r e n t attempt to c l a r i f y t h i s sub-culture f o r the p u b l i c . Movies and t e l e v i s i o n f o l l o w the same p a t t e r n . Whatever the explanation f o r t h i s concentration may  be,  o b j e c t i v e data points to i n c r e a s i n g i n t e r e s t i n medical r o l e s and values.  <  Despite t h i s type of mass media, which may reach only a c e r t a i n type of i n d i v i d u a l , s e v e r a l types of p u b l i c images predominate:  The M i n i s t e r i n g Army of Florence Nightingale You know, the g i r l i n white, the m i n i s t e r i n g angel, that k i n d o f t h i n g . At l e a s t i t was w i t h me anyway.  I t h i n k people very h i g h l y regard nurses. Any time you say to them "Well, I'm i n n u r s i n g , " they're t h r i l l e d . They t h i n k i t ' s the most wonderful t h i n g a g i r l can do. I guess they've a l l had a l i t t l e experience w i t h a nurse and most nurses are very n i c e . Don't you t h i n k they are a nice group to t a l k to? And they t h i n k that nurses do a l o t of good, and they do. The above quotations, from the subjects interviewed, speak f o r themselves i n showing the nursing perspective on a p a r t i c u l a r . p u b l i c image.  I t i s an image which has i t s genesis  i n the V i c t o r i a n era and the a s p i r a t i o n s of Florence N i g h t i n g a l e to e s t a b l i s h a s e c u l a r , p r o f e s s i o n a l nursing r o l e f o r women.  I t has two phases:  t h e concept o f V i c t o r i a n womanhood as  g e n t l e , withdrawn and obedient; and the d r i v e by women f o r emancipation  and p r o f e s s i o n a l r e c o g n i t i o n . These two are  somewhat c o n t r a d i c t o r y . One shows woman as being passive and content t o remain i n a subordinate p o s i t i o n , w h i l e the other shows her as a g g r e s s i v e l y a g i t a t i n g f o r e q u a l i t y w i t h men. One part o f the image endows the nurse w i t h a l l the d e s i r a b l e q u a l i t i e s o f the V i c t o r i a n woman — patience, v i r t u e and charity.  She i s i n a subservient p o s i t i o n and i s the one to  perform the l o w l i e r tasks o f h e l p i n g the s i c k . but a l s o k i n d and understanding.  She i s strong,  She professes i d e a l s o f  s e r v i c e and a l t r u i s m . Florence Nightingale claims that every V i c t o r i a n woman would make a nurse.  This connection o f women,  and a l l t h e i r V i c t o r i a n q u a l i t i e s , w i t h the s i c k has p e r s i s t e d and may account, i n p a r t , f o r the d e f i n i t i o n o f nursing as a woman's occupation.  Furthermore, h e r subordinate p o s i t i o n i n  the s o c i e t y o f the day made her i d e a l l y s u i t e d to the h o s p i t a l s i t u a t i o n where the p h y s i c i a n was i n a p o s i t i o n o f a u t h o r i t y . There i s another side t o the p i c t u r e o f the nineteenth century. Nursing began t o be taught as a v o c a t i o n . demands f o r emancipation  This was followed by  and p r o f e s s i o n a l status f o r women.  I n c r e a s i n g l y greater emphasis was placed on f a c t o r s such as e f f i c i e n c y , independence and i n t e l l i g e n c e . Therefore, when nurses are r e f e r r e d t o as " l a d i e s w i t h the lamp" o r " m i n i s t e r i n g angels," the image i s t w o f o l d . I t  207  sees women as ranging from the " e f f i c i e n t and brusque" to "kind and sympathetic."  I n one instance they are emancipated  women w i t h desires to be the equals o f men,  and i n another they  are V i c t o r i a n women w i t h t h e i r w e l l - d e f i n e d c h a r a c t e r i s t i c s . Both parts o f the image are i n v o l v e d i n " l a d i e s w i t h the lamp" and the f o l l o w e r s o f Florence N i g h t i n g a l e .  Although they seem  c o n t r a d i c t o r y aspects w i t h i n the same image, both are  considered  as q u a l i t i e s o f a good nurse.  Nurses, Waitresses and Housewives —  Scrubwomen?  I wish I could have a job where I could get as much out o f nursing without doing a l l those menial things -- cleaning t h i s and cleaning that and doing the other.  Men would t h i n k the reward f o r nursing was a sore back. They would do a l o t o f complaining. They wouldn't f i n d anything much i n i t . This image o f nursing i s also prevalent.  As an  example o f how t h i s image i s transmitted, the f o l l o w i n g shows how  such a t t i t u d e s could become p u b l i c knowledge.  A daily  newspaper c a r r i e d an advertisement f o r a c l i n i c shoe, which was recommended as "A new s e r v i c e . . . a new comfort . . . f o r Nurses, Waitresses and Housewives."  This i m p l i e s that those  three r o l e s were s i m i l a r , i n that each r e q u i r e d the same equipment t o c a r r y out t h e i r t a s k s .  This i s a s u r v i v a l from  the V i c t o r i a n era where the work o f women was associated w i t h  menial tasks of a lower order.  Such a p u b l i c image as t h i s ,  undoubtedly, leads to a low occupational status and a disadvantage  i n any desire f o r p r o f e s s i o n a l s t a t u s .  Such an image compares to the previous image o n l y i n as f a r as the tasks are concerned.  The only d i f f e r e n c e I s  t h a t , although both d e p i c t t r a d i t i o n a l V i c t o r i a n women, t h i s l a t t e r Image gives them a low s t a t u s . Women of the V i c t o r i a n era enjoyed a high status as "women," although t h e i r work was of a l o w l y order.  This l a t t e r image sees nurses as c a r r y i n g  out the tasks of V i c t o r i a n women, but afforded the status given to such tasks i n present day s o c i e t y . They l a c k the "sacred" context, which was,  and i s , given to the f o l l o w e r s  of Florence N i g h t i n g a l e .  Hard Workers, Non-Drinkers and Puritans I t h i n k the Ideas have come from, you know, nurses are a l l t h i s or a l l t h a t . They expect a l l nurses to he . . . because i n the o l d days they were. I don't want them to be P u r i t a n s , mind you, but I don't l i k e them to go out d r i n k i n g and beering, and a l l t h a t , I don't t h i n k that i s part of nursing.  They t h i n k that nurses work hard, they've probably seen them. Nurses aren't allowed to s i t down by the p a t i e n t ' s bedside when on duty. You do an awful l o t of walking. These statements by student nurses show the existence of a P u r i t a n philosophy.  The d e f i n i t i o n o f t e n given to the  term "Puritanism" tends to m i s i n t e r p r e t the meaning o f the philosophy.  They are seen as being non-hedonistic, p l a i n ,  and i n ways, dogmatic, pedantic and narrow-minded.  To have  P u r i t a n i d e a l s i s not considered as e n t i r e l y d e s i r a b l e .  In  r e a l i t y , however, although the Puritans valued s i m p l i c i t y , the d i g n i t y of hard work and t h r i f t , they surpassed philosophies i n t h e i r humanism and l o g i c .  other  They b e l i e v e d that  man was b a s i c a l l y a r a t i o n a l and responsible creature.  Man  was the master, woman merely h i s h e l p e r ; they had no b e l i e f i n the e q u a l i t y of men.  Heavy d r i n k i n g , dancing, s l o t h and  "wasting time" were considered the u l t i m a t e i n s i n .  Their  h i s t o r y i n the New World i s marked w i t h t a l e s of hardship lack of luxuries.  and  The i n d i v i d u a l could indulge i n l u x u r y and  l e i s u r e only i f t h i s indulgence could be j u s t i f i e d i n terms of 3  the dominant values o f the philosophy. This p u b l i c image sees nurses as conforming to the P u r i t a n r e l i g i o u s philosophy.  C e r t a i n l y P u r i t a n i d e a l s are  dominant i n North American c u l t u r e , and i t s values are s t r o n g l y supported i n the nursing p r o f e s s i o n .  Florence N i g h t i n g a l e ,  h e r s e l f , despite her wish to reform and elevate the l o t of women, declares t h a t nurses should pay l i t t l e heed to g e t t i n g ahead status-wise and to g a i n i n g e q u a l i t y w i t h men. leave these jargons, and go your way  ". . . Oh,  s t r a i g h t to God's work,  3 Perry M i l l e r and Thomas H. Johnson, The P u r i t a n s . New American Book Co., 1 9 3 8 .  York,  i n s i m p l i c i t y and singleness o f heart."'  Women w i t h "Loose Morals"? I get so fed up w i t h people saying "Oh, nurses know everything'." o r "Oh, you can t e l l a nurse a d i r t y j o k e l " I t just makes me so mad. And the a t t i t u d e s o f the boys i n the same way: "Oh, you're going t o be a nurse, I can t e l l you t h i s l " Well I don't t h i n k t h a t ' s r i g h t at a l l . '"You shouldn't get embarrassed — you're a nurse." Every time anyone says t h a t , I f l a r e up. My own f a t h e r even has s a i d t h a t . When nursing l e f t the realm o f the monastery and nunnery, where i t was c a r r i e d out by i n d i v i d u a l s who played r o l e s c h a r a c t e r i z e d by a d i s i n t e r e s t i n s e x u a l i t y , i t became the occupation o f young, unmarried women. S o c i a l norms define a t t i t u d e s towards the body and towards s e x u a l i t y .  These women  i n the normal process o f s o c i a l i z a t i o n acquire the s o c i a l norms. Hence they l e a r n that s e x u a l i t y and p a r t s o f the body and i t s functions remain unknown and undiscussed.  One o f the f i r s t  requirements Imposed by the nursing r o l e I s t o unlearn these s o c i a l norms.  A new set o f norms, which encourage knowledge  of the body and o f i t s f u n c t i o n s , i s taught and adopted. C o n f l i c t s undoubtedly a r i s e .  This could be seen when the  subjects o f t h i s study had d i f f i c u l t i e s  early i n their training  l|. N i g h t i n g a l e , Notes on Nursing, p. 1 3 6 .  i n bathing and tending to male p a t i e n t s . The p u b l i c , however, i s not aware that s o c i a l norms are unlearned, o r i f not replaced by nursing norms, at l e a s t d i s s o c i a t e d and d i f f e r e n t i a t e d from them.  The tendency i s to  associate knowledge o f the body w i t h s e x u a l i t y .  This  i n t e r p r e t a t i o n I s made i n terms o f s o c i a l norms which imply that knowledge o f the body i s synonymous w i t h sexual promiscuity. Hence a p u b l i c image, which tends to regard nurses as women w i t h "loose morals,"  Occupational  arises.  Self-image  Some o f the above quotations have given an i n d i c a t i o n of nurses' a t t i t u d e s towards the various p u b l i c images.  These  r e a c t i o n s , together w i t h a d e s i r e to conform to c u l t u r a l v a l u e s , such as a l t r u i s m and humanitarianism, images.  determine nursing s e l f -  Values such as a l t r u i s m , ' s e r v i c e and b r o t h e r l y l o v e ,  on the one hand, and independence, i n i t i a t i v e and p r o f e s s i o n a l i s m on the other, p l a y important parts i n these Images.  Public  Images are defined as e i t h e r "good" o r "bad," and an attempt i s made to correct them.  Thus the view o f nurses as " m i n i s t e r i n g  angels" i s good, w h i l e the image o f nurses as "women w i t h loose morals" i s bad.  The image h e l d out t o nurses by the occupational  group would promote the f i r s t and t r y t o i n f l u e n c e a c o r r e c t i o n of the second.  212  Occupational images, t h e r e f o r e , i n c l u d e c u l t u r a l and i n s t i t u t i o n a l expectations.  The values of s o c i e t y and the  medical sub-culture are a large p a r t of the image. of b e l i e f s , i d e a l s and myths.  I t i s a set  Appropriate behaviour, i n s i d e and  outside of the sub-culture, i s defined by e t h i c s , and i s supported by myths of achievements and success. view of the values o f the group.  I t i s an i d e a l  As such i t does, to a c e r t a i n  extent, ignore r e a l i t y , although i t i s based on the r e a l i t y of what i s expected and what nurses are able to do.  Nurses are  committed to these values and t h e i r behaviour i s regulated by them.  Thus nurses are expected not to frequent beer-parlours,  nor to conduct themselves  i n an u n p r o f e s s i o n a l manner.  Occupational images manifest themselves i n defined standards and codes of e t h i c s . an " i d e a l nurse."  Adoption of these e t h i c s makes  A look at the I n t e r n a t i o n a l Code o f Nursing  E t h i c s shows the o b l i g a t i o n s o f every nurse: 1.  The fundamental r e s p o n s i b i l i t y o f the nurse i s t h r e e f o l d : to conserve l i f e , to a l l e v i a t e s u f f e r i n g and to promote h e a l t h .  2.  The nurse must maintain at a l l times the highest standards of nursing care and o f p r o f e s s i o n a l conduct.  3.  The nurse must not only be w e l l prepared to p r a c t i s e but must maintain her knowledge and s k i l l at a c o n s i s t e n t l y high l e v e l .  Ii.  The r e l i g i o u s b e l i e f s of a p a t i e n t must be respected.  5.  Nurses hold i n confidence a l l personal information entrusted to them.  213  6.  A nurse recognizes not o n l y the r e s p o n s i b i l i t i e s but the l i m i t a t i o n s o f her or h i s p r o f e s s i o n a l f u n c t i o n s ; recommends or gives medical treatment without medical orders o n l y i n emergencies and r e p o r t s such a c t i o n t o a p h y s i c i a n at the e a r l i e s t p o s s i b l e moment.  7.  The nurse i s under an o b l i g a t i o n t o c a r r y out the physician's orders i n t e l l i g e n t l y and l o y a l l y and to refuse to p a r t i c i p a t e i n u n e t h i c a l procedures.  8.  The nurse sustains confidence i n the p h y s i c i a n and other members of the h e a l t h team; incompetence and u n e t h i c a l conduct o f associates should be exposed but only t o the proper a u t h o r i t y .  9.  A nurse i s e n t i t l e d t o just remuneration and accepts only such compensation as the c o n t r a c t , a c t u a l or i m p l i e d , provides.  1G.  Nurses do not permit t h e i r names t o be used i n connection w i t h t h e advertisement o f products o r w i t h any other forms o f s e l f advertisement.  11.  The nurse co-operates w i t h and maintains harmonious r e l a t i o n s h i p s w i t h members o f other professions and w i t h her nursing colleagues.  12.  The nurse i n p r i v a t e l i f e adheres t o standards of personal e t h i c s which r e f l e c t c r e d i t upon the p r o f e s s i o n .  13.  I n personal conduct nurses should not knowingly d i s r e g a r d the accepted patterns of behaviour o f the community i n which they l i v e and work.  li+.  A nurse should p a r t i c i p a t e and share r e s p o n s i b i l i t y w i t h other c i t i z e n s and other h e a l t h professions i n promoting e f f o r t s to meet t h e h e a l t h needs o f the p u b l i c -- l o c a l , s t a t e , n a t i o n a l and i n t e r n a t i o n a l .  Conformity to these standards makes an " i d e a l nurse" and a l l nurses are expected to aspire to t h i s .  I t i s an occupational  expectation, which i n time becomes a s e l f - e x p e c t a t i o n .  Thus  a nurse cannot go i n t o a beer p a r l o u r without a sense of discomfort and a hope that she i s not ;  .  detected.  E t h i c s serve many f u n c t i o n s .  the appropriate behaviour  and a t t i t u d e .  M a n i f e s t l y , t h e y define They are part of the  "expressive" knowledge that a nurse i s expected to master. L a t e n t l y , however, they i n t e g r a t e the members of the occupational group, g i v i n g them a sense o f "we," o u t s i d e r s , who  as opposed to  do not have the same system of e t h i c s .  The  consistency o f the nursing sub-culture i s maintained by having the appropriate standards t r a n s m i t t e d to a l l members.  They  serve to d e f i n e nurses as p r o f e s s i o n a l selves i n that they emphasize such p r o f e s s i o n a l q u a l i t i e s as trustworthiness and competence.  confidence,  This enables nursing to be  grouped w i t h the p r o f e s s i o n a l occupational group, g i v i n g i t higher s t a t u s .  Above a l l , nursing e t h i c s f u n c t i o n to c o r r e c t  p u b l i c images and to f o s t e r the p u b l i c image that the nursing group d e s i r e s . The p u b l i c can then see nurses as trustworthy, p r o f e s s i o n a l selves w i t h a s t r i c t set of e t h i c s , which prevents them from being "women with loose morals" or "scrubwomen." The occupational Image and the p u b l i c image combine to form the self-image of nurses.  On the whole, adverse p u b l i c  images are considered by nurses to be the r e s u l t s o f  incomplete  knowledge o f the nursing r o l e , or a lack of experience w i t h the work and r e s p o n s i b i l i t i e s of nurses. considered u n j u s t .  Nurses who  I n b r i e f , they are  are o v e r l y influenced by adverse  p u b l i c images are not conforming to occupational Hence nurses who  expectations.  l i k e n t h e i r r o l e to that of scrubwomen or  waitresses are considered deviants.  They are members of the  group whose a t t i t u d e s are l i a b l e to d i s t o r t the p i c t u r e that nurses d e s i r e to present to o u t s i d e r s .  2.  Character  of Obligations  The o b l i g a t i o n s o f a nurse r e f e r to what she must do and how  she must do i t .  They are concerned w i t h tasks that  have to be performed and standards that govern these performances.  The Tasks Nurses perform a v a r i e t y of t a s k s .  They range from  measuring and administering the r i g h t medication to making sure that the d i e t k i t c h e n does not put gravy on Mr. Smith's potatoes.  I t i n v o l v e s t u r n i n g a cheerful face and a pleasant  "good morning" to a l l the p a t i e n t s i n the ward and l i s t e n i n g to Mr. Brown's m a r i t a l problems.  Among t h i s multitude  of  d i f f e r e n t o b l i g a t i o n s , there are two d i s t i n c t aspects to her work:  that d e a l i n g w i t h impersonal t a s k s , and that dealing  w i t h personal t a s k s .  These i n v o l v e the two sides of a nurse's  o b l i g a t i o n s , the t e c h n i c a l side and the personal s i d e .  The Impersonal Tasks P h y s i c a l l y the nurse performs c e r t a i n s k i l l s .  She  handles the instruments i n an operating t h e a t r e , she prepares f o r the surgeon and she cleans up a f t e r him.  On the wards she  washes p a t i e n t s , gives them enemas, hypodermics, medications and food.  She does s k i n preps and makes beds.  bed pans i n and out.  She  carries  She marks f l u i d intake and output.  She  notes the r e g u l a r i t y and the nature o f bowel movements. deciphers d o c t o r s  1  orders and makes nursing notes.  The  She colour  of a p a t i e n t ' s s k i n , h i s sleeplessness and r e s t l e s s n e s s , h i s p a i n and h i s l o s s of appetite observant glance.  none of these escape her  Chocolates and confectionery are taken from  a d i a b e t i c p a t i e n t , and a l l d i e t s are checked. f o s t e r bed and does a wound i r r i g a t i o n .  She turns the  The flow o f an  intravenous, or the r e s p i r a t i o n o f a dying p a t i e n t , are constantly checked. window.  She answers the l i g h t and closes the  A sudden haemorrhage or asphyxiation, and  immediately  summons the i n t e r n and the oxygen t e n t .  she She keeps  the clean apparatus clean, and the s t e r i l e apparatus s t e r i l e . She re-makes a s o i l e d bed.  She gives g a s t r i c gavages and  lavages, wet and dry dressings. discharged.  Patients are admitted  and  Temperature, pulse and r e s p i r a t i o n rates are taken  p e r i o d i c a l l y and recorded.  She keeps the s e r v i c e room supplied  and i n order, and places p a r s l e y and gravy on p a t i e n t s ' p l a t e s i n the k i t c h e n .  She c o l l e c t s specimens and counts drugs.  Charting, treatments, medications  and ward t i d i n e s s are a l l her  217  responsibility.  She runs messages or supervises the ward.  A l l these tasks she performs i n the impersonal aspect o f her work. A nurse's impersonal tasks could be seen i n the l i g h t o f Parsons'  "pattern v a r i a b l e s . " Her behaviour  i n these  instances i s a f f e c t i v e l y - n e u t r a l , i n that her r e l a t i o n s h i p to her p a t i e n t during the performance of these tasks i s unemotional and formal.  I t i s u n i v e r s a l i s t i c , i n that the techniques  are  administered t o the p a t i e n t because o f h i s r o l e as p a t i e n t , independent of any other r o l e s he may p l a y .  Her r o l e i s a l s o  c h a r a c t e r i z e d by a s p e c i f i c i t y of f u n c t i o n . The area o f these impersonal tasks Is w e l l - d e f i n e d .  She cannot perform any  functions normally a l l o t t e d to the doctor, nor does she do the work of other personnel.  She deals w i t h the p a t i e n t , only i n  so f a r as h i s i l l n e s s i s concerned, and she, as a nurse, help  can  him. These tasks are u s u a l l y of the r o u t i n e v a r i e t y , dealing  w i t h b a s i c techniques, household duties and r o u t i n e care of the body. When s p e c i a l treatment  i s r e q u i r e d , the impersonal  tasks  take on a more personal f l a v o u r .  The Personal Tasks There i s also the human r e l a t i o n s aspect of the nurse's work.  She l i s t e n s to the p a t i e n t ' s t r o u b l e s , whatever  t h e i r nature.  She consoles him before he i s wheeled to the  operating t h e a t r e .  She gives him encouragement before he  receives h i s a n a e s t h e t i c . labour.  She holds the hand of a mother i n  She stops to t a l k to the immigrant, i s o l a t e d because  o f language d i f f i c u l t i e s .  She remembers that Mrs. Brown should  be moved t o another ward so as to be away from Mrs.  Jones.  The explanations and reassurances f a l l to her l o t .  She has a  smile f o r v i s i t o r s , a pleasant cooperation f o r doctors and a sympathetic ear f o r the woes of other nurses. and ward aides expect h e l p from her and get i t .  Student  nurses  She l i s t e n s  to p a t i e n t s on matters o f t h e i r i l l n e s s , f i n a n c e s , broken love a f f a i r s or hobbies.  She takes time to go to the candy counter  to buy a chocolate bar f o r a p a t i e n t . She arranges the flowers i n just the way that p a t i e n t s w i s h . v i s i t o r s by name.  She knows and greets  I n general, she shows that there i s a  personal side to her work. In t h i s aspect o f her work, the nurse as a " p r o f e s s i o n a l s e l f " f a l l s i n t o the background, and the nurse as a "person" takes over.  She does not concentrate so much on  the I l l n e s s , as on the p a t i e n t h i m s e l f . Her o b l i g a t i o n s are a f f e c t i v e , p a r t i c u l a r i s t i c and d i f f u s e .  She considers the  p a t i e n t and. t h i n k s of him i n terms of h i s p a r t i c u l a r c h a r a c t e r i s t i c s and defines him i n terms of her own a t t i t u d e s towards him, and not i n terms o f h i s being a p a t i e n t .  The  boundaries to the tasks she can perform i n t h i s area are not defined, and she can be c a l l e d on to perform a l a r g e v a r i e t y of tasks.  The Nursing D e f i n i t i o n of Work We were t a l k i n g about n u r s i n g , you know, about what to do f o r our p a t i e n t s , or something. And she saw us standing there and she came running down: "Nurses, nurses, what are you doing?" And then she s a i d , "Look here, I've got a few t h i n g s f o r you to do." Well she sent me counting bed pans, and she sent someone else doing p i d d l y l i t t l e things . . . I don't know what she expected me to f i n d . Miss Brown t o l d us so many times, "Now whatever you do, always look busy, whatever you do."  I would l i k e to do away w i t h a l o t o f the people that run around too much without doing anything . . . I l i k e to see a l l o f them r e a l l y doing the work . . . I don't know, they rush so much and everything's just a b i g . . . baloney. Nursing i s a r o l e c h a r a c t e r i z e d by a c t i o n .  The  p r e v a i l i n g a t t i t u d e i s t h a t constant motion s i g n i f i e s work. As the above quotations i n d i c a t e , unceasing a c t i v i t y seems t o be valued more f o r the e f f o r t i n v o l v e d , than f o r any ends that i t may serve.  At such times i t f u n c t i o n s only as a means.  A side-product of t h i s i s that such e f f o r t l o s e s the p s y c h o l o g i c a l reward that i s experienced when an a c t i v i t y i s followed to i t s c o n c l u s i o n . Nurses f e e l that they should c o n s t a n t l y be i n motion. This i s a m i d d l e - c l a s s , P u r i t a n d e f i n i t i o n of work.  They must  be doing something w i t h t h e i r hands, whether i t i s dressing a wound, or t i d y i n g the medicine cabinet. Thus when without work, they "make work."  In t h i s way they escape the  s c r u t i n i z i n g eye o f t h e i r superior, who evaluates them i n terms of t h e i r a c t i v i t y , apparent or r e a l .  They rush b u s i l y down the  h a l l , go i n t o the service room, but have nothing t o do there. They t u r n the pages o f a p a t i e n t ' s chart, w i t h a worried frown on t h e i r faces, but they are not l o o k i n g f o r any m a t e r i a l . They t i d y the medicine cabinet f o r the second time.  Under no  conditions do they "just s i t , " when there i s no work to do. The other side o f t h i s i s when the nurse has too much to do. She rushes around w i t h the knowledge o f a dozen tasks yet to be f u l f i l l e d .  She hunts f o r l i n e n on another ward,  because her own ward does not have the rubber draw sheet that she r e q u i r e s to remake a bed.  At the same time she reminds  h e r s e l f that she must shut the window i n the end room, that Mrs. Jones requires a bedpan, that the l i g h t i n one room was on, that the head nurse had asked her to go on a message t o the c e n t r a l supply room, that a dressing has t o be changed on another p a t i e n t , that there i s some charting that she must f i n i s h and a c l i n i c she should attend and that her coffee time has passed.  This i n many instances i s the nature o f "work" f o r  nurses.  The Standards Not only i s the nurse o b l i g e d to do these tasks, she i s obliged t o do them i n a c e r t a i n manner.  A minimum  l e v e l o f competence i s r e q u i r e d i n every task; i f a nurse works  below t h i s l e v e l , s o c i a l c o n t r o l operates to force her to r e t u r n to the required standards.  So i f a nurse i s u n t i d y i n  her work, the head nurse may point t h i s out to her and  imply  that she should correct her work h a b i t s . The  standards r e q u i r e d of a nurse are o b j e c t i v e l y  l i s t e d on a Nursing Student E v a l u a t i o n Report.  Each student,  on l e a v i n g a ward, i s evaluated on t h i s report by the head nurse, who  s u b j e c t i v e l y estimates her a b i l i t y to perform tasks  according to the r e q u i r e d standards.  Any i n a b i l i t i e s  and  mistakes are pointed out, and t h i s implies that the student i s now under an o b l i g a t i o n to correct and improve.  For Impersonal Tasks The impersonal tasks are measured and evaluated under the f o l l o w i n g headings:  performance of nursing d u t i e s ;  recording; r e s p o n s i b i l i t y f o r m a t e r i a l s - equipment and environment; a p p l i c a t i o n of the knowledge of nursing p r i n c i p l e s ; dependability; and personal appearance.  Under each heading the  evaluator i s given f i v e p o s s i b l e choices, one o f which has to be i n d i c a t e d .  Thus, under performance of nursing d u t i e s , the  head nurse can choose:  1) discharges  assigned duties adequately  i n a reasonable time, d i s p l a y s c o n s i d e r a t i o n f o r the p a t i e n t , 2) i n e f f e c t u a l i n the performance of assigned d u t i e s , 3) a s k i l l e d performer, accomplishing  her work q u i c k l y and w i t h  f i n i s h , d i s p l a y s c o n s i d e r a t i o n f o r the p a t i e n t , I4.) discharges assigned duties w e l l , shows i n s u f f i c i e n t concern f o r the  222  p a t i e n t , o r , i s careless i n c a r r y i n g out assigned d u t i e s , but i s considerate o f the p a t i e n t , 5) accomplishes q u i c k l y and thoroughly patient.  assigned duties d i s p l a y i n g c o n s i d e r a t i o n f o r the Before asked to evaluate on t h i s s c a l e , the head  nurse i s reminded o f the r e q u i r e d standard:  "A nurse when  assigned r e s p o n s i b i l i t i e s f o r ward r o u t i n e should be capable of c a r r y i n g these out n e a t l y , a c c u r a t e l y and w i t h despatch, conscious always that these a c t i v i t i e s are f o r the p a t i e n t ' s welfare."  I n the other items to be evaluated, a nurse i s  expected to record a c c u r a t e l y , completely, n e a t l y and c o n c i s e l y ; she i s to avoid waste by developing  a consciousness f o r the cost  of m a t e r i a l and how much i s needed f o r adequate nursing  care;  she must have thorough knowledge o f medical and nursing p r i n c i p l e s behind her procedures; she must be conscientious i n performing the duties assigned t o her; she must appear w e l l groomed, have good posture and be dressed c l e a n l y and n e a t l y .  For Personal Tasks The tasks that I have termed "personal" are also evaluated.  To quote from the evaluation sheet:  Teaching A b i l i t y : A nurse should he able to teach p a t i e n t s , r e l a t i v e s and her co-workers through personal example, by i n s t r u c t i o n and demonstration w i t h i n the l i m i t s of her education and experience . . . A t t i t u d e Towards her Work: A sustained and growing i n t e r e s t i n a l l aspects of n u r s i n g care i s e s s e n t i a l i n the development of a nurse . . . Response to Supervision: A f r i e n d l y , r e s p e c t f u l r e l a t i o n s h i p should e x i s t between the nurse and her s u p e r i o r s . This l a r g e l y determines the nurse's a b i l i t y to co-operate, to accept c o n s t r u c t i v e c r i t i c i s m , and to b e n e f i t from the i n s t r u c t i o n given . Executive A b i l i t y : Executive a b i l i t y measures the s k i l l i n l e a d e r s h i p of the nurse i n d i r e c t i n g the work o f others, and assuming commensurate r e s p o n s i b i l i t y . . . R e l a t i o n s h i p to the P a t i e n t : This r e f e r s to the nurses' s k i l l i n e s t a b l i s h i n g rapport w i t h the p a t i e n t so he w i l l develop confidence i n the nurse and her a b i l i t y to meet h i s needs . . . Inter-Personal R e l a t i o n s : This f a c t o r measures the success w i t h which the nurse e s t a b l i s h e s h e r s e l f among those w i t h whom she comes i n contact . . . Poise and Self-Confidence: I t i s e s s e n t i a l that a good nurse be emotionally s t a b l e and able to adjust to a l l s i t u a t i o n s i n such a way that her responses tend to remove or reduce tension. The standards of a nurse's work are c l e a r l y defined by the nursing group and by the medical sub-culture.  They f u n c t i o n to  maintain the s t r u c t u r e of the sub-culture and the purpose o f the h o s p i t a l .  Besides the primary goal of tending to the  welfare of p a t i e n t s , nurses have the secondary goal of tending to this welfare i n the manner p r e s c r i b e d . They s t r i v e f o r both goals. Boundaries of her O b l i g a t i o n s The functions of a l l r o l e s could he seen as l i m i t e d by boundaries.  These come i n t o being through i n t e r a c t i o n w i t h  other r o l e s and are e i t h e r w e l l - d e f i n e d o r i l l - d e f i n e d , depending on the type o f f u n c t i o n and the r o l e s w i t h which i t i s i n i n t e r action.  W i t h i n the "impersonal" area, the r o l e o f t h e nurse i s  c l e a r l y d e f i n e d , and she i s aware o f the tasks that she must fulfill.  Her tasks are s p e c i f i c .  For example she cannot i n s e r t  intravenous tubes, cannot diagnose o r operate.  Each o f these  tasks i s designated f o r m a l l y by the sub-culture as being the r e s p o n s i b i l i t y o f another r o l e . work are c l e a r l y i n d i c a t e d .  The l i m i t s o f the student's  One "probie" s t a t e d :  We had i t d r i l l e d into u s , and d r i l l e d i n t o us that we're not allowed t o give medications, and yet we've had people come up t o us and ask us t o take t h i s p i l l down to Mrs. So and So. I t may be an a s p i r i n or a 222, but i t ' s the p r i n c i p l e : you're not allowed to give medications. I n the "personal" aspects o f her work, the boundaries are not w e l l d e f i n e d .  Her r o l e I s f u n c t i o n a l l y d i f f u s e .  She  could be asked to do a v a r i e t y o f tasks that she had not expected.  There i s an informal i n d i c a t i o n of d u t i e s , which  o f t e n cuts across the formal boundaries.  This i s exemplified  by a c o n t i n u a t i o n o f the above quotation: And some o f the grads have become quite annoyed when we have refused t o do that, and then again, maybe you're g i v i n g a treatment t o a p a t i e n t and the nurse comes along w i t h h i s medication. The patient can't have i t at that moment and so the nurse puts i t down and asks you to see that the p a t i e n t gets h i s medicine. W e l l , t h e o r e t i c a l l y when you p i c k up that medication and give i t t o him, you're g i v i n g the p a t i e n t a medication. I t s o r t o f puts you on a spot t h e r e . I f e l t a w f u l l y g u i l t y even when they can't reach i t and you've got to hand i t t o them. But what are you supposed to do? You can't go b u s t l i n g down to the n u r s i n g s t a t i o n and say: "Would you mind coming back and g i v i n g so and so h i s medicine." When you're on the ward, you've got to do i t .  225  Here two values, or standards of behaviour, have come i n t o conflict.  F i r s t l y , the nurse must l i m i t h e r s e l f to the  standards  of the "impersonal" area and not perform tasks beyond her boundaries o f competence.  Secondly, she must meet the  standards  of her "personal" and i n f o r m a l duties by being cooperative.  In  t h i s case the i n d i v i d u a l chose the l a t t e r of the two, because the t h r e a t o f punishment was more immediate i f she d i d t h i s . Had she followed the r u l e s she would have been subjected to the annoyance of her co-workers.  A l s o , by choosing the l a t t e r , the  chances were that her deviance from the formal expectations might not be discovered. 3.  Rewards  The rewards of the nursing r o l e are o f two kinds: s a t i s f a c t i o n s from p l a y i n g the r o l e f o r i t s own sake, and s a t i s f a c t i o n s that can be achieved through the medium o f p l a y i n g the r o l e .  I have suggested  four p o s s i b l e rewards:  1) personal s a t i s f a c t i o n ; 2) s e c u r i t y ; 3) remuneration; prestige.  and  Gf these, personal s a t i s f a c t i o n i s the only  reward where nursing i s seen as an end i n i t s e l f .  The  other  three rewards accrue from the nursing r o l e as a means to an end.  1.  Personal S a t i s f a c t i o n This reward comes from seeing the purpose of nursing  fulfilled.  I t comes w i t h the f e e l i n g of having  accomplished  one's tasks i n the required manner and according to the prescribed standards.  A nurse f e e l s r e p a i d f o r h e r duties when she f i n d s  that p a t i e n t s , who have been i l l ,  are able to respond, or when  her p a t i e n t s get b e t t e r and go home.  She f e e l s s a t i s f a c t i o n i n  being o f s e r v i c e and i n being able t o work w i t h , and f o r , people. A reward o f t h i s nature i s the reward that i s considered  appropriate i n p r o f e s s i o n a l r o l e s .  Professional  selves are not expected to be i n t e r e s t e d i n monetary income, i n f i n a n c i a l or other forms o f s e c u r i t y , o r i n the p r e s t i g e that a p r o f e s s i o n a l r o l e enjoys. rewards from being of s e r v i c e .  They are expected t o get t h e i r These expectations,  socially  a t t r i b u t e d to p r o f e s s i o n a l r o l e s , are i n t e r n a l i z e d t o such a degree i n the p r o f e s s i o n a l s e l f , that they are considered as inherent.  Thus the i n d i v i d u a l i n the r o l e f e e l s that only her  work o f helping others could reward h e r . I t gives you a sort o f nice f e e l i n g Inside . . . People are always very glad f o r everything you do f o r others.  I didn't q u i t e a n t i c i p a t e the f e e l i n g you get when a p a t i e n t smiles a t you. I t r e a l l y does something to you. They say: "Gee that f e e l s good." These rewards come from conforming to the expectations o f the nursing r o l e , and a c t i n g according to occupational norms. That does not mean, however, t h a t other rewards are not also r e c e i v e d .  Obviously without the support of the other  three s a t i s f a c t i o n s , remuneration, s e c u r i t y and p r e s t i g e ,  there would he f a r fewer nurses.  These other rewards, however,  are not considered important to p r o f e s s i o n a l r o l e s , and are therefore Ignored.  2.  Security Because o f the continuous occurrence o f disease and  accident, the medical sub-culture w i l l p e r s i s t . a l l times there w i l l he a demand f o r nurses.  Therefore at  Nurses  feel,  t h e r e f o r e , that they w i l l always be needed, and would never be i n a p o s i t i o n o f having to compete f o r work.  As n u r s i n g i s a  woman's p r o f e s s i o n , i t has a large turnover, l e a v i n g vacancies to he f i l l e d .  Thus nurses f e e l secure I n being able to f i n d  employment "at any time." They also f e e l that nursing o f f e r s s e c u r i t y i n t h a t i t "prepares a g i r l f o r marriage." emergencies  She i s able to face  and to l o o k a f t e r the needs o f a f a m i l y .  They f e e l  that they are b e t t e r equipped f o r these demands than members of other occupational groups. 3.  Remuneration As f a r as monetary rewards go, nurses imply t h a t they  are underpaid.  Like a l l p r o f e s s i o n a l groups, however, they  d i s p l a y a s u p e r f i c i a l l a c k o f i n t e r e s t i n t h e i r monetary income. I t would he safe to assume, however, that i f the income were o v e r l y small, fewer nurses could be r e c r u i t e d .  Income, being  a means o f l i v e l i h o o d , i s undoubtedly  the expected reward from  any occupational r o l e .  [).. P r e s t i g e One reward o f the nursing r o l e i s i t s favourable p u b l i c image and the s o c i a l status t h a t goes w i t h i t .  Nurses  are incumbents i n a r o l e which i s o f t e n defined as being "good work f o r women," and hence an i d e a l feminine r o l e .  They also  enjoy the p r e s t i g e o f working i n a r o l e , whose e t h i c s imply a l t r u i s m and s e r v i c e .  Nurses are respected f o r t h e i r values,  which bear s i m i l a r i t y to those upheld by middle-class P u r i t a n culture.  They are considered as devoted, humble, s e l f -  s a c r i f i c i n g i n d i v i d u a l s w i t h high moral standards.  R e l a t i o n to Others The nursing r o l e could be considered i n r e l a t i o n to other r o l e s w i t h i n three contexts. includes groups o f other r o l e s .  Each o f these contexts  Nursing can be seen i n the  context o f s o c i e t y and i t s r e l a t i o n s h i p t o other r o l e s t h e r e i n can be speculated.  I t can be seen i n the context o f the  occupational world, and i t s status to other occupational r o l e s can be discussed. the women's world.  I t can also be given the status o f a r o l e i n F i n a l l y i t can be seen i n the context o f  the medical sub-culture.  Status r e f e r s to the p o s i t i o n of a r o l e i n r e l a t i o n to 'other r o l e s . w i t h others.  I t i s determined by the i n t e r a c t i o n of a r o l e  I n that way  status i s important as a c o n s i d e r a t i o  when the r e l a t i o n s h i p o f nursing to other r o l e s i s assessed. Status i s u s u a l l y a two-dimensional t h i n g , depending, on the hand, on how  one  a r o l e i s perceived by other r o l e s , and on the  other hand, on how  i t i s perceived by the incumbents of the  role i t s e l f . The  status o f a nurse i n the s o c i a l system at large  and i n the occupational  system i s ascribed on the b a s i s of the  meaning o f the r o l e of "nurse." same s t a t u s .  That i s a l l nurses occupy the  W i t h i n the medical sub-culture, however, the  status of a nurse depends on her i n d i v i d u a l performance. i s therefore an achieved s t a t u s . many s t a t u s e s .  In t h i s way,  It  each nurse has  Yet a l l three statuses are interdependent, i n  that the status o f a nurse i n the s o c i a l system depends upon her status i n the occupational system.  S i m i l a r l y her  status  i n the occupational system depends upon her status i n the medical sub-culture and i n the s o c i a l system.  A l l are also  undoubtedly i n f l u e n c e d by her status as "woman."  R e l a t i o n to Others i n S o c i a l System The nursing r o l e i n the s o c i a l system i s i l l - d e f i n e d . This can he seen by the numerous p u b l i c images.  On the  one  hand she i s endowed w i t h the q u a l i t i e s of womanly v i r t u e . the other hand, however, she i s classed w i t h waitresses  and  On  scrubwomen.  The p u b l i c image o f the nurse as a woman "with  loose morals" should also be considered.  Hence she i s  considered a p r o f e s s i o n a l person, a servant o r performer of menial t a s k s , and a community l e a d e r .  I n the s o c i a l system  at l a r g e , t h e r e f o r e , the r e l a t i o n s h i p o f the nurse t o other r o l e s i s somewhat u n c e r t a i n , i n that i t can vary from one f a c t i o n o f the population t o the next.  Obviously much would  depend on the r o l e w i t h which the nurse was i n t e r a c t i n g . I t would depend on the age, sex and socio-economic status o f the other.  Relations t o Others i n the Occupational Sub-System Whereas i n the s o c i a l system, the insecure p o s i t i o n of the nurse i s due t o h e r status as a woman, i n the occupational sub-system, her p o s i t i o n i s also not w e l l d e f i n e d .  The  i n s e c u r i t y here hinges on h e r occupational s t a t u s , that i s , whether i t i s a p r o f e s s i o n a l status o r not. Nursing has the a t t r i b u t e s of several categories o f occupational r o l e s .  F i r s t l y i t uses science, and i t i s a  p r o f e s s i o n I n that i t possesses a body o f s p e c i a l i z e d t e c h n i c a l knowledge, which has been accumulated as the r e s u l t o f a lengthy p e r i o d o f l e a r n i n g .  Procedures and tasks are c a r r i e d  out according t o the l a t e s t s c i e n t i f i c techniques.  Secondly,  i t i s also an a r t , i n that performance depends on i n d i v i d u a l talents.  Books f o r nurses o f t e n s t r e s s t h i s aspect o f the r o l e  231  in  order  to  formulate  Nightingale's of  the  a systematic  statement  fine  arts,"  is  occupation,  and as  such  "servants,"  or,  the  "professions." former,  yet  many o f  they  are  trustworthy,  with  other  Relation  to  Others  o f men.  is  that  they  Here nurses  roles,  women.  professional  men and i s  professional  and s t a t u s e s . the  qualities  kindliness  Yet of  at  figure,  maternal  role  on them.  So t h e  desirable  nurse  those the  of  the  the  same  to  dual  time Interaction of  expectations. i n the  places  the  as  the  latter,  equality.  she  is  both the  sex  subordinate integrates  of  performs privileges  encouraged  qualities.  equals  that  She  Charity,  to  retain  sympathy, She  is  role  and  t o men  and  the  home,"  the  afforded similar  same t i m e  Is  of  those of  s i m i l a r i t y to  with  and i s  She  role  can depend on any  their  bears  with  "service"  group,  should "stay  V i c t o r i a n womanhood.  o f woman.  a  one  World  they  treated  associated  at  is  role.  grouped w i t h  the  but  subject  that  and empathy a r e  feminine  dependent  are  duties  it  is  similar to  therefore,  nursing  Her r o l e  it  s i m i l a r to  should take  are  —  and h i g h l y s k i l l e d .  i n t h e Women's  professional  similar  are  are  altruistic  One v i e w t o w a r d s w o m e n i s other  tasks  the  art  occupational  t i d y and wash,  of  an  Thirdly,  "service"  As women, n u r s e s  the  is  Florence  c l a s s i f i e d w i t h the  values  occupational  definitions  quoted.  its  its  clean,  "Nursing  can be  Many o f  Nurses  four  often  other  latter.  the  that  self-image.  a the  qualities  of  the woman who "stays at home" w i t h the q u a l i t i e s o f the woman who leads a p r o f e s s i o n a l l i f e .  R e l a t i o n s t o Others i n the Medical  Sub-Culture  The medical sub-culture i s composed o f h i e r a r c h i e s . Each nurse i s faced w i t h a medical h i e r a r c h y , a nursing education h i e r a r c h y , a nursing s e r v i c e h i e r a r c h y , a h i e r a r c h y of p a t i e n t s o f d i f f e r e n t socio-economic l e v e l s , as w e l l as other h i e r a r c h i e s w i t h which she does not come so c l o s e l y i n t o contact.  This would include the d i e t i t i a n s , the a d m i n i s t r a t i o n ,  the s o c i a l w e l f a r e , the laundry and maintenance workers and the kitchen help.  To each l e v e l o f each h i e r a r c h y her r e l a t i o n s h i p  is different.  The p a t t e r n i s f u r t h e r complicated, as a l l  h i e r a r c h i e s are not s i m i l a r l y organized. To the h i e r a r c h y that ranges from the head o f a medical department to the newest i n t e r n , the nurse i s i n a subordinate p o s i t i o n .  She i s c a l l e d t o a s s i s t , to handle  instruments, and t o keep t h e p a t i e n t under observation.  She  i s not allowed t o make any d e c i s i o n s as to treatment o r medication, and a t a l l times her actions are governed by the orders o f the doctor. Each i n d i v i d u a l doctor, however, i s evaluated i n terms o f the respect he shows the nurse.  I f he greets her  every morning and explains h i s medical diagnosis and the p a t i e n t ' s c o n d i t i o n t o her, he i s considered l i k e a b l e and  pleasant.  I f , however, the only communication between doctor  and nurse i s through the p a t i e n t ' s c h a r t , the doctor i s defined as "snooty" or unpleasant.  In the l a t t e r case the nurse i s  l i a b l e to punish the doctor concerned by the nature of the assistance she gives him.  Therefore she i s able to c o n t r o l  the s i t u a t i o n i n t h i s manner, and to w i n f o r h e r s e l f the respect of the doctor, who  depends on her f o r r e p o r t s on the p a t i e n t ' s  progress. The nursing education h i e r a r c h y c o n s i s t s o f a group of i n s t r u c t r e s s e s .  These transmit the Instrumental and  expressive knowledge o f the medical sub-culture to students, but l o s e s i g n i f i c a n c e as a u t h o r i t y f i g u r e s once the student graduates.  Hence the student l e a r n s from her i n the classroom.  On the ward, however, she e i t h e r welcomes her appearance or dreads i t .  This depends on the p e r s o n a l i t y o f each i n s t r u c t r e s s .  Whereas i n the classroom they are evaluated mainly on t h e i r teaching a b i l i t y , on the ward they are evaluated on t h e i r f r i e n d l y and h e l p f u l manner.  Hence the advice o f an  tempered, unpleasant i n s t r u c t r e s s i s seldom sought.  illHer  appearance does not give support to the student, but only makes her more nervous.  She defines the f u n c t i o n of the  i n s t r u c t r e s s e s , not as one of guidance and a s s i s t a n c e , but one of e v a l u a t i o n . The n u r s i n g s e r v i c e h i e r a r c h y ranges from the "probie" to the head nurse and the s u p e r v i s o r . While a  23k  "probie" a student f e e l s subordinate  to a l l of the h i e r a r c h y ,  but once she becomes a graduate, she i s subjected o n l y to the a u t h o r i t y of the head nurse, the charge nurse and the  supervisor.  In a teaching h o s p i t a l , such as the one studied i n t h i s t h e s i s , a graduate nurse c a r r i e s some a u t h o r i t y i n that she can give orders to students, and does not do "routine jobs."  She i s ,  however, under the j u r i s d i c t i o n of the head and a s s i s t a n t head nurses. Because of a r i g i d system o f a u t h o r i t y and i n f l u e n c e , there appears a phenomenon which could, best be c a l l e d "taking i t out on those below you."  An a u t h o r i t y f i g u r e i s , i n most  cases, defined as unpleasant, and those under the a u t h o r i t y o f t e n f e e l persecuted. hardships  They f e e l that they had to endure  to become the kind o f nurse that they are, and t h i s  to them then becomes the only way by which a nurse can moulded.  he  They, i n t h e i r t u r n , then impose the same system of  a u t h o r i t y on those that f o l l o w them. The r e l a t i o n s h i p s w i t h p a t i e n t s are wide and v a r i e d . Nurses f e e l most comfortable w i t h p a t i e n t s who i s , p a t i e n t s who and who  t a l k to them, who  get b e t t e r .  respond, that  are t h a n k f u l f o r services  Socio-economic l e v e l s , sex, age and  the  type of i l l n e s s would also define the k i n d of r e l a t i o n s h i p between p a t i e n t and nurse.  Nurses tend to he over-kind to  p a t i e n t s o f a lower socio-economic status than they, and uncomfortable i n the presence of p a t i e n t s w i t h whose s o c i a l  status they are not f a m i l i a r .  They often i n d i c a t e that they  p r e f e r men to women as the l a t t e r tend to be too "demanding" and too f a m i l i a r with some o f the instrumental tasks performed by the nurse. children.  Most nurses, however, i n d i c a t e a preference f o r  These p a t i e n t s are mostly e a s i l y handled i n the  "personal" aspects o f her work.  They f i n d i t easy to t a l k to  c h i l d r e n , because o f t h e i r own superior experience.  Children,  u n l i k e a d u l t s , are not c r i t i c a l of nursing performances and give a nurse the respect given.to a s u p e r i o r , both i n age and knowledge.  This makes her work e a s i e r .  With other female p r o f e s s i o n a l r o l e s w i t h i n the medical sub-culture the nurse has two types of r e l a t i o n s h i p . I t i s e i t h e r one o f competition or one o f cooperation, and i n most cases both.  Hence w i t h a d i e t i t i a n and a s o c i a l worker  the i n t e r a c t i o n i s one o f p r o f e s s i o n a l c o l l a b o r a t i o n .  The  former, however, tend t o regard the r o l e o f the nurse as an i n f e r i o r one, i n that the nurse has not a u n i v e r s i t y education and i s asked to perform menial t a s k s .  The r e a c t i o n o f the  nurse i s to d e f i n e her r o l e as the one of greatest  "importance,"  i n that she, alone, i s c l o s e l y connected w i t h the c e n t r a l purpose o f the h o s p i t a l , the cure o f i l l n e s s . are considered a u x i l i a r y and dispensable.  The other r o l e s  She f u l f i l l s the  immediate needs o f the p a t i e n t , and t h i s i s the c l a i m that she l a y s to s t a t u s .  236  With n u r s e s ' a i d e s , maintenance workers, and k i t c h e n h e l p e r s the nurse i s p l e a s a n t , i f not somewhat condescending. O f t e n she i g n o r e s them, when she i s a graduate, as the r o l e she p l a y s does not b r i n g her i n t o contact w i t h these workers. I t i s the student who  has the most t o do w i t h them.  There Is  a common bond between them, both f e e l i n g themselves to be "under-dogs."  T h i s l e a d s both groups to each o t h e r ' s p r o t e c t i o n  should o c c a s i o n warrant i t .  CHAPTER IX STRAINS AND  CONFLICTS  In human i n t e r a c t i o n strains are inevitable. i n d i v i d u a l i s a complex organization personality t r a i t s .  Each  of r o l e s , norms, and  Each organization  i s unique.. Indeed, such  i s the heterogeneity of society that contacts between individuals often prove incompatible.  This discrepancy results i n s t r a i n .  The underlying cause of c o n f l i c t i s , not variety and diffuseness  so much the  of norms adopted by the r o l e s , as  phenomenon of "vested'interests:.  This i s a-term used by  11.  Parsons to imply the emotional attachment towards the state of b e l i e f s and practices.  the  existing  Each individual's thoughts  and behaviour are fashioned by the p a r t i c u l a r norms which he has internalized i n the playing of h i s roles,  ^hese norms are  defined by him as.being "the best"' and the most appropriate for him.  When he comes into contact with d i f f e r e n t norms, or i s  asked to accept d i f f e r e n t norms, strains arise.. I f , however, he does not consider h i s own .norms as "good"-, no strains occur when the contact takes place.  He may  his former norms i n exchange for the new  1 Parsons, S o c i a l System, p;.  ^91.  may  be eager to reject  ones.  As f a r as the nurse's role i s concerned, strains  may  occur as the r e s u l t of external pressures or i n t e r n a l discord. Thus: strains can be externally imposed when the nursing r o l e , with a l l i t s norms, interacts:with other r o l e s , or when outside forces impose r e s t r i c t i o n s .  C o n f l i c t s also occur within the s e l f  as a result of c o n f l i c t i n g i n t e r n a l i z e d norms.. This chapter s h a l l dwell on:; 17 the nature and the extent of the strains that occur i n connection x*ith the nursing r o l e , and how they are manifested;,  2) the i n s t i t u t i o n a l ways  by which they are overcome;; and 3) the functions, both p o s i t i v e and negative, that they serve..  1..  The Nature of Strains i n Nursing.  A. nurse i s often i n a position where she must conform to diverse expectations.  The s t r a i n s , that are incurred, arise  from:  The Unsatisfactory Status of Nursing ^he role of the nurse i s i l l - d e f i n e d .  In the s o c i a l  system they are i d e n t i f i e d , on the one hand, with people devoted to helping others, with carrying out specialized work, and with being "ministering angels".  On the other hand,  however, they are considered as being people with "loose morals," who  1  also perform the lowly tasks of carrying out bedpans and  "'cleaning uppmesses."  In the occupational sub-system also, t h e i r  professional status i s debateable. menial tasks they perform.  This i s the result of the  Their occupational status i s further  complicated by the fact that nursing i s largely a women's profession and hence carries with i t the stigma: of female: subservience, a survival of pre^'emancipated, V i c t o r i a n womanhood. One nursing student, feeling this.discrimination, remarked: I think- nurses, are l e s s respected than any otherprofession. Even less than teachers:.  Unfavourable Public Images Adverse public images are a source o f . s t r a i n . Nurses" knowledge: of the human body i s often identified*with promiscuous..experiences, and they are, therefore, defined.as unmoral.  Nurses., on the other, hand, become..indignant  at. such  attitudes, and f e e l insulted when they are t o l d uncouth storiesi on the basis of t h e i r being nurses, and hence, "In a p o s i t i o n to understand."  There i s a c o n f l i c t i n being accused'of  socially-disapproved behaviour on the basis of onei s occupational knowledge.. Many" student s. admit they think t h i s u n f a i r , e s p e c i a l l y when they consider themselves r e l a t i v e l y naive. Some sections of the public define nurses i n the same category as scrubwomen, performing " d i r t y work"". unjustly accused.  Nurses f e e l ,  They claim that they are given a lengthy and  s c i e n t i f i c t r a i n i n g , that they are i n possession of some of the l a t e s t medical techniques and that they are indispensable to both doctors and patients.  They r a t i o n a l i z e . t h e i r menial work i n terms  of t h e i r a l t r u i s t i c b e l i e f s — "someone has- to do it"'.  They imply  that such tasks f a l l to the l o t of nurses; as.a r e s u l t of bad. organization and the scarcity of personnel.,  At the same time,,  they claim, such duties, are of prime importance to the function of the hospital., A'nother source of c o n f l i c t i s the public image which defines nursing a-s being, easy and a. role that "'anyone could do"This obviously detracts; from the status of the profession in. classing i t with u n s k i l l e d jobs.. Nurses.,, under, this., strain,, point out the long hours o f study, the examinations physical hardships..  end the  The public, they feel,, are not aware of.  the nature and extent of nursing knowledge, and obligations..  B i d for Professional.Status: Nursing, as; an occupation, could be c l a s s i f i e d with several categories of occupational roles:. science..  F i r s t l y , , i t uses,  I t possesses a. body of specialized technical knowledge  which has: been accumulated and i s taught during a lengthyperiod of training*.  Procedures: are carried out acc.or.ding to  s c i e n t i f i c techniques...  Secondly,, i t i s . an a r t , i n that  performance i n the role is: dependent to a. large extent on i n d i v i d u a l talents:.-  Books on nursing often stress: t h i s aspect:  of the'role.. Florence Nightingale writes.: "Nursing i s . an ar_t — i t . i s one of the fine, ar.tS5»"  r  Thus: i n its; f i r s t  and  second categories-,, nursing occupies: a relatively, high status.. T h i r d l y , however,, i t i s a ""service"' occupation, with its; two:  21+1 diverging, images... It-can be. classifie.dL either-with "'servants'* or. with "professions"'.  Many nursing,tasks, are. similar,-to the-  former, while most of: i t s norms are.-similar.-to the l a t t e r * Thus: nursing is., a role where incumbents wash, clean,, and runerrands.,  At .the same.-time^ however., they profess, attitudes: of.'  altruism,, trustworthiness and. a disregard, for.monetary reward., Professionallyhowever,  nursing .is; i n . an insecure.  position., I t possesses, specialized, knowledge,,, a period, of t r a i n i n g , a system of ethics, a professional association and. a: monopolby over i t s , recruits: and. members.  Yet its; f u l l  acceptance as a profession depends, on the medical d e f i n i t i o n of their role.  As long .as; c e r t a i n segments, of the public refuse;  to give professional status to nursing, and.persist i n defining i t as " d i r t y work"'", "drudgery"' and. "menial tasks."",. professional standing can not be acquired..  Not u n t i l the public accepts.  nurses, with doctors:, lawyers: and clergymen w i l l the status: of. nursing be professionally secure.  Nurses, express t h e i r strained.  p o s i t i o n i n the following terms.r I. vrish I could have •a. job-where ...I could get: as. much out of nursing without, doing a l l those menial things: — cleaning • t h i s , and cleaning that, and doing the other. The nursing group attempts, to a t t a i n professional status by urging i t s members to act i n a. "professional manner".  Nurses are discouraged,  t  and often forbidden to behave  i n ways that are attributed to the lower classes; and to unskilled, workers..-. They are not allowed to whistle or  hum.  on the. wards., They cannot chew. gum.or place their..hands.: on t h e i r hips.. They are told.not to slouch., They are-forbidden to use:: perfumes: and n a i l p o l i s h or wear long_.hair,, i n other, words, they are encouraged.to divorce themselves: e n t i r e l y from, #  sensuous: expressions: of femininity'.. This, function i s further, boosted by the uniform,,which is:,, at once, disguising and. equalizing.. At; the same, time., however,, the maternal  expressions:  of femininity are;, greatly encouraged.,  Nursing ..as a. Marginal Role The.role.of the nurse; i n r e l a t i o n to the hierarchies:. of the hospital i s also not c l e a r l y defined.  There? is. a c o n f l i c t :  here which results: i n a:, constant b i d for power-and prestige.. The. ambiguity and s t r a i n of the nursing role can be: exemplified by the following:. It"s- so limited.. Ybu know. Ybu. can only do so much., For instance, one thing..... when ypu- f i n i s h , , l i k e when I. f i n i s h I w i l l have f i v e years of t r a i n i n g and study and yet you" s t i l l can t say something was soy i f only appears so.. Ybu can*t: say i t because you don t: know that, sort of thing. And you have.to say seems-, even though you're pretty damn sure i t is., i t seems so s i l l y . l!  -  r  Nurses f e e l they are q u a l i f i e d to perform certain tasks;,,, and. often they f e e l they are b e t t e r able to perform them than other per Sonne!..  They are, however, i n a p o s i t i o n of.subordination  to the doctor.. The doctor may only v i s i t a patient, for a few: minutes: each day, yet:.the nurse.; is. i n constant  attendance.  Therefore. she., feels, more q u a l i f i e d to evaluate the ; patient"s.  condition and to give, him f u l l care.  Yet. she. is. forbidden to  do anything without the doctor's orders.. to that of the doctor.  Hen role is;, mar.gj.nal.  She;; has.. less; technical, knowledge:, and.  a b i l i t y , a smaller, area" of competence, lower..-status.-, a smaller.-  2.. income, and less- prestige., She. knows the nature of the patient's,, condition, , and. she I s expected, to recognize; important, symptoms., but she cannot convey t h i s information to the patient. is. the doctor"s..prerogative.  That,  Although to some nurses., usually  of the "practitioner.""-type, t h i s i s . f u l l y acceptable;,, the-"theoreticians!^ with initiative.; f e e l the strain..  They imply  that they are doing less than they know and f e e l capable, of. doing. This c o n f l i c t . over, status, seems, to he f e l t on both sides... The concept of marginality implies: that the well-established status group attempts, to keep out the i n t r u d e r s , , i n t h i s case; the nursing group, while the marginal-status, group seeks to (  acquire the higher status..  Doctors, when lecturing to nurses,  do so i n such a manner that the material i s too d i f f i c u l t ; f or. nursing students to comprehend.and.suitable only f o r medical students... Nurses r e t a l i a t e b y complaining  of the i n a b i l i t y of  doctors, to see patients, "as individuals"", thus attacking, t h e i r humanistic values:, which are.considered very important i n professional r o l e s .  Doctors t a l k to nurses, i n a.disrespectful,  manner., often implying that they are there merely as t h e i r 2 The c r i t e r i a - for evaluating the marginality of a r o l e , as. suggested by Wardwell, Walter. I.. "A: Marginal.Professional.Role.: The Chiropractor!'-,, Social: Forces.., 39 „ 3:339H$-°V 1952-  helpers:, to carry out'.the u n i m p o r t a n t m e n i a l tasks*, of medicine. Nurs.es',, on the other hand,, cannot rationalize: the r e a l i t y of: t h e i r - l o w status: i n r e l a t i o n to doctors..  They release their,  tension i n h o s t i l i t y towards doctors, by grumblings about t h e i r : ignorance, of s t e r i l e technique..or their, i l l e g i b l e w r i t i n g .  Nurses, are also Women Undoubtedly, much of. the s t r a i n caused.by an.insecure: and. ambiguous, status i s due. to the fact ..that nursing i s an occupation peopled'.primarily by women.. There; are two concurrent, yet..conflicting,; views: on women.. There i s the. t r a d i t i o n a l notion of the i n f e r i o r i t y of women, and the modern North American notion,, in.which women are.not placed, in.a. role of subservience.. The.hospital tends.to adopt, the former view:by expecting nurses to show: subordination to doctors.. Yet, the h o s p i t a l . a l s o giveS; them professional' status,,thus making them the colleagues, of. other, professionals., such as doctors... In addition, nurses; are; products: of the present day c u l t u r a l definition,, where women are given a high status. subservient to doctors..  Therefore they strive not to be Yet h o s p i t a l rules, require the nurses  to stand.when a doctor enters, the room, whereas the sameindividual,-, as a woman, would remain seated.. ;  This i s a xvell-  defined. sanction meant t o imply respect,. while outside: of the medical, sub-culture the very same respect would.be shown tothe woman. This s t r a i n of c o n f l i c t i n g norms; i s most;marked, when a nurse: and doctor are i n the same elevator- and one has; too precede,-the other out of the open doors..  Is the self-image-  o f the nurse;; to be that of a "'woman'., or. that of: a "hurse." 2. 1  r  ;  The; Strains, i n Change .of MilieuChange usually means, the. giving„up; of one • set; o f "vested.interestsr* f o r another..  If.there.is.no process, o f  unlearning, there i s . s t i l l a.process*.of integration, o f old values.; with new., The subjects, of t h i s study experienced, a. change when: t h e y l e f t the .university campus f o r the hospital.. This was. the. cause., o f many conflicts.; The; attitudes fostered, at;the university, differ, d r a s t i c a l l y from, t h o s e . i n s t i l l e d , at:the hospital...  In the-  university setting students; are encouraged, to show: i n i t i a t i v e . , charisma: and individuality..  The h o s p i t a l , on the other hand',,  to maintain i t s . existing pattern of organization, tends, to discourager these. attitudes.. They expect, students to f o l l o w orde.rs., to overcome charismatic, tendencies.., and to do their, ;  work without question or argument.  They are equalized, not  only by their, uniform, but. also by their, behaviour, which has. been pre-defined.  Yet. at-the same., time students, are. expected,  to be able to take.the i n i a t i t i v e ; and.the r e s p o n s i b i l i t y i n an emergency,- ^mother-instance  of. strain..  University versus: Hospital They come from.an environment where.they are defined, as students.,  As such they are under no obligation.to the  university to pass examinations  or to become good, students...  Their.'only obligations are to outsiders, such as. parents and. friends.. When they enter, the.;hospital, however.., they are; s t i l l defined, as. students., but are expected to render services.. They are also under an additional.obligation to the. school to give proper care to patients, and to learn the material presented, to them.. The head nurse, and the seniors: and everyone, is. getting^ after, you,, while out. at the university everyone i s . just.so nice to you: "That s. f i n e , .Hiss: Smith, that s. very, nice..,"* You get: down here-and .bang. 11  11  5  They feel.that t h e i r l i f e i s r e s t r i c t e d , and that they are now; forced.into f e e l i n g responsibilities:, not only towards themselves but also towards, t h e i r superiors..  This, ambiguous, status, which  waverS;. between that of a student and that of a workerleads., to feelings, of strain.,  They release tension by complaining  about losing t h e i r independence, about the lack of. imagination, i n the s t a f f and about the monotony of uniformity.. and hospital-program  Instructresse  nurses r e t a l i a t e by i d e n t i f y i n g the  university students with snobs..  University students; complain,  that when head nurses hear that they are i n the degree-program, they expect; extra c a p a b i l i t i e s , from them.  The-instructresses  state that; they are disappointed.in the u n i v e r s i t y c l a s s , or claim that "The u n i v e r s i t y class..,...they c a n H even do simple:, mathematics.."' At the u n i v e r s i t y the students, are submitted, to a. t r a i n i n g sequence.made, up almost e n t i r e l y of t h e o r e t i c a l , knowledge.. They f e e l the s t r a i n of being defined as. student nurses..,, yet being far. removed, from a l l aspects, of nursing and  hence.; not .having the. s a t i s f a c t i o n s gained.when dealing with patients*  They claim, they/are student nurses., but. have, never.  been near-a-patient, and show: a. marked.eagerness, to enter the hospital:.phase; of their, trainings  Once i n the hospital,,  however, they soon f i n d that, t h e i r t r a i n i n g has: become almost'; completely; of an apprenticeship; type:j, and they begin to complain of not learning enough material.  So from an environment.where;,  they are submitted, to an oppressive. load, of theory, they come;to one,, where they are .entirely separated from t h e o r e t i c a l . learningand.subjected to the monotony: of routines activity.,  They, complain  that the .lectures, and exams are too: easy" and that, the teaching, llr  i s on an elementary l e v e l *  ?  They f e e l they are ."-being,, treated.  l i k e - c h i l d r e n i n elementary school."'' The; hospital-program, students;, resent this: demoralizing., attitude,.-  Their  resentment;  is. further heightened by the extras, privileges; given to the; university students;, such as; a f f i l i a t i o n s : to the mental h o s p i t a l -and.public health agencies., University students-feel._that t h e i r "'vested interests *" 1  are abused, when they discover.that, what was taught to them ate the u n i v e r s i t y , is: not observed.in the r e a l nursing situation.. They were taught at the.university that;magazines  should not.be  passed, from patient;,to patient, yet'-they find.that t h i s i s ; practised, constantly.,  They were; taught to give attention.to  the personal needs of the.patient and to give.him psychological. care,, yet they see; graduate nurses, ignoring ^the .patient f o r the sake. of speed" and accuracy., Towards, the ..people .that taught them they were expected.to show, respect,, and they were .expected  to: approach them with t h e i r queries., At the h o s p i t a l , they feel, the expectations, are d i f f e r e n t : There i s • a difference between the u n i v e r s i t y g i r l s and the others.., They wouldn't' dream of speaking to t h e i r instructors: the.'way we do., They complain that they seldom s.ee.the instructresses, and i f they do, they are crabby and expect, too much from them as. university girls:,, or treat" them as; i f they were; Wstupid."" She scares me.. I. wish she d i d n t bawl-us out l i k e . that. We don't, seem to be able to do anything to: please her.. She says. that, she i s disappointed i n the whole university class:. r  i  On the whole the i n i t i a l to withstand the s t r a i n *  attitudes: and values; appear-  Most university g i r l s feel, that they  did w e l l i n taking the u n i v e r s i t y course and would.advise others, intending to: become nurses to take the same course:.  They claim  that not only are they older.,, but they understand people, a l i t t l e more.  They feel.that they have more, insight into the  psychological problems of the patient and that the h o s p i t a l program tends to cram too much knowledge; into too short a time of concentrated study.  This i s a drastic change., from t h e i r  i n i t i a l , s t r a i n at the u n i v e r s i t y of "'too much theory and not; enough practice."'  The Pressure, of I n s t i t u t i o n a l - L i f e . I n s t i t u t i o n a l l i f e takes into account such phenomena: as; hospital, hierarchies, h o s p i t a l org.anizEtt.ion and routine,, residence, l i f e , , and s t r i c t l y enforced, regulations:.  It; must bes  remembered that the students: who enter t h i s kind, of l i f e ; had!  previously;-been u n i v e r s i t y students:, l i v i n g at Home or i n u n i v e r s i t y residences, and '.in general, existing ..according, m  to t h e i r own desires... Upon coming to the hospital, they, are r e s t r i c t e d to hours, to hospital meals,, to times, when they work and when they study,., and. to an isolated existence where., most of t h e i r contacts; are with members: of the n u r s i n g s group..  They feel, that  their, independence, and privacy are impinged upon., They f e e l a. d i s t i n c t ; l a c k of outside • interests,, and complain that..they have nothing to discuss, with outsiders.  They begin.to f e e l more  and more l i k e outsiders: i n non-nursing groups.  Having accustomed  themselves to the lax: rules that exist at t h e i r homes; and i n the university,, they consider the '"militaristic! ' nature. of 1  i n s t i t u t i o n a l r u l e s a s '"petty.,""' C o n f l i c t s occur, when they lose, t h e i r "late.leave!!- because of a. ten-minute; lateness.^ or. when their, superiors take;drastic;measures when they,, as students absent.-mindedly precede:; them through doors., Feelings; of h o s t i l i t y develop; towards, residence .matrons; when students miss; telephone c a l l s from boy-fir.iends because the matron, did: not: ring_long enough,, or f a i l e d to enquire f o r them, i n the lounge... They complain about the. "stupidities! " of .'residence rules.. This 1  occurs usually when they cannot rationalizes the regulations. They cannot understand why they should be i n t h e i r rooms; at ten-thirty, i n the evening., when they; could stay out of the; residence: u n t i l , eleven.  They object to restrictions-, which  do not, allow: them .to have magazine, stands,, gramophones: or. plants; in.their, rooms... Only, when rules: make sense,, or. are compatible with the overall, values; and standards; of the profe s sion. do • they-- comply/ without; f e e l i n g s; of" strain.-  One  student: nurse.:bewails: her. loss , o f independence: and: defines: her-  reactions, as t Independence;. D e f i n i t e l y independence... And,, I" don t . know,, I think: I'-m. losing, my/ i n i t i a t i v e : ; I never, r e a l l y exert myself; to do: anything.. Ybu. get-to the point. where - you can.*'t. be bothered' tb> do; anything,. Maybe-its because you^-re. tired, and', you: just, haven . 1. the:; oompii: to: get up and.do something. But, I don t know, you get sort of cut off: from. everything, else; too., I f i n d myself out with peoples and I just, don . t know: what, to t a l k about. Because;-all. I. can think: of now is; n u r s i n g y o u .startliving..: i t and. that Vs. a l l . you know., And' i t ; bothers, me., too.. l:  1  1  l  !  :  The. Problems, of being "The.Lowest of the Low."* The hospital, is: a bureaucratic- structure; consisting: of setS: of well-defined, hierarchies..  Each student, when she-  takes on the nursing role.begins as., a.'"probie-"' and s t a t u s wise, i s ; placed., at the bottom.of the nursing,and the. medical, hierarchy.  Coming from the u n i v e r s i t y milieu, and.kinship  systems.-, where they are., encouraged, to become: independent i n . both action and thought,, ""probies!" ' f e e l . the...strain of being., 5  the; ''lowest, of the.low,"- and. subjected to authority..  This:  results in.feelings of personal., devaluation, or in. aggressive;:  attitudes:, which turn into h o s t i l e actions when they move, up the hierarchy.. I n other word's.-^ nurses; i n positions o f authority have forgotten what i t was l i k e to he a. "probie,"' or. f e e l that a l l . student's, should experience, that phase: with i t s subordination, i n order to be. a: successful nurse..  Feelings; of  insubordination,, accompanied, by strain,, are experienced, when doctors: "usually look right through you and don't; even see; you,"' or ignore your status: as: a woman and precede., you through doors..  I. suspect that doctors tend to define student nurses as  children,, and not as; women,,, and hence; f e e l j u s t i f i e d . in, ignoring, them and not extending t o them the courtesies, usually given to women., "Probies"' feel.that other nurses consider bed-making and other routine tasks as; below t h e i r l e v e l . o f competence and' therefore refuse to do them.  When they s i t down to rest i n the .  nursing station graduate nurses remark that they "'didn't know that 'probies' could s i t down.,"'- Even students;,, who have reached, a. higher l e v e l of competence-sometimes: refuse during .of f-duty hours: to a l l o w them to use equalizing forms of address:,, such as; c h r i s t i a n names.,, by reminding them:; "Miss Jones, to you.," They are. forced to greet; doctors;, who are also family friends,; with a. s t i f f ""Good morning,"' even though the evening bef.bre they had conversed' on equal terms., These are a l l " instances o f strain..  The S t r a i n of C o n f l i c t i n g Demands; Students: are placed under conditions; of c o n f l i c t ' when traditional.norms, which they have been taught,, are.  supplanted', by new norms i n the real, s i t u a t i o n *  There, i s often.  a. difference; between what they know and what actually i s . practised.,  A student i s t o l d that she should never diagnose  the patient or divulge to him the signs, and symptoms; of his; illness:.  She must recognize; them,, but cannot do anything about  them.. She must'report them to the doctor,, who. then gives, the; pertinent information to, the patient* feelings? of frustration*.  This is: the source of  A's one; student;-put i t *  They can t e l l , when they have; a. temperature; and! they would lp:s.e.. f a i t h i n you. asr a. nurse; if." you t o l d them'that they did.not have one*,.* but. we. were. told, never to give temperatures:* They are..- forbidden, as; ""probies-,"" to: give, medications;..  They  confide.-, that they feel' s i l l y when they say they are; unable to. give; medications, when ""all. you: have t o do is; take a: pxL'lll down to the patient*"' T  n e  y are; taught to carry out s t r i c t  infectious; diseases; techniques;, with cases; of staphylococcus; aureus, boils;*  Yet. in. r e a l i t y they oib serve; these patients;  wandering around the wards without restrictions.,  They claim  that i n the lecture.—room such things; as; ""good nursing care;,"' "'patient teaching"'' and "-reassuring the patient"' are frequently stressed.. When they reach the ward situation,. however, these terms; become meaningless*  The demands: made; upon them are. i n  terms; of action i n the physical sense and they have l i t t l e ; time f o r giving psychological care.. Great-stress-is caused when one instructress or. head", nurse, teaches; one version, of a procedure,, yet; when the student changes; floors;,, another head nurse demands another version of.  the same procedure.  Students also claim that they see t h e i r  instructresses too infrequently and, during this- absence of contact,, they work under t h e i r own r e s p o n s i b i l i t y .  When the  instructress; returns:, however, they are once more treated as: students., and the work,, that they performed previously as: members of the s t a f f , comes under observation and  evaluation.  Higher i n Authority,, Lower i n Competence Nursing norms expect that student nurses show the appropriate respect to those i n positions of authority, such as doctors, head nurses and graduates.  They are t o l d that, i n  cases of indecision,, they should consult the nurse i n charge of the ward or the instructress.. These people are defined as ?•. having the knowledge and the required attitudes: of the profession..  Such expectations  are often the cause of s t r a i n  when student nurses discover that the i n d i v i d u a l s i n positions of authority are not desirable models., as they seem to be ignorant of much of the knowledge that they,, as have already  students,  acquired.-  Students respect doctors, for t h e i r knowledge,, but are indignant because they show ignorance of such nursing procedures and techniques as the " s t e r i l e f i e l d J  15  Doctors; s i t on the side  of a: bed i n the i s o l a t i o n section, or throw a. chart on the and l a t e r retrieve i t . .  bed  They also claim that doctors give l i t t l e  attention to the psychological care of the patient, which they  have been t o l d i s an important function of the medical subculture „ He couldn't have prepared the kid.. He; probably went i n and saidr "I. want some of your blood""..-., of course, the k i d just bawled ....all he..wanted was two ccs. The k i d probably thought he was going to take a. pint.. Ybu see^ .no. preparation whatsoever., 1  Although they are expected to taice t h e i r problems, to the head nurse, i n r e a l i t y students often approach other students,, or graduates..when i n trouble. incompetent  The head nurse may be  i n t h e i r eyesy or they may have developed an image  which identifies- her with a tyrant ready to devaluate them because they cannot perform t h e i r tasks without help., One junior spoke of her head nurse i n the following terms: She*s r e a l l y stunned. I. have to t e l l her what to do, even though she i s i n charge., We had a^ new patient the other day and I had to ask her i f she had phoned the doctor. ""Oh no, 1 11. do i t now*.. ..Hello:, Dr. Green....* . Miss Watson, what do we want'him for?....Oh, yes....."' 11  Conflict. also occurs, when students, who have been on a f l o o r where there..were twenty patients, and nineteen nurses, discuss their work with students, who. have been on a. f l o o r where there were twenty patients; and four nurses..  Together  they complain about the i n a b i l i t y ofLthe administration to org_anize the duties..of the s t a f f more e f f i c i e n t l y . . Students note with disillusionment that the values, of the nursing profession are often abused by those i n positions.  of authority.. They complain that head nurses;and graduates are too e f f i c i e n t , and often quite} mechanical, in. t h e i r relationship to the patient.  They repeat. anecdotes, of where-nurses, i n  administrative .positions, forbade s t a f f patients, to f i l l ' t h e i r  1  fountain.pens, i n h o s p i t a l ink:.. Graduates, they feel.,, are often two>f'aced.  They w i l l .be-pleasant; to a patient,, but then  grumble to each other-about her and.make, such statements: as.: "T wish to heck she'-'dL die."" In many cases, students; f i n d i t : d i f f i c u l t to render- the: right. amount; of respect; to these; graduates., after, they have observed, such v i o l a t i o n of. nursing, norms.,  Occupational Demands: Exceed .Physical A b i l i t i e s . When a student; "'takes on'*'-the professional role; she; 1  begins to internalize: the values of the r o l e . u n t i l they become; a part,of the s e l f .  Often,. however,, these, expectations demand  more.from.the nurse,than she. i s p h y s i c a l l y able.to give. C o n f l i c t s arise.between the. nurse;,, as a human being and'the nurse as: a: professional s e l f .  As the, former, she i s oriented,  to. following the. dictates of her organic needs and is. l i m i t e d by her. i n t e l l e c t u a l , and physical capabilities...  As the latter,,  she..is. controlled b y the., expectations, of a professional r o l e , where; she. i s oriented to the welfare.of others, at the. expense: of. self-interest:.  A. Nurse! S; Work i s Never Done. A nurse i s faced with the problem of organizing.  two things.: her. time, and her. tasks.,  She i s allotted', a- s p e c i f i c  amount, of time to complete., the tasks, that f a l l to her l o t . Having the values, of our. society concerning activity,, she:, is. inclined'..'to f i n i s h a performance once she begins, it... calls, f o r speed..  This  She.balances this: against a shortage of time.-,  her.-own a b i l i t i e s ; and .the nursing,norm. of accuracy.. When she; is; not .able; to follow a c t i v i t i e s ; to their, l o g i c a l conclusions, or: is. forced: to spend, more time on a. task than the; particular. performance, requires.,. or when she has. not had the. opportunity to learn the required.technique, strains, develops Not having enough time.for thing &:...,..like; you'Te.; rushed:,, you donH have time; to f i n i s h what;you re-doing.,....or. just; get; finished", and be.called away to do something else ......you. never have.; time to look upo on a: chart;what you*ve; been, doing .-..•you'Te. very busy., ,!  They begin to avoid c e r t a i n rooms on the ward, because.they know, that t h e i r appearance signals the development  of many  needs.:.. Suddenly windows have to be opened, pillows; have to be adjusted, candy has to be bought from the candy stand, a magazine has to be picked up, a t h i r s t has to be quenched, or a bed pan has to be fetched.. The climax i s reached when one patient requires an open window^, while the man i n the opposite bed,,wants i t shut., While the nurse i s braiding Mrs. Jones  f;  h a i r , Mrs., Brown asks f o r help i n turning over, Mrs., Smith signals that she needs her help;,, no: nurse is., answering the l i g h t i n the room opposite, and the head nurse i s waiting to see her.. So; while she busily braids; the hair and absently chatters with Mrs.,Jones:, she i s also organizing her next move*  Above a l l , she i s t i r e d and would l i k e to s i t i n the nursing station and perhaps acquaint herself with the patienf's charts. A l l . nurses are faced with the i n a b i l i t y to ever have t h e i r work e n t i r e l y completed..  They are always aware of more  tasks that could have been done.. The u n i t s or the cupboards need t i d y i n g , the ward manual or the patients' charts, should be read,, or the thermometer water should.be changed.,  The  work of nursing i s defined by a state of constant activity.. This engenders.an anxiety i n nurses, as they seem never to have t h e i r duties completed.. These feelings of anxiety and the need f o r constant movement are reinforced by head nurses., who  cannot tolerate,  students standing or s i t t i n g without p h y s i c a l l y doing anything.. pans.  They are sent to perform such tasks as counting bed  This causes f r u s t r a t i o n as they are unable to see-the  need f o r such performance and see themselves being forced to work, not; f o r the end i t could serve,,but merely f o r the sake of making work an end i n i t s e l f .  Tasks.beyond Their Competence She \ralked on the ward when ward rounds: v/ere going on. The doctor stopped her and gave her a specimen bottle and t o l d her to take care of i t . She continued down the h a l l without the f i r s t idea of what to do with i t . , Such situations occur when doctors; are not aware of  the specific d e t a i l s of nursing education and cannot estimate a student's; exact degree of knowledge by her uniform..  S'tudents.  remark that they have d i f f i c u l t i e s i n t e l l i n g others that they do not know how to perform simple tasks or "have not learnt that yet."' I t is.humiliating and status:-lowering and another r  instance., of strain.,,  The Strain of Integrating C o n f l i c t i n g Norms I t shoiild be remembered that before a- student takes. on the role of a nurse she i s an incumbent of several otherroles.  She i s 'a daughter,, a. " teen-ager," a. middle-class high r  school or u n i v e r s i t y student*  Her attempt to take on the  nursing role i s , to a-certain extent, controlled by the experience she has had i n performing these other r o l e s .  She  has. to integrate her previous convictions with the convictions; held out to her by her occupational role..  Thus attempts to  conform are complicated by the persistence of learned patterns; of behaviour and thought..  Conflicts, arise when she i s torn  between simultaneously incompatible expectations and the desire to r e t a i n previous patterns and yet adopt the new., As. "'teenagers."" and.members of a family, i n North America,, students have:.learned, to expect: i n d i v i d u a l attenti'on. and. condolence.,  Their, anxieties: and. f r u s t r a t i o n s have: been,  considered, matters of importancej deserving attention., A's. nurses.,, however,, they are. socialized, into a sub-culture.where.;  their, i n d i v i d u a l i t y and their.-problems., are .de-emphasized",, and. often.ignored.  They experience..stress; when.the former,  expectations haves to be unlearned:, to make way f o r the nursing; role. Most.nurs.es. belong to a socio-economic. group.', which,, ;  for. the. sake ..of a better description,, could, be called, middle^ .class.... They have the values, and expectations of that class:. Their patients,;, on. the other hand.,, come; from, three; possible, socio-economic stratast: upper,, middle, and lower.  Although  nursing norms forbid.discrimination, most nurses: indicate that; they prefer the nursing.of middle.class, patients..  They would,  f e e l uncomfortable.with those on the status, p o s i t i o n above, them, and somewhat condescending to those, i n the positions; below, them.. C u l t u r a l l y they are somewhat incompatible with both.. Nursing ideals.,, however,, encourage .them to help, the weak and show charity to the poor.  Often, therefore,, they indicate-  that they prefer to nurse staff" patients... By such an i n d i c a t i o n they imply t h e i r conformity to occupational ideals..  On the.,  other hand,, however,. they complain of the squalor,, the d i r t , the swearing and the smell. The stink down there h i t s you as soon as you go. near i t . The patients come, i n f i l t h y and stinking... ..all from Skid. Row. As nurses,, they know they are expected" to disregard-, status and rewards.  Yet previously acquired values,, as members  of the middle c l a s s , make:them.wish for higher salaries,, or for a release from routine and."dirty" tasks..  They have to  26a  integrate their. images of their_ prof essional selves::-the; image., that': they are . specialists.,, experts,,, highly i n demand,, and' that; their, standard of l i v i n g should, imply, this;,, with" the; image;-that they are .dedicated, to service .to others, and s e l f interesto is., unimportant.  Such contradictions, lead to s t r a i n .  C u l t u r a l Ignorance and.Professional Knowledges C u l t u r a l norms, of the. appropriate behaviour for; young women expect.them to observe, the., correct: inhibitions: with regard, to knowledge, of the.body and sexuality., They are; expected" to show ignorance of such topics:. r  Nursing norms.,  on the other hand, expect; them to be well-versed, i n a l l . aspects of the: human body and to be able to perform nursing, procedures: on this-body.  Students, at;the beginning often have much  d i f f i c u l t y i n tending to male patients.. They show: a marked. awareness: of. the privacy which i s required by patients and place: emphasis: on the correct,draping-and concealing techniques.These . d i f f i c u l t i e s ; are eased by having orderlies; tend to the;"private"" needs of male patients, or by having a male patient ""finish his own bath.,"-" Another s t r a i n . occurs., when these students. go to the operating., theatre.  A l l . pretences at modesty and respect  for: privacy are .dropped, and norms, regarding the human, body are v i o l a t e d as. a normal pattern of behaviour. To think of a l l the trouble we go to to drape the patient,, and here there, is. no thought f o r such a. thing.  C o n f l i c t i n g Attitudes towards Patients: A": well-known contradiction, of a l l professional roles; i s the . dilemma, of e f f i c i e n c y versus humanitarian the nurse, i s e f f i c i e n t , , accurate,, impersonal  views;.,  If  and f u n c t i o n a l l y  specific,, she i s successful, as f a r as the technical, aspects; of her work require her to treat the patient.as an individual, and to show him.the., sympathy and interest: that are. beneficial, to his psychological welfare.  I f she tends: toward, the. former.,,  she. is- defined' as. "'callous'*" and she.violates the nursing norm of "personal care.I*" I f she.tends, towards, the latter.,, she., i s liable, to i d e n t i f y with the patient; to such an extent,, that, her own emotional, s t a b i l i t y i's threatened, when the patient; becomes, worse or dies.  This, i s backed by. her. obvious  preference f o r patients; that., improve,, and therefor.e.j, i n most; cases.,, f o r surgical.patients..  B a r r i e r s to Psychological Care Psychological, care, i s emphasized.. Several other aspects of her existence make t h i s d i f f i c u l t to perform. F i r s t l y , , psychological care means d i f f e r e n t i a t e d care.  Nursing  training tends, to equalize students and to introduce.; a " l i k e mindednes.s.,"" This makes i t more d i f f i c u l t for them to a t t a i n insight into the wide range of problems that could beset a patient.  Secondly,, nursing ..is an. activity-oriented, role,, as  I. have pointed out .before. activity..  Work for a nurse., is., constant.  Psychological understanding,, however,, can only be;  attained, through mental activity..  In. most instances., the kind,  of physical and mental a c t i v i t y required, cannot be carried, out s u c c e s s f u l l y / i f attempted simultaneously., even while performing  Therefore,  a task that requires., l i t t l e  intellectual  concentration,,, such as washing medicine glasses,,; a nurse..cannot direct her thoughts, s u f f i c i e n t l y towards, the psychological problems of a patient.. Thirdly,, nurses are.; faced with the choice between i n s t i t u t i o n a l re.quirments.,  ;  such as charting,  and. paper, work, and the giving..of psychological care..  Hurting,, yet.. Curing^ Often, the process., of curing a patient. involves causing him more pain. who  Nurses, define themselves as. people who  soothe,, and who help..  cure,,,  They have a d e f i n i t e . d i s l i k e for.  nursing techniques, that force them to i n f l i c t pain and. therefore, contradict their-image  of helper... They have; to  rationalizB. their., actions: and to build a. defense. against .wails: of pain and statements such as ."you"re.;cruel,,nurse Undoubtedly, t h i s is; an area of great i n t e r n a l strain.-  The  s e l f has to integrate.the performance: of painful.techniques, with; the: nursing..norm of a l l e v i a t i n g suffering., Another such s t r a i n i s the fear, of error.  Techniques  are;exacting and nurses, are aware of the fact that often any mistake on t h e i r part could injure or even k i l l a. patient.. This, accounts-for the fact that when they are .unsure, of their'  263. a b i l i t i e s ; they show; greater, desirea to tend, to patient's who are cured and do not need, the administration of complicated:, procedures...  I t also explains, t h e i r fear, of the operating., room,  for. here the need. for. accuracy, and speed, are .emphasized.. They are expected.to treat patients as people, and. not to perceives them i n terms; of t h e i r illness;.. This; increases: the s t r a i n of having ..to perform p a i n f u l . techniquesInner, c o n f l i c t s are therefore prevalent in.the operating room where students, see; incisions.,, or worse.-; s t i l l , when students; are asked, to dispose of amputated, limbs..  They adjust to this;-  by developing attitudes where they defined.patients: as:. cases„" ,,:  Ih other.words, they'become u n i v e r s a l i s t i c . Thus strains, occur. i n t h e i r orientation towards: patients... They begin by being p a r t i c u l a r i s t i c , , and then become universalist i c .  At the same, time,. as students, they focus  t h e i r interests, on the s p e c i f i c area of t h e i r tasks..  They  find,, however,, that they become involved i n diffuse, functions. They are then faced with the c o n f l i c t i n g problem of integrating, t h e i r p a r t i c u l a r i s t i c . a t t i t u d e s and specific.areas of function, i h the beginning and t h e i r u n i v e r s a l i s t i c attitudes and d i f f u s e areas, of function when they, begin to