Continuing and inservice educators recognize that our society is faced with ever-increasing ferment over the quality of health care services. The gap between consumer expectations and delivery of health services will remain a problem for years to come. Health care workers themselves readily admit that there is need for improvement in "quality of care." Yet this phrase may remain an empty one unless increasing consideration is given to the personal development of the helpers involved, a great many of them nurses. A general dictum among people helpers says that in order to become more effective one must begin with one's self - the quality of care given by an individual will be consistent with the kind of person that individual is. Paradoxically, nursing has long had a passionate interest in the selfconcept of patients but has not manifested interest in the self-concept of nursing practitioners as persons.
Though the nursing profession comprises the largest group of persons engaged in a helping relationship, comparatively few studies have been done regarding the selfconcept of nurses, particularly graduate nurses. An overview of these studies may provide insights for those who design educational offerings. Further, it will serve as background for the more recent study reported here.
Poland (1961) studied the relationship between self-concept and supervisory and peer ratings with success in nurses' training using a self-descriptive inventory. No significant correlations were found when the group was analyzed in total. When subjects were divided into two groups (most successful and least successful, based on nursing supervisor ratings) it was determined that the most successful students had obtained higher scores on the self-descriptive inventory.
Kormorita (7977,) in her study of the selfconcept of nursing students using 12 measures from Bills Index of Adjustment and Values found significant differences on three of the measures according to year in school. Nine of the 12 self-concept measures correlated with grades of these were more frequently related to clinical grades than to theory grades.
The self-concept has been studied in relation to academic achievement with the majority of investigators finding a positive relationship (Fitts, 1972). In addition, findings cited by Thompson (1972) indicate that good interpersonal communication is associated with a well integrated sellconcept.
Frerichs, (1972) found a significant relationship between age and self-esteem using the Coopersmith Self-Esteem Inventory (among 1435 associate degree nursing students in her study.) Thompson (1972) likewise reported an association between age and self-esteem scores, with older subjects reflecting higher scores. In elderly subjects, this phenomena was perceived as defensiveness and a disinclination toward self-criticism.
Davis (1969) in comparing the selfconcepts and role expectations of nursing and social work students found the nurses' self-concepts best described as conscientious, capable, methodical, dependable, and willing to sustain a subordinate role. In contrast, the social work students described themselves as predominently independent, spontaneous, and assertive. If this study were repeated in 1975 there would conceivably be changes not only in the attitudes of female nursing students but also changes attributable to the influx of men into the nursing profession in recent years.
Nevertheless, nurses have not for the most part been encouraged to expand their self-awareness and to view themselves as "first human beings, and then nurses" according to Wilson (1971) who speaks of the need for nurses to develop a sense of self-identity, independent and different from culturally ascribed roles.
It must be remembered that internalized motivation toward self-growth and development is basic and essential to any external efforts to increase technical proficiency, supervisory capacities, or further human relations skills which are becoming increasingly important to the nursing profession. Thus the need arises to examine the levels of self-improvement motivation or aspiration felt by nurses.
Studies done regarding aspiration in nursing practice have centered around job satisfaction. $\ocum(T972) based his study on Maslow's theory of need pre-potency in which an individual, after satisfying his basic needs, turns attention to higher order needs such as those for affiliation, nurturance, and esteem. Finally, if the individual has achieved some degree of satisfaction of these first-order and middleorder needs, he may spend effort in trying to satisfy the highest order need, that of self-actualization or fulfillment. . ."the desire to become more and more what one is, to become everything that one is capable of becoming..." (Maslow, 1970). Slocum advised administrators to focus on reducing deficiencies in all need categories, but especially in selfactualization needs by providing "on-thejob opportunities for nursing personnel to meet their expectations for growth, development, and self-fulfillment."
Saleh (7965) in a study of nursing turnover, found that over 30 percent of the nurses in his study left employment because their work was not appreciated or recognized, because of lack of advancement possibilities, or because they wanted new experience elsewhere. These nurses did not find a chance to achieve what they expected. Their work did not satisfy their needs for what may be called self-actualization or psychological growth.
Here the implications for continuing educators and staff development personnel come sharply into focus. As Erik Erîkson's phrase reminds us " identity is never gained nor maintained once and for all." Often by changing a person's situation, that person can be encouraged to change, to grow, progress. . .the working assumption being that people can and do change. This is an area frequently neglected by mservice and continuing education programs: emphasis on increasing interpersonal skills and selfassessment with regard to one's actions and their impact on others. An expanded self-awareness is essential to a well integrated personality able to give ego support and compassionate care to clients and families. As Rogers (1958) and Combs (1969) have maintained, effective helping relationships are firmly grounded in the helper's adequacy as a human being.
STUDY METHODS AND DESCRIPTION OF SAMPLE
This study was undertaken with the intention of discerning the level of selfesteem and career aspiration held by nurse participants of continuing education and to determine the relationship between selfesteem and career aspiration in these nurses. Additionally, the study examined selected background variables of the nurse participants - age, marital status, children, husband's educational and occupational level, length of active nursing experience, present position, future educational and career goals, and stated primary reason for continuing education attendance - all in an effort to identify significant relationships between these factors and self-esteem or career aspiration.
The sample consisted of 503 registered nurses out of a possible 1,301 who had participated in the Continuing Nursing Education program at a large private university during a two and one-half year period. Mailed questionnaires were sent initially to 402 randomly chosen participants from among this group. The Rosenberg Self-Esteem Scale (SES} and the Hall Occupational Orientation Inventory (HOOI) aspiration scale were incorporated, with appropriate permission, into the questionnaire to determine the self-esteem and career aspiration of the sample group. Both measures have been well documented by usage of numerous researchers. Returns quickly revealed high scores on the Rosenberg SES. In order to test the validity of such high self-esteem scores, an additional measure was added to the questionnaire - the Coopersmith SelfEsteem Inventory (SEI) -and another group of 400 randomly chosen subjects from the same population were mailed this instrument.
The return rate for Group I who had received the initial questionnaire containing only one measure of selfesteem was 267 out of 402 mailed (66 percent); the corresponding rate for Group Il who had received the same questionnaire plus an additional self-esteem instrument was 236 out of 400 mailed (59 percent). Together, these two groups comprised the total sample of 503 nurse participants of continuing education who responded to the survey.
Generalizing from the data, we find a composite picture of the "typical" nurse participant of continuing education: she is married, has one or two children, and is employed full time in a hospital. She is under 30 years of age, has worked for at least four years and is likely to be employed as a staff nurse. Her career goals in terms of five years hence are those of instructor or supervisor. Her ultimate professional objective is likely to be a position as director of nursing. Her husband holds at least an associate degree and is engaged in a professional or semiprofessional occupation. She attends continuing education courses primarily as a way of keeping "up to date" with current practice, and is not likely to seek further formal education for herself. If she is lucky, her continuing education expenses are paid totally by her employing agency (42.3 percent) but almost just as likely is that she assumes the entire cost (33.4 percent).
One could infer from results of previously cited personality studies done with nurses in the not-too-distant past that nurses would hold relatively low self-attitudes. Nurses' abilities to fill subservient roles and their frequent submissive stance had often gained them a reputation for reticence. Also, it was frequently assumed that nurses as a group were not especially advancement oriented in terms of their careers and not particularly eager to take on additional responsibilities. Generalizations such as these in the literature had led the researcher to examine the actual self-esteem and career aspiration among the aforementioned registered nurse sample.
The data clearly did not support the above contentions. To the contrary, the registered nurses in this sample reported high self-esteem and relatively high levels of career aspiration. There was also one significant correlation between self-esteem and career aspiration: those nurses scoring lower on self-esteem also scored lower on career aspiration.
In addition, the nurses in this sample were not found to be different in career aspiration or self-esteem on the basis of marital status, children, or their husbands' attainments. Differences in self-esteem were evident between those having further formal educational plans and those not having such plans with the former group exhibiting higher self-esteem. Also, those nurses having further formal educational plans scored significantly higher on the HOOI aspiration scale than their less educationally minded nursing colleagues.
The overall self-esteem scores on both the Rosenberg SES and Coopersmith SEI were skewed in the direction of high selfesteem. For example, the SES mean for the total sample of 503 nurses was 4.99 with the maximum score being 6. Likewise, for the 236 nurses who additionally responded to the SEI, the mean was 82.5 with a possible score range of 0-100. In line with such results, a correlation of .42 (statistically significant at .01 level} was found between the Rosenberg SES and Coopersmith SEI. both of course designed to measure selfesteem.
With regard to career aspiration, the majority of HOOI aspiration scores were in the middle range (stanine scores 4-6) with 57.1 percent of the nurses reporting scores in this range. However, nearly one-third of the sample group (32.6 percent) scored high on the HOOI aspiration scale with stanine scores in the 7-9 range. Relatively few nurses (10.3 percent) reported scores in the lowest range of 1-3 on the scale. The overall mean score for the 503 registered nurses on the HOOl aspiration scale was 5.7 with the maximum stanine score being 9.
Individual responses to self-esteem and career aspiration measures in this study indicated that few generalizations cou Id be made on the basis of biographical data. Therefore, it was not possible to characterize the participant nurse as to self-esteem or career aspiration on the basis of age (the one exception being higher career aspiration manifested by those under age 30), marital status, children, length of nursing experience, or present position. These factors appeared to bear little relationship to the self-esteem or career aspiration of the nurses studied, nor was their husbands' educational or occupational level, or their reason for attending continuing education programs revealed to be associated with differences in self-esteem or career aspiration scores. Significant relationships revealed by this study were between self-esteem and level of projected goals (both five-year projections and ultimate professional objectives), and also between career aspiration (and self-esteem) and further educational plans.
The relationship found between selfesteem and career projections indicates that high career goals were associated with high self-esteem in the nurses studied, lower self-esteem with lower career goals. For these nurses, their self-esteem was congruent with career goals chosen for themselves. It could be further inferred of course that at some point in time those with lower self-esteem had adjusted their career aspirations downward in keeping with their own self-attitudes, while those with more favorable self-attitudes set their sights higher.
In this regard, Coopersmith (7967, p. 147) proposes that "experiences of success lead to expectations of success and that aspirations mirror these expectations." Thus, the high esteem individual perceives his world as bright and friendly, the low esteem person often perceives the same world as dark and threatening. According to Coopersmith, this pessimism and lack of confidence lowers aspirations so that a self-fulfilling prophecy effect occurs.
In speaking of further educational plans held by nurses in relation to their selfesteem it seems likely that the above explanation by Coopersmith could also be considered. For example, a striking difference in self-esteem occurred on the Coopersmith SEI between these two groups: those nurses indicating further educational plans reported a mean of 85.2 on the SEI while those with no such plans reported a mean of 80.5, nearly five points lower! This marked difference clearly points to an area where further research may be indicated.
Another finding of import is that concerning the level of career aspiration manifested by nearly one-third of the sample group. In this study, 165 of the 503 nurse subjects reported HOOI aspiration scores indicating an advancement type orientation toward work activity. These nurses, by their HOOI scores, clearly indicated a willingness to accept more responsibility and a determination to "get ahead," through extra effort. This is in contrast to the picture given by earlier personality studies done with nurses.
The generally high level of self-esteem evidenced by the nurses in this sample indicates a high degree of potential professional effectiveness based on the tenets of self-psychology. These nurses are capable of much in the way of ego support for patients and their families: a meaningful finding in light of continual need to increase skill in the area of human relations. Such nurses, with a firm base of self-esteem, have much to build on in their relationships with other members of the health team. The days of standing back and apart may be truly over for nurses as they move toward increasing involvement in their own destiny.
Further research is needed to substantiate the findings of this study among other samples of registered nurses to determine if the patterns reflected here are consistent with overall tendencies of registered nurses in other settings. We cannot assume such high levels of selfesteem in other registered nurse populations without such validation. Accordingly, those persons involved with continuing education and staff development programs need to consider offerings related to interpersonal skills with emphasis on self-assessment.
Self-renewal workshops are one avenue of approach to this problem and are being adopted by continuing educators in an effort to reach the often neglected but basic of all nursing skills - enhancement of the human personality of the helper. Such workshops, which focus on examination of attitudes, feelings, values, and getting in touch with one's self are, a source of renewed vigor to continue in demanding helping relationships. Continuing educators 'thus have a tremendous contribution to make to the self-development of the nurses in their programs and indirectly to the patients and personnel whom their lives touch.
Nurses are at the crossroads and it may well be that unless the profession (and nurses individually) undergo a major selfassessment to include seeing ourselves as others see us, we may be in for some surprises. One of the most encouraging signs that nurses are beginning to look at themselves in a new light came from a student nurse's comment upon her recent graduation from a baccalaureate program and quoted in a local newspaper. "I am a person. I am a woman. We are persons who are nurses, and we deal with persons who are patients." This statement though seemingly simple, illustrates a profound sense of new identity, grounded in selfconfidence, and with fewer illusions. One cannot help but feel that such strength will be a needed infusion for the work ahead as expanded roles for nurses increase and new challenges are met. Many stereotyped images of nurses will be swept away in the process.
- Combs A: The nature of the helping professions. Florida Studies in the Helping Professions, University of Florida Monographs: Social Sciences No. 37, University of Florida Press, 1969.
- Coopersmith S: The antecedents of self-esteem. San Francisco, W-H. Freeman, 1967.
- Davis A: Self-concept, occupational role expectations, and occupational choice in nursing and social work. Nurs Res 18:55-59, 1969.
- Erikson E: Childhood and society. New York, W.W. Norton, 1950.
- Fitts W: The self-concept and performance. Nashville, Tennessee, Counselor Recordings and Tests. 1972.
- Frerichs MC: Relationship between age and dogmatism, internal versus external control, self-esteem, and grade point averages, among community college nursing students. Unpublished doctoral dissertation. Northern Illinois University, 1972.
- Komorita N: Self-concept measures as related to achievement in nursing education. Unpublished doctoral dissertation, Wayne State University, 1971.
- Maslow A: Motivation and personality (2nd ed). New York, Harper and Row, 1970.
- Poland H: The relationship between self-concept and supervisory and peer ratings of success in nurses' training. Unpublished doctoral dissertation, Fordham University, 1961.
- Rogers C: The characteristics of a helping relationship. Personnel Quid J 37:6-16, 1958.
- Saleh S: Why nurses leave their jobs - an analysis of female turnover. Personnel Adminis 27:25-28, 1965.
- Slocum J: An Analysis of need satisfaction and job performance among professional and paraprofessional hospital personnel- Nurs Res 21:338-341, 1972.
- Thompson W: Correlates of the self-concept. Nashville. Tennessee, Counselor Recordings and Tests, 1972.
- Wilson V: An analysis of femininity in nursing. Amer Behav Sci 15:213-220, 1971.