The American Nurses' Association (ANA) has its roots in a meeting that took place in Chicago in 1883 at which Edith Draper, Superintendent of Illinois Training School, Chicago, addressed the need for the national unification of nurses and the establishment of a national association (Hampton, 1949). As far back as those early days, nursing leaders saw the need for a strong association that would unite and strengthen nurses in their professional responsibility of service to the public. Today, the purpose of the Association continues to focus on improvement of health standards and availability of health care services for all in addition to promoting the professional development of nurses (ANA, 1980).
We are faced with a serious problem of declining membership in the professional association, and this crisis in membership has been consistent over the years. Approximately 14% of all registered nurses are actual members of the Association. Declining membership has been a concern of leaders within the Association and no doubt has been one of the driving forces behind the organizational restructuring of the ANA from an individual membership association to a federation of state nurses' associations (American Nurses' Association, 1982). Though efficiency of operation and strength at the state level is a hoped for result, membership may continue to be a problem since basically the act of officially becoming a member of the association does not change.
This study was designed to determine if there are relationships among models of influence, other association experiences, and attitudes toward the ANA and professionalism and ANA membership patterns of first-year baccalaureate nurse graduates joining or not joining the American Nurses' Association. The purposes of this study were to:
1. identify influencing factors affecting membership in the professional association;
2. examine the relationships among influencing factors of membership in the ANA;
3. provide information conducive to recruitment of nurse graduates into the professional association;
4. provide information on the continuing learning needs of graduate nurses regarding their socialization to the profession and to the ANA.
Review of the Literature
Social evaluation theories, specifically, reference group theory, provide a framework for exploring factors influencing socialization of new graduates to the professional association. Merton (1957), Brim (1976), Hyman (1942), and Lum (1978) stressed the influence reference groups have in the process of socialization.
Eisenstadt (1954I saw reference groups as determinants of an individual's behaviors, attitudes, opinions, and beliefs. He identified the importance of "communicators" of various types as significant to one's orientation to reference group norms. The concept of communicators is a basic component in looking at the effect deans, faculty, supervisors, and peers have as models of influence for the new graduate with respect to her decision to join or not join the American Nurses' Association. In addition, the relationships among the graduates' attitudes toward the ANA and professionalism will reflect the extent to which the graduate identifies with the professional association as a meaningful reference group.
Corwin and Taves (1962), Kramer (1968), and Lurie (1981) all found the work setting to be a major socializing influence on the professionalism of young practitioners.
Hall (1968) studied professionalization and bureaucratization among various occupations, including nursing. He found nurses to be strongly professionalized regarding "belief in service" and a "sense of calling."
Simons (1982) used Hall's Professional Inventory Scale to examine the relationship of education, work experience, and position of employment to professionalism in nursing and found that nurse managers had a higher mean score than staff nurses for two scales: the professional organization as a major reference and feeling of autonomy. If nurse managers scored higher on these scales, the work setting must be considered with regard to the rapport managers have with new graduates, and the potential managers have for modeling professional association behaviors.
Since studies on professionalism have been so varied and complex, it is imperative to examine professionalism as it relates to ANA membership and belief in the importance of the professional association to plan better for dealing with the need for member expansion.
This study was conducted using an exploratory survey design with a mailed questionnaire.
Sample: Deans of the generic baccalaureate nursing programs within New York, New Jersey, and Pennsylvania were contacted to determine their willingness and ability to participate in the study by supplying a mailing list of 1981 graduates. A systematic sampling procedure was used to select respondents from available lists, using a random start. Based on the number of 1981 graduates from each state as reported by the National League for Nursing in September, 1982 (personal communication), a sample of 75 graduates from each state was determined to be sufficient for data analysis. An overall response rate of 40% was obtained. No identification of subjects was made.
Instrument: The questionnaire consisted of four sections. Section A consisted of a four-point 20-item measurement scale of the subject's perception of the importance of ANA held by deans, faculty, supervisors, head nurses, and peers. Six additional items asked for the extent to which specific models influenced the subjects decision concerning membership in the ANA. Two open-ended questions in this section requested information regarding any other influences for or against membership in the ANA.
Section B consisted of a five-point measurement scale of the subject's value and opinion of ANA's functions, activities, and issues. The 18 items on this scale were developed based on the purpose and functions of the ANA as outlined in the bylaws of the Association (ANA, 1980) and in review of the literature regarding criteria for a profession. An open-ended question in this section requested subjects to comment about the ANA and its functions, activities, and issues.
Section C consisted of 25 selected items from Hall's Professional Inventory Scale.
Section D included items concerning ANA membership, other association experience, curriculum content regarding professionalism and information about the ANA, and demographic data.
The initial draft of the questionnaire was reviewed by a panel of experts to determine the clarity of the directions and the clarity of meaning of the statements. The content validity of the instrument also was established by this process. Construct validity of the measurement scale regarding attitude toward ANA and professionalism was established through logical analysis of the items with the literature regarding the ANA purposes, activities, and issues and criteria for a profession. Reliability of the ANA scale was established in the pilot study, which demonstrated a coefficient a - .80. The same method was used to establish reliability in the sample study.
Hall's Professional Inventory Scale was factored into five scales measuring attitudinal attributes having to do with the use of the professional organization as a major referent, a belief in service to the public, belief in self regulation, a sense of calling, and autonomy. He obtained a reliability of .80 and the tool was chosen for its reliability and its apparent content validity regarding what constitutes professionals as defined in the literature.
The majority of the sample (N = 163 1 were between 21 and 24 years of age. Almost all respondents were female, 155, and employed full time ( 77<7f ). In total, 20 (12.3%) of the respondents were engaged in some study program.
Membership Status and Previous Association Experience: Of 162 responding to the question regarding ANA membership, 130 reported that they were not members at any level. There were 24 tri-levei members, two bi-Ievel members, five state-only members, and one district-only member. Fewer than half (39.9%) reported that they had been members of the National Student Nurses' Association (NSNA). Few belonged to other organizations except for Sigma Theta Tau and alumni associations. When asked for other comments they would like to share about what influenced their membership status in the ANA, the three largest areas of comment had to do with membership fees being too high, lack of information about the ANA, and a desire to be professional.
Models of Influence: Respondents were asked their perceptions of how different models felt about the ANA. An average of 135 respondents (82.8%) perceived the dean to have been encouraging regarding faculty participation in ANA and student participation in NSNA. Sixty-five graduates (39.9%) were not sure if the dean was a member of ANA; however, 97 (59.5%) perceived her as being an active member. Some 150 respondents (92.0% ) perceived faculty as discussing and stressing membership in ANA as important as well as 142 (87.1% ) who perceived faculty as encouraging participation in the NSNA. A majority, 110 (67.5% ), felt the faculty did share their experiences in professional associations with students.
Nursing supervisors were perceived by 70.6% of the graduates as not encouraging their participation in ANA, and 72.2% of the sample agreed that supervisors did not share information about the activities and issues of ANA. Eighty-four percent disagreed with the statement that head nurses encouraged ANA participation; only 9.2% perceived head nurses as sharing information with them about activities and issues of the ANA.
In general, respondents did not know if their peers were members of ANA or other associations. About 68.7% of graduates felt their peers were not interested or enthusiastic about the ANA.
Respondents were asked specifically if deans, faculty, supervisors, head nurses, peers, or staff of NSNA had any influence on their decision concerning membership in the ANA. Supervisors, head nurses, peers, and staff of NSNA were reported by a large number of respondents as having had no influence on their decision, with supervisors and head nurses category having the highest negative responses. Of respondents, 52.8% felt the dean had no influence, while 46% felt she did influence them to join. Respondents also were divided on faculty influences, with 39% reporting they had no influence and 59% feeling they did. About one third did see NSNA staff as influencing them to join.
In identifying course content regarding professionalism and the ANA, 95.7% and 81.6% respectively, reported having had the content in their curriculum; 14% of respondents reported no content about the ANA. Content was distributed over the four years with the largest percent of respondents (19.4% ) identifying the senior year.
MEAN SCORES ON FIVE FACTORS - ANA SCALE
COMPARISON OF MEAN SCORES ON FACTOR I OF HALL'S SCALE AND MEMBERSHIP IN ANA
COMPARISON OF MEAN SCORES ON FACTOR V OF ANA SCALE AND MEMBERSHIP IN ANA
Attitudes and Opinions of ANA's Functions, Activities, and Issues: Responses referring to opinions of ANA were factored by using varimax rotation. The data yielded five factors. Loadings of .30 or higher were deemed meaningful. In this investigation, factor analysis of the ANA items was used to construct scales representing the specific functions, activities, and issues of the ANA to which the participants could respond and be measured on. Reliabilities of the five generated factors were estimated using Cronbach's Alpha method to determine internal consistency and ranged from .818 (Factor I, Promoter of Standards) to .357 (Factor IV, Role in Economic and Ethical Welfare, and Continuing Education) and indicate, with the exception of Factor IV. that the factors are reliable.
Mean scores on the five factors ranged from 20.75 (Voice for Nursing) to 8.22 (Role in Economic and Ethical Welfare, and Continuing Education). Mean scores and standard deviations on each of the factors for the entire sample are reported in Table 1.
Attitudes Ibward Professionalism: Factor arrays for Hall's Professional Inventory Scale as reported in the literature are labeled as "Use of the Professional Organization as a Major Referent," "Belief in Public Service," "Belief in Self-Regulation," "Sense of Calling to the Field," and "Autonomy." Mean scale scores were computed. The respondents scored highest on Belief in Public Service (19.48) followed by Belief in Self-Regulation (18.41!, then Use of the Professional Organization as a Major Referent (16.6), Autonomy (15.81), and last, Sense of Calling to the Field (14.38).
Other Relationships: Comparisons between factors in the ANA scale and Hall's Professional Inventory Scale were computed using Pearson product-moment correlations. Only two factors from the ANA scale were found to have a significant relationship to one factor on Hall's scale; Use of the Professional Organization as a Major Referent was related positively to identifying the ANA as a Promoter of Standards (r - .26) and As the Voice for Nursing (r - .27). No other significant relationships were found.
Having had ANA content in the curriculum was related to two factors in the ANA scale, Role of ANA as Voice for Nursing (t - 4.13, df - 154, p =<. 05), and Role of ANA as Promoter of Human Rights (t - 2.88, df - 152, p =<.05). Having had professionalism content was not significantly related to any factor on the ANA scale or on Halls scale. There were no significant differences among those who had had ANA content and professionalism in their curriculum and mean scores on Hall's Professional Inventory Scale.
Membership status and Using the Professional Organization as a Major Referent, and seeing the Role of ANA as Accreditor yielded a significant difference as described in Tables 2 and 3. However, whether one was a member or not and mean scores on Hall's scale did not yield a significant difference. There were no significant differences between graduates who were members of NSNA and those who were not in relation to them becoming members of ANA.
Since the respondents did not identify with the professional association through membership nor were they seeking identification with other nursing groups, it would appear they were not oriented to the ANA or to specialty organizations as reference groups for their own professional identity. There were no significant differences between those who were members of the student association and those who were not and membership in the ANA.
Deans and faculty members were reported as being perceived by the respondents as most positive toward the ANA as compared with supervisors, head nurses, and peers. The graduate saw the dean and faculty members as encouraging ANA membership among themselves and for other nurses and as encouraging NSNA membership for students. Faculty were identified as having most influenced graduates to join the ANA. This does not mean they became members, as only 32 were members, but that they felt faculty had been more positive toward membership as compared to deans, supervisors, head nurses, peers, and NSNA staff. In contrast, respondents reported peers, supervisors, and head nurses as being negative influences regarding ANA membership. Although respondents identified faculty and deans as positive influences toward ANA this influence did not appear to have increased ANA membership for this sample.
The data in this study do support the consistency of respondents in identifying the ANA as nursing's professional association and as having the responsibility of speaking for nursing and promoting standards for the profession.
Having had content dealing with professionalism in the curriculum had no significant relationship with any of the factors on the ANA and Hall scales. Having had content about the ANA did have a positive significant relationship with seeing the ANA as a Promotor of Human Rights and as a Voice for Nursing. Curriculum content did not appear to be a major influence for the respondents in this sample with regard to their perception of the ANA and their level of professionalism. Of interest is that of 156 respondents, 23 (15%) indicated that they had had no ANA content in their curriculum. This is important in light of the fact that all were graduates of baccalaureate programs.
There were positive significant differences between ANA members and nonmembers in relation to Use of the Professional Organization as a Major Referent and seeing the ANA as Accreditor. Prior membership in the National Student Nurses' Association was not significantly related to membership in the ANA.
Limitations: Findings of this study can be generalized only to graduates of basic generic baccalaureate nursing programs within New York, New Jersey, or Pennsylvania. Inherent in a mailed questionnaire is the possibility of a low response rate, with a potential bias in responses of actual participants. Since the questionnaire deals with perceptions, values, and opinions, it is important to keep in mind that the data collected represent what the respondent says she or he perceives, values, and has opinions about. What the respondent actually feels, values, and does may be quite different. The study is limited to examining relationships among four variables of influence regarding membership in the association; other variables not examined in the present study may serve to influence membership. Opinions and attitudes toward the ANA and professionalism could not be related to behavior in this study. The voicing of favorable opinions regarding the ANA and being professional may represent socially acceptable responses.
Implications and Recommendations: Findings from this study have identified a gap between being committed to the values of the American Nurses Association and actual membership in that Association. Further study is needed in the area of value, attitude, and behavior in relation to this phenomenon. The ANA has the responsibility to address the issue of low membership in regard to those areas identified by the respondents as lack of information, high fees, and not relating to the "working nurses." The change in structure from individual membership to a federation of states model may not be the answer to increased membership. The Association must become more visible at the local and state level. Interests and concerns of the Association need to be congruent with those of the working majority, i.e., those employed as general staff in institutional settings.
Professionalism content in the curriculum needs to be examined in light of the lack of relationship between having the content and scores on the professionalism scale and membership in the ANA. Research concerning what is being taught and its relevance for the professional association is crucial. Schools need to set specific objectives with regard to socialization of the student to the professional association. Faculty need to explore their own behavior in regard to their actual participation on the local and state level and how that behavior is transfered to their students. The role of faculty as mentor needs to be seriously considered. Given the importance of our professional image regarding unity, and the political power that unity can provide, it is imperative that this issue be addressed at the student level of beginning professional socialization.
Although some respondents belonged to the National Student Nurses' Association, a general lack of transference of that experience to membership in the ANA was described. Given fees for the beginning graduate are lower at present, other appeals to professional identity, benefits derived from membership, and beginning practitioner support in regard to clinical practice should be developed and advertised.
The work setting has been identified as a negative influence regarding the professional association. Supervisors and head nurses, though identified within the setting as management in most cases, need to look at themselves and their behavior as professionals. In the past, professional behavior studies have dealt with clinical nursing behaviors. Attitudes and opinions of professional nursing staff regarding their orientation to the professional association need to be identified, and the relationship of these behaviors to those of the professional neophyte should be compared in order to work toward improving professional role model behavior in the work setting. Professional socialization of beginning practitioners does not cease upon graduation. We need now to be concerned with supervisors' and head nurses' continued socialization to the ANA if graduates are to perceive them as positive influencing models with regard to their membership in the American Nurses' Association.
Given the findings of this study that graduates do indeed perceive the ANA as the professional representative for nurses but fail to join the Association, we now need to study the negative influencing factors identified in an effort to increase membership.
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MEAN SCORES ON FIVE FACTORS - ANA SCALE
COMPARISON OF MEAN SCORES ON FACTOR I OF HALL'S SCALE AND MEMBERSHIP IN ANA
COMPARISON OF MEAN SCORES ON FACTOR V OF ANA SCALE AND MEMBERSHIP IN ANA