An important process in any profession is the development of professional identity. Because many educational experiences for nursing students occur in hospital settings, it is not surprising students often identify with other professionals in the hospital. In fact, the refrain from many has been to work 1 year in a medical-surgical unit before doing what one really wants to do. As educators across the United States revise curricula to reflect the ever-changing health care environment, clinical settings for students and the intellectual, psychomotor, and communication skills required for various settings are shifting. Educators focus on these skills to help students feel competent and a sense of professionalism. However, do educators know what this sense or experience of professionalism is? Understanding how students experience professionalism is important to provide appropriate educational experiences to foster this aspect of professional socialization.
Students often study and debate nursing's professional status, considering criteria from various sources. According to Zerwekh and Claborn (1997), common criteria are that a profession:
* Provide an important service to society.
* Have a distinct body of knowledge on which its practice is based.
* Be self-regulated.
* Have a code of ethics.
* Require a commitment to lifelong learning.
* Have its own subculture.
Figure 1 . Vases/faces picture representing the concept of figure/ground. Adapted from Valle & Hailing, 1989.
Although the professional status of nursing focuses on nurses in general, the American Association of Colleges of Nursing (AACN) (1998) addressed the individual baccalaureate nursing graduate, for whom it detailed "the essential knowledge, values, and professional behaviors expected" (p. 1). The purpose of the AACN (1998) document was to provide guidance to nurse educators and executives regarding expectations of baccalaureate nurses as they enter into professional practice. According to the AACN (1998), professionalism is transmitted through professional education that encompasses a liberal education, professional values, core competencies, core knowledge, and the development of professional nursing roles. Various strategies to achieve this educational goal have been suggested by the AACN (1998).
Whereas the AACN (1998) approached professional development from a third-person perspective, several studies examined professionalism from a first'person perspective. These studies most frequently refer to professional identity or socialization.
A concept analysis with Schwartz-Barcott and Kim's hybrid model combining "theoretical analysis with fieldwork" (Ohlen & Segesten, 1998, p. 721) validated an analysis of the literature through semistructured interviews with eight nurses. Ohlen and Segesten (1998) concluded that professional identity is "based on personal and interpersonal dimensions from a theoretical perspective focusing on interaction, growth, and maturity" (p. 725). This developmental nature has been well documented in the literature (Reutter, Field, Campbell, & Day, 1997).
Howkins and Ewens (1999), confirming earlier findings, noted that the developmental nature of professional socialization proceeds in "fits and starts," with students playing an active, rather than passive, role. They also emphasized that professional socialization encompasses values and norms, as well as skills and behaviors.
A longitudinal study of professional socialization (n = 17) using grounded theory methodology found a developmental process that culminated in the assumption of a staff nurse role (Gray & Smith, 1999). Socialization was considered in terms of what students could and could not do in the clinical setting. An example of what students said they could do was "assess, plan, implement, and evaluate care from a holistic perspective" (Gray & Smith, 1999, p. 644). However, students said they had "difficulty delegating" (Gray & Smith, 1999, p. 645). The authors concluded that "the mentor is the linchpin of the students' experience" (p. 639).
Mentoring has received much attention in the nursing literature. Glass and Walter (2000) found peer mentoring to have a positive influence on students' personal and professional growth, whereas Cahill (1996) reported mentoring by staff nurses to be more controlling than supportive. Relationships with others are clearly an important facet of professional socialization.
No literature was found describing what it means to an individual to be professional. Nurse educators play a key role in the socialization of new members to the profession. Understanding what it means to be professional will help nurse educators provide student experiences to enhance professional role development. Therefore, this study investigated what it means to be professional from the baccalaureate student nurse's perspective.
This qualitative study was based on Pollio, Henley, and Thompson's (1997) interpretive framework, which takes an existential-phenomenological approach. The pin-pose of the interpretation was to recognize patterns or themes in an experience. Figurai experiences (i.e., experiences that stand out for an individual and are important and meaningful in one's life) emerge against a backdrop, or ground. Figure 1 provides an analogy of figurai/ground experiences-one image cannot exist without the other. Because each image provides the background for the other, only one is clearly in focus (i.e., figurai) at a time. Therefore, the image or experience that stands out for an individual provides significant glimpses into what is meaningful to that person. In this research perspective, unreflected experiences are sought to capture meanings as they are lived.
Pollio et al.'s (1997) approach to an existential-phenomenological inquiry usually involves in-depth phenomenological interviews used to uncover complete descriptions of an experience. Transcripts are read aloud in a qualitative research group for interpretive analysis. With larger groups, Pollio et al. (1997) asks participants to submit a written response to a phenomenological question. In this study, baccalaureate nursing students in professional nursing issues classes described, in writing, specific experiences of feeling professional. Students were asked to, "Think of a specific time in a clinical setting when you felt professional as a nurse. Describe the experience as fully as you can."
The sample was from a baccalaureate program in a metropolitan university in the southeastern United States. Three classes of students taking a professional nursing issues course were invited to participate. Students provided oral and written consent, and the written consent forms were kept separate from the data. Students were told they were not obligated to participate and would not be penalized for not participating. Names did not appear on any of the written work. Demographic data were collected on a separate page and were not connected to the written descriptions. Students also were assured that the written descriptions would be typed by a secretary prior to faculty analysis so handwriting could not be identified.
Students were asked to participate in the study at the beginning of their class period. After informed consent was obtained, the question was written on the blackboard and read to students. Students were asked to describe in detail a specific experience of feeling professional, and they were told there was no time limit. All students had completed writing within 15 minutes. The consent forms were placed in one envelope, the written responses in a second envelope, and the demographic data in a third envelope. This procedure was repeated with two other classes. None of the data were analyzed until data from all classes were obtained.
The researchers (i.e., three faculty members) participated in a bracketing session to clarify preconceptions of the experience for students and their own experience. Notes from this bracketing session were recorded. The analysis was conducted during weekly meetings that included the researchers, other faculty, and interested graduate students. Notes were written directly on the transcripts by all people participating in the analysis.
Prior to analyzing student transcripts, the researchers discussed what being professional in the clinical setting meant to them. This discussion served as the first step in bracketing, a process in which researcher biases are explicated. Bracketing helps researchers see their own perspectives, and although one's perspective cannot truly be put aside, understanding one's biases opens the possibility of seeing other points of view. Included in the discussion were ideas such as collegiality, competence, and connection with others, particularly moments that stand out as being meaningful between a nurse and patient. Discussion also centered on the tension between a focus on tasks and human connection, and students' difficulty integrating both. All researchers believed students would focus on competence in psychomotor skills as the experience of professionalism.
Participants' written descriptions were read aloud in the research group and analyzed in a part-to-whqle dialectic within each description and across descriptions. The individual descriptions were analyzed and then viewed in the context of all the descriptions within a class and then across classes.
In this approach, the interpretations are always in the context of the whole and in participants' terms, and they avoid theoretical explanations. In addition, for all interpretations, specific passages in the descriptions must be offered in support. This keeps the analysis close to the text and continues the bracketing process to avoid an overlay of researcher perspective. Group members should offer competing views, point out biases, and maintain focus on the participants' actual words. Credibility, rather than validity, is a term often used in phenomenology, and the group provides this ongoing credibility. Truth, value, and credibility are maximized by participants reviewing the final structure and by using direct quotations to support the themes. Pollio et al. (1997) offer a complete description of the procedure and process of data analysis.
Participants were enrolled in a nursing program that consisted of five semesters of nursing major courses. Participants were students from three professional nursing issues classes during a 2-year period. The total number of participants was 64, having an age range of 21 to 47. The first class (n = 32; 4 men, 28 women) was near the end of their fifth nursing semester (i.e., near graduation). The second class (n = 18; 2 men, 16 women) was at the beginning of the fourth nursing semester. The third class (n = 14; 2 men, 12 women) was at the beginning of the third nursing semester. The first and second classes were in an older curriculum, based on a traditional medical model, whereas the third class was the first class in a new curriculum that placed more emphasis on nursing science. The first and second classes had completed in-hospital adult nursing and psychiatric mental health clinical rotations, as well as an intensive preceptorship between the junior and senior years. The first class had completed all clinical requirements, whereas the second class was beginning the family nursing rotation. The third class had completed a fundamentals-type clinical course and a community mental health clinical rotation, as well as a nursing science course.
The student experience of being professional was grounded in a world of self and others. From this ground emerged three interrelated themes (Figure 2):
Figure 2. Representation of self and others as backdrop for students' experiences of belonging, knowing, and affirmation.
The ground of self and others provides the backdrop of the experience. It is through self and others that the figurai themes are experienced. It is important to emphasize the interrelatedness of the themes. For example, the experiences of belonging and knowing were affirming to the students, and affirmation enhanced their sense of knowing and belonging.
All experiences described by the students related to people- themselves, nurses, patients, families, or physicians. Self and others places the ground of professionalism in nursing as relational, or oriented toward people. This ground gives rise to the themes. Belonging is, by definition, a connection between self and others. Knowing, as an experience, also is a connection between self and others. While knowing was a self-affirming personal experience, it also was meaningful in how it connected students to patients or others on the team. Finally, affirmation was of self, by self, and by others.
Belonging. Being a valued part of the nursing team was echoed through students' descriptions. They wrote about camaraderie with nurses, as well as other students, during their clinical experiences. Students explicitly noted when they felt "part of the team" or like "a real nurse." The experience of belonging helped them feel pride, affirmed they were "already a professional nurse [sic]," and increased their confidence in expressing what they knew. Students stated:
* I felt professional when I would talk with the doctors on their rounds about my patients. This made me feel as part of the professional staffing of the hospital. I was able to voice my opinion on the care that my patients were receiving from me and also the peers working there.
* I knew, though, that I had acted as a professional and knowledgeable nurse and even though that man died, the team did everything they could to keep him alive and I was a team member. It was a satisfying moment.
Knowing. Knowing was a figurai theme for the participants. This frequently was expressed as an ability to inform patients or families. For example, students stated:
* I was able to answer their questions.
* I can give them [patients, families] information about their medical problems/care and knowledgeably answer their questions.
According to the students, they sometimes knew more than other professionals:
* I also caught some fairly serious mistakes made by a[n] RN on the previous shift.
* Before any of the other nurses, I recognized the patient was in atrial flutter.
Knowing was deeply satisfying to the participants. One student stated, "I felt more complete and whole." Knowing also facilitated students' sense of being competent. Students stated, "I was able to reduce her levels of nervousness by explaining..." and "I could confidently assess..." Knowing helps students feel they belong in a professional team. Another student stated, "I no longer felt like just a nursing student." Knowing also provides an avenue for affirmation of being a professional. According to one student:
For myself, my nursing knowledge and actions make me a professional. However, when this nursing knowledge is applied and the client and family express their appreciation of my nursing efforts, then I feel professional.
Affirmation. Affirmation was an experience of professionalism that surfaced during interactions with others. According to one student, making a difference in someone's fife was affirming:
She [the patient] was appreciative of me, and I felt like I had met her needs . . . she touched me and told me good luck and what a good nurse I would be. That really boosted my self-confidence, and I will always remember her, the baby, family, and overall experience of taking care of a mother and baby.
At times, students experienced affirmation due to their knowledge. One student stated:
Hearing myself explain answers to her questions and seeing her listen so intently to my answers made it very apparent to me what I was doing. I no longer felt like just a nursing student.
Another student experienced affirmation because she made a difference when she persisted about something she knew:
I noticed the report I received didn't match my assessment findings. In reporting this to my preceptor, she was hesitant to check on my patient. Progressively he got worse. Insistently telling my nurse to come and check on the patient, she proceeded to go back to his room. I proceeded to call the doctor. While doing so my preceptor decided to check and, sure enough, he [the patient] had progressively gotten worse. I felt good knowing I possibly saved this patient's life.
Affirmation also was described in terms of external validation from others. Students stated:
* The greatest feeling of all was a simple "thank you" or "you will make a great nurse someday."
* I had one family who just couldn't believe I was in nursing school. They stated that I was so "professional and caring" and that I was a "great nurse." Then I said, well, I'm not a nurse yet. 111 be graduating in 1 year. That made me feel like I was actually a nurse.
* I felt a part of the team when [the] doctor was appreciative that I had noticed this potential problem. Increasing independence also helped affirm students' professionalism. One student stated:
I took the full load of 6 patients. I did an admit [admission] with little supervision by my preceptor. I felt professional in that I had the responsibility to fully care for these patients.
Professionalism has been studied most often from a third-person perspective, examining sociological criteria and the process of socialization, but this says little about what it is to be professional. This study examined the meaning of professionalism to baccalaureate nursing students. Students in this sample represented juniors and seniors; a traditional, medical-based curriculum; and a new nursing and community-based curriculum. However, the themes of being professional transcended these categories.
The themes are not discrete categories but are interconnected experiences. For example, belonging is facilitated and strengthened by knowing and affirmation, while it also bolsters the experience of affirmation. These themes emerged from a ground of self and others.
The need for belonging is basic to humans, who connect to family, friends, and communities. This is emphasized by Merleau-Ponty (1945/1962), who quoted de Saint-Exupéry, "Man is but a network of relationships, and these alone matter to him" (p. 456). Nursing is where these students choose to have a network of relationships, or reciprocal connections with those in a field they hold in high esteem.
Educators have long believed skill acquisition was an important step in the path to professional practice. However, these students described something much deeper than simply competence in the traditional psychomotor skills. Being able to perform the skills was important to them, but the knowing these students described went much deeper. Sometimes the knowing was related to the person for whom they were caring. For example, one student stated, "I knew what he needed."
In phenomenology, humans are seen only in the context of their world- the relationship is inextricable. According to Merleau-Ponty (1945/1962), "there is no inner man, man is in the world, and only in the world does he know himself' (p. xi). It is through others that people know themselves, so it is not surprising that novice nurses look to their world for affirmation. The world that is important to nursing students is nursing.
IMPUCATIONS FOR NURSING
Nurse educators focus on knowledge and skills essential for professional nursing practice. Most curricula also have a professional issues course, which allows for reflection on the profession. However, this type of course often is completed late in the program. Reflective courses or seminars on professionalism should begin with the program-developing a sense of professionalism is equally important as the knowledge and skills.
Keatley (1998) described students' experiences of critical incident stress during painful encounters with nursing staff and faculty in clinical settings. In this study, the critical incidents magnified students' sense of alienation, which left them feeling demeaned and ignorant. Critical incident stress contributes to students' professional socialization in a negative, self-defeating way. This study can be viewed in terms of polar opposites of critical incident stress. Feeling professional meant belonging, not feeling alienated; being affirmed, not feeling demeaned; and knowing, not feeling ignorant.
Early experiences in professional education may enhance professionalism in students. For example, in the authors' former curriculum, students' first clinical experiences were in acute care facilities. Although well supervised, students had limited opportunities to experience the themes expressed in this study. In fact, it was this type of complex environment in which students experienced critical incident stress. In the new curriculum, clinical experiences include blood pressure screenings and immunization clinics, which are well-circumscribed skills that offer opportunities to experience a sense of professionalism. By providing services to communities, students become valued members of a team before they complete the first semester.
As students progress in more complex environments, it is important to continue to structure clinical experiences to enhance the theme of professionalism. For example, faculty often select assignments based on patients and their conditions. However, as Keatleys (1998) study demonstrated, staff often cause critical incident stress. Instead, assignments should be selected based on available staff- only those who genuinely want to contribute positively to students' growth should participate. This will facilitate a sense of belonging and affirmation, while students explore the limits of knowing.
Mentoring is a concept with many definitions that is discussed often in nursing literature. Ashley (1980) asserted the importance of nursing "establishing a community of shared caring" through "meaningful connections with the lives of other nurses" (p. 21). In a study of student experiences with peer mentoring, several themes related directly to the themes found in this study (Glass & Walter, 2000). Glass and Walter (2000) used focus groups and reflective journaling with six participants in a supportive group. Some of the themes these authors reported correspond with those found in this study, including experiencing belonging, feeling validated, and being acknowledged, which emphasizes the human need for connection. Finding suitable mentors in clinical agencies is an important priority for faculty.
For the researchers, who also were part of the research group for Keatle/s (1998) study, the experience of analyzing the data in this study was affirming. In the study of critical incident stress (Keatley, 1998), the researchers often felt defeated reading the transcripts in which students repeatedly related negative experiences with faculty and staff. Students often cried as they recounted painful experiences. In this study, the researchers were uplifted by the positive experiences students expressed. In a postanalysis review of the themes, faculty discussed professionalism, finding the thematic structure resonated with their own experiences. Therefore, the themes were descriptive of both entry-level and experienced nurses.
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