Journal of Nursing Education

Beginning Students' Definitions of Nursing: An Inductive Framework of Professional Identity

Tom H Cook, PhD, RN; Mary Jo Gilmer, PhD, RN; Carolyn J Bess, DSN, RN

Abstract

ABSTRACT

Nursing identity is a developmental process that evolves throughout professional nurses' careers. Educational systems that prepare nurses include experiences that are important in the early development of nursing identity. Therefore, faculty in nursing programs are interested in understanding how their students perceive and define professional identity.

For this study, a qualitative design was selected to explore students' early beliefs and concepts about nursing. Data were collected on the students' first day of the nursing program using the open-ended question, "What is your definition of nursing?" Using a qualitative descriptive approach, thematic analyses of the data are provided. Results revealed an inductive framework of professional nursing identity based on students* descriptions and definitions of nursing.

These results demonstrate that nursing students come to an educational program with more than a rudimentary conception of professional identity. Use of these data may lead to opportunities to improve nursing students' educational experiences and foster tibe development of professional identity. Faculty can use knowledge of students' definitions of nursing to enrich student learning.

Abstract

ABSTRACT

Nursing identity is a developmental process that evolves throughout professional nurses' careers. Educational systems that prepare nurses include experiences that are important in the early development of nursing identity. Therefore, faculty in nursing programs are interested in understanding how their students perceive and define professional identity.

For this study, a qualitative design was selected to explore students' early beliefs and concepts about nursing. Data were collected on the students' first day of the nursing program using the open-ended question, "What is your definition of nursing?" Using a qualitative descriptive approach, thematic analyses of the data are provided. Results revealed an inductive framework of professional nursing identity based on students* descriptions and definitions of nursing.

These results demonstrate that nursing students come to an educational program with more than a rudimentary conception of professional identity. Use of these data may lead to opportunities to improve nursing students' educational experiences and foster tibe development of professional identity. Faculty can use knowledge of students' definitions of nursing to enrich student learning.

Educational systems that prepare nurses are challenged to meet the demands of an ever-changing health care environment (Buerhaus & Staiger, 1996). The U.S. health care system constantly struggles with challenges that profoundly affect both consumers and the availability of health care providers. The current nursing shortage supports the need for nursing faculty to develop educational opportunities that prepare professionally versatile nurses to respond to the changing health care environment. One important aspect of preparing professional nurses is supporting the development of their nursing identity.

Identity is foundational to professional nursing practice. Identity in nursing can be defined as the development within nurses of an internal representation of people-environment interactions in the exploration of human responses to actual or potential health problems. Professional identity is foundational to the assumption of various nursing roles (Ohlen & Segesten, 1998). Given the current nursing shortage, nurse educators must explore educational initiatives that enrich the development of nursing identity in their students.

Because nursing students are expected to develop an understanding of their evolving nursing identity, nursing education programs should include didactic and clinical experiences that help students develop this professional identity. Faculty members' understanding of beginning students' definitions of nursing can provide insights that can be used to develop educational experiences that support and enhance students* professional nursing identity and ultimately affect their future practice. This study analyzed beginning nursing students' definitions of nursing to develop a framework to foster nursing students' professional identity.

LTTERATURE REVIEW

Although there is a lack of literature related to beginning students' definitions of nursing, the available studies Eire predicated on the concepta of personal and professional identity. Glen (1998) posited that the existence of professional identity is contingent on personal identity. Erikson (1968) and Bronfenbrenner (1979) proposed theoretical underpinnings for a discussion of personal identity development. Three of the eight psychosocial stages of development described by Erikson (1968) relate to identity formation and development.

In The Ecology of Human Development, Bronfenbrenner (1979) explored human development in the context of environmental influences. He contended that human development, including identity formation, is a function of the interactions of people and their environment. According to Bronfenbrenner (1979), through a systematic study of the processes in which people and environments interact, researchers may seek to understand the process of continuity and change in individuals' characteristics throughout the Ufe span. In this way, personal identity provides a framework for examining professional identity.

Flexner (1915) extended the concept of personal identity development by describing criteria of a profession as knowledge, individual responsibility, autonomy, and altruism. Research has begun to emerge that focuses on nursing students' perceptions of professional identity (Manninen, 1998). Studies include attention to conceptualizations of nursing, influences on identity development, and descriptions of nursing components (Ohlen & Segesten, 1998; Watson, Deary, & Lea, 1999).

Early conceptualization of an identity in nursing may contribute to student success. Beck (2000) described an opportunity to express their desire and love to help other people as one aspect that motivated University of Connecticut nursing students (N = 27) to choose nursing as a career. Several countries outside of the United States have identified the progression of nursing students' conceptualization of nursing. Spouse's (2000) interviews with British nursing students (N = 10) indicated retention in the program tended to correlate with the early presence of foundational ideas on how students envisioned themselves practicing as nurses in the future.

À positive indication of identity development in England was demonstrated in Buckenham's (1988) survey of 190 student nurses, staff nurses, and ward sisters. First-year nursing students' perceptions of the staff nurse role were significantly different from staff nurses' perceptions. However, second-year students' perceptions were more congruent with those of staff nurses. The influence of preceptors, educators, patients, and health care team members; students' own self-esteem, knowledge, and skill level; and nursing identity were shown to mold students' (N - 30) development in Sweden (Fagerberg & Ekman, 1998).

The theme of caring as a component of nursing identity was highlighted in several studies conducted outside of the United States. One study contrasted perceptions of nursing and medical students. Irish medical (N = 11) and nursing UV » 19) students' attitudes toward their professions were compared in a cross-sectional, descriptive study using a 31-item questionnaire. Significant findings revealed that medical students were more "cure oriented," while nursing students were more "care oriented" (Ryan & McKenna, 1994). Watson et al. (1999) used the 35-item Caring Dimensions Inventory and the 35-item Nursing Dimensions Inventory in their longitudinal study of Scottish nursing students. Results indicated that after 1 year of education, the students' UV = 124) idealism regarding nursing and caring had diminished somewhat. However, the remainder of the inventory concepts identified in year one were perceived as being synonymous 1 year later by the same students.

Qualities of the "ideal type" of nurse indicated by Australian nursing students (N = 173), participating in a cross-sectional, descriptive study, included a strong orientation toward service to clients and an emphasis on caring for people (du Toit, 1995). Manninen's (1998) study of Finnish nursing students (¿V = 158) in the last phase of education found that students most strongly viewed the role of nursing as a professional activity with a scientific knowledge base that advocates health promotion and human well-being. This description of nursing components indicates a higher level of synthesis, which is necessary for professional identity development.

In summary, several studies have explored nursing students' perceptions of professional identity, but few investigated nursing students' perceptions of professional identity in the United States, despite a rapidly changing health care environment and current nursing shortage. Studies have described reasons students choose nursing as a career, their attitudes toward nursing, and the components of an ideal nurse, but no studies have used a qualitative, descriptive approach to develop an inductive framework of professional identity. Addressing this gap in the literature can help develop experiences within nursing programs that influence formation of nursing identity.

METHOD

In this study, which was approved by the university Institutional Review Board, a qualitative, descriptive design was used to generate comprehensive descriptions of nursing students' definitions of nursing. The qualitative, descriptive method refers to a fundamental approach to qualitative data analysis that produces a "valued end product in itself* (Sandelowski, 2000). The study population was nursing students enrolled in a university nursing program located in the southeastern United States. On their first day of the nursing program, toward the end of a regularly scheduled class, all incoming students wishing to participate were asked an open-ended question regarding their definitions of nursing. Students not wishing to participate exited the room without missing any class content. The question was administered anonymously using a coding format, Unking data only, not individuals. The data from the nursing students were composed of clear, concise statements describing their understanding of professional nursing.

Sample

One hundred fourteen students were approached for the study, and 5 chose not to participate. Therefore, 109 beginning nursing students comprised the sample. Students' ages ranged from 19 to 45, with a mean age of 25.4. Eighty-seven percent were women, and 89% Caucasian. Of the remaining students, 4% were African American, 3% were Hispanic, 1% were Asian, and 3% did not report their race. Seventy-five percent of the participants reported holding a baccalaureate or higher degree in a non-nursing discipline.

Data Analysis

The goal of the analysis was to identify and describe concepts used in beginning students' definitions of nursing. Data were collected from students' answers to the openended question, "What is your definition of nursing?" A qualitative content analysis style (Crabtree & Miller, 1992; Sandelowski, 2000) was used to explain the data.

Data analysis began with open coding by examining data line by line. The researchers constructed themes, categories, and subcategories. As the data were analyzed, themes and categories were refined. Some subcategories were unsupported and discarded, while others reoccurred frequently, thus gaining support.

The researchers developed categorization schemes and corresponding codes and definitions, which were used to sort and organize the data using the Non-numerical Unstructured Data Indexing, Searching, and Theorizing (NUD*IST N4 Classic) (1997) computer program. Coded data were compared and contrasted to develop mutually exclusive conceptual categories that reflected nursing students' personal definitions of nursing.

Lincoln and Cuba (1985) described adequacy criteria of confirmability, credibility, dependability, and transferability to evaluate qualitative research. In this study, the researchers systematically analyzed students' responses and searched for disconfirming evidence. Each researcher addressed confirmability of study data by coding data independently and then comparing results. When coding disagreements occurred, the researchers discussed inconsistencies in data interpretation and reached consensus, thereby increasing data credibility. In addition, an audit trail was established by using the NUD*IST computer program for data management. However, due to the study design, dependability of the data over time was not established. Using a purposive group of beginning nursing students and detailing an account of the analysis methods used in this study positively influence transferability to similar populations of students.

RESULTS

Using the responses of the 109 participants, 438 total data points were coded. Data points refer to participants' own words and phrases used to define nursing. Data analysis revealed three major themes of personal definitions of nursing - nursing as a verb, noun, and transaction. The researchers established definitions of these three major themes to clarify coding choices. Student responses were categorized as a verb if the words expressed action, existence, or occurrence. Forty-five percent of the total data points coded fit in the nursing as a verb category. Examples of students' definitions of nursing as a verb included:

* "the act of caretaking and facilitating care of a patient.... They also provide clinical intervention..."

* "Nurses provide care for patients.... Nurses function in a variety of roles: teaching, advocating, collaborating, referring, and caring for the whole person (physical, social, psychological, spiritual, emotional needs)."

* "Establishing a therapeutic relationship with a patient with the goal of helping the patient.... The role of the nurse involves teaching, caring, empathy, and professional expertise (monitoring vital signs, giving medication, etc.)."

* [Nursing is] caring for, comforting, educating, tolerating.. .respecting an individual in need."

Nouns are words naming or denoting a person, place, or thing, and 33% of the total data points coded fit in the nursing as a noun category. Examples of how students defined nursing as a noun included:

* "The blending of arts and science in the healing arts encompassing body, mind, and spirit of the client/patient."

* "...nurse is a health care provider that uses a holistic paradigm for patient care."

* "Nursing is a profession, a career..."

* "Nursing is a helping profession based on holistic and scientific theories related to health and illness."

A transaction is "a dynamic reciprocal process involving provider and client" (Lazarus, 1993, p. 234), and 22% of the total data points coded fit in the nursing as a transaction category. Examples of how students defined nursing as a transaction included:

* "Nursing is the process of returning a person who is unhealthy to health or aiding that person in dealing with being unhealthy in the event of a chronic or terminal illness."

* "It [nursing] involves health promotion and helping the ill regain their health."

* "...a goal of helping the patient meet his or her health care goals."

* "Nursing... help[s] them [clients] achieve as healthy a Ufe as possible through recovery from illness or promotion of health in a community.1*

The three themes were represented further by research-defined categories and student descriptions (Figure).

Total data points coded in categories explaining nursing as a verb included caring (34%), nurturing (23%), teaching (19%), implementing (11%), assessing/analyzing (6%), advocating (4%), and managing (3%). The category caring included watching over, attending to, and providing for the needs of others. Student descriptions included "caring for patients," "aiding and assisting another person," and "caregiver." Nurturing included providing warm and affectionate physical and emotional support and care for the purposes of promoting growth and development in a supportive environment. Student descriptions included "care about," "compassion," and "comforting." Teaching included providing information about illnesses, medications, treatments, and rehabilitation. Student descriptions included "teaching," "teaching good health," and "educating patient and/or community." Implementing included initiating and completing actions necessary to meet the physical and psychosocial needs of clients. Student descriptions included "interventions," "carrying out physician and nurse practitioner orders," and "hands on patient care." Assessing/analyzing included collecting and processing data. Student descriptions included "problem solving," "assessing," and "reviewing each patient and their [sic] illness/wellness thoroughly and completely." The category advocating includes protecting clients' self-determination, mediating between clients and people in clients' environments, and acting on clients' behalf. Student descriptions included "patient advocate," "patient representative," and "advocate for his or her community's health." The managing category included organizing patient care, deciding priorities, and ensuring quality of care. Student descriptions included "managing," "facilitating care," and dealing with consequences."

Total data points coded in categories describing nursing as a noun included profession (42%), holistic system (24%), connecting system (16%), delivery system (12%), and discipline (6%). The category profession included an occupation requiring advanced education and training. Student descriptions of profession included "health care professional," "career," and "knowledge and skill." The category holistic system focused on the whole, with consideration of the interrelated parts to accomplish a goal. Student descriptions included "holistic regimen" and "includes both physical and mental aspects." The category connecting system included interpersonal relationships for the purpose of improving the health care of individuals, families, and populations. Student descriptions included "go between practitioner(s) and patients," "working with other members of health care team," and "communicating." The category delivery system included delivering or distributing health care services. Student descriptions included "complex works on many levels," "a manner of care," and "administering personal effective health care." The category discipline included the nature of nursing as a human science, the art of nursing practice, the caring nurse-client relationships formed, and the concern for individuals' health and well-being. Student descriptions included "art and science," "science of caring," and "service to others."

Total data points coded in categories depicting nursing as a transaction included promotion of health (38%), treatment of illness (36%), prevention of illness (20%), and promotion of self-care (6%). The category promotion of health included strategies and behaviors nurses use to increase clients' well-being and actualize human health potential. Student descriptions included "promoting wellness," "promoting and maintaining health," and "promotion of health." The category treatment of illness included strategies and behaviors nurses use in the care and management of clients whose physical, emotional, social, and/or intellectual functions are impaired. Student descriptions included "treat health problems," "recovery from illness," and "aid in healing process." The category prevention of illness included strategies and behaviors nurses use that reduce the risk of individuals' physical, psychosocial, and cognitive functions becoming impaired. Student descriptions included "preventing," "disease prevention," and "preventive care to various populations." The category promotion of self-care included strategies and behaviors nurses use to encourage clients' deliberate actions to optimize their well-being. Student descriptions included "self-care," "support patient's health care goals," and "aiding that person in dealing with chronic or terminal illness."

DISCUSSION

This study analyzed beginning nursing students* definitions of nursing to develop a framework to foster nursing students' professional identity. Although previous studies explored the development of identity in nursing students at various stages in their educational programs in Europe, Scandinavia, and Australia, few studies have investigated this important issue in the United States. This study began by asking 114 nursing students on the first day of their nursing program the question, "What is your definition of nursing?" This first step in the qualitative, descriptive research process provided contextually rich descriptions of nursing by students. The study analysis provided an inductive framework (Figure) involving three major themes - nursing as a verb, noun, and transaction. Although similarities existed between these findings and those of earlier studies, there also were important differences.

In this study, nursing as a verb included the categories of caring, nurturing, teaching, implementing, assessing/analyzing, advocating, and managing. Ryan and McKenna (1994) found that medical students were more cure oriented and nursing students were more care oriented. This study also found caring to take precedence over implementing and managing in students' definitions of nursing. Watson et al. (1999) found that caring and nursing were considered increasingly synonymous during the course of students* educational experiences. Similarly, in this study, beginning students did not necessarily consider caring and nursing synonymous.

Beck (2000) identified eight categories of reasons for choosing nursing as a career. The top three themes in frequency of responses were desire and love of helping others, fulfilling profession, and prior work or volunteer experiences. Beck's (2000) description of her first theme is consistent with the findings in this study of caring as a dominant theme. Traditionally, caring has been characterized as the "core" (Watson, 1998) or "essence" (Leininger, 1984) of nursing.

Nursing students have been asked to identify the importance of role functions in the development of nursing identity. Buckenham (1988) ranked novice student responses in the following order: management, clinical and interpersonal (ranked equally), teaching, and administration. These results differed from those of this study, which found caring, nurturing, and implementing were stated more frequently than managing. Disparities in the culture of health care delivery systems between the United States and England may contribute to this difference.

In this study, the theme of nursing as a noun included the five categories of profession, holistic system, connecting system, delivery system, and discipline. In developing a Professional Socialization Scale, du Toit (1995) found that independence, leadership, critical thinking qualities, and commitment to the profession were important to professional identity in nursing. Not surprisingly, the nursing students in the current study appeared to possess a depth of understanding of professional characteristics that enhance nursing identity, and a few participants referred to nursing as a discipline. However, they did not delineate and label the traits specifically related to professional identity, as described by du Toit (1995).

The categories of holistic, connecting, and delivery systems were found to be similar to three nursing student transition themes identified by Fagerberg and Ekman (1998). Fragmented conceptualization of the transition themes evolved to positive nursing identity development. Integration of theoretical knowledge and technical skills, cooperation of health care team members, and nursing care of elderly patients developed by the end of the third year of the nursing program. In contrast, beginning students in the current study described characteristics attributed to holistic, connecting, and delivery systems in their definitions of nursing at the beginning of their program.

In this study, the theme of nursing as a transaction included the categories of promotion of health, treatment of illness, prevention of illness, and promotion of self-care. Manninen (1998) reported that toward the end of the nursing program, students' perception of nursing was as an "activity that promotes human health and well-being and is based on professionalism" (p. 390). This perception coincides with that of students in the current study (i.e., promotion of heath, prevention of illness, promotion of self-care). In addition to these three categories, this study identified treatment of illness as another part of the transaction theme. This inconsistency between the two studies related to inclusion of treatments may be explained by differences in students' educational levels.

The students' responses in this study are similar to findings by Ryan and McKenna (1994), Fagerberg and Ekman (1998), and Manninen (1998), and are markedly different from the findings of Buckenham (1988) and du Toit (1995). Differences in students' definitions of nursing may be related to the length of time they spend in coursework and clinical experiences, which may provide a rationale for inconsistencies in students' responses across studies.

LIMITATIONS

A qualitative, descriptive approach is intended to generate comprehensive descriptions of the identified phenomena. The current study included 109 students, with 438 total coded data points. The participants provided contextually rich descriptions of nursing. Scientific rigor, described in the Methods section, addressed credibility using researcher triangulation, and confirmability was achieved through independent review of each of the definitions by the researchers. Transferability is limited to students with similar demographics. However, dependability of the data over time was not addressed in this study. Not returning to participants to verify study findings was a weakness in study design. In addition, the researchers served as the study instruments, potentially increasing the risk of bias in data analysis. Future studies conducted in the United States may include further qualitative research involving students' definitions of nursing at various points in their nursing programs. Longitudinal studies would provide additional documentation of nursing students' professional identity development.

IMPLICATIONS

This study clarified and updated understanding of beginning student nurses' definitions of nursing. The nursing students demonstrated a wide range of preexisting perceptions of nursing. Some of these perceptions differ from and expand on prior research completed outside the United States. When reviewing beginning nursing students' professional identity frameworks, nurse educators can explore structural changes in their own curricula that may connect with those frameworks. By building on nursing students' current perceptions of nursing, nurse educators can improve their professional identity development and positively affect educational outcomes.

Preparation of nurses for an increasingly complex and diverse society may require a variety of educational experiences in areas not addressed in current curricula. Nurses who have developed a firm professional identity are more flexible when faced with role changes. In this study, beginning students' definitions of nursing included very few descriptions of ethics, cultural, legal, and economic issues in clinical practice. In addition, there was a deficit in their perceptions of nursing as a significant component of the health care delivery system, and nursing was not always identified as a distinct discipline. These findings emphasize the need to provide opportunities for professional identity development.

Recognizing that current curricula may lack content in areas foundational to nursing identity, another implication of this study is that courses should be developed for beginning students that will provide them with introductory information related to professional identity, including key learning issues in ethics, patient-provider communication, finance and health policy, law, cultural competence, and interdisciplinary issues. The proposed course(s) could provide a forum for students to experience complex interactions with these issues, through analysis and discussion of clinical situations. Understanding beginning nursing students' perceptions of nursing can enhance curricula to prepare nurses for the current and future health care environment.

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10.3928/0148-4834-20030701-08

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