Socialization of students to the nursing profession is a challenge for nursing faculty and important enough to incorporate into the accreditation standards for nursing curricula (Accreditation Commission for Education in Nursing, 2013; American Association of Colleges of Nursing, 2013). According to Dinmohammadi, Peyrovi, and Mehrdad (2013), “professional socialization is a dynamic, interactive process through which attitudes, knowledge, skills, values, norms and behaviors of the nursing profession are internalized and a professional identity is developed” (p. 32). Researchers have studied the influence of nursing faculty on students’ socialization, the role of nurse mentors in practice, clinical experiences with patients, curricula, and the role that individual student characteristics have on the development of professional values, norms, and beliefs (Bradby, 1990; Leners, Roehrs, & Piccone, 2006; Nesler, Hanner, Melburg, & McGowan, 2001; Secrest, Norwood, & Keatley, 2003; Ware, 2008; Wilson & Startup, 1991). Due to the importance of socialization to the nursing profession and to further expand on the research of others, a decision was made during a planned curriculum revision to prioritize educational support for the socialization of nursing students to the profession at the authors’ school of nursing.
Multiple processes and models have been discussed in the literature to address effective socialization of nursing students to the role of professional nurse. Utley-Smith, Phillips, and Turner (2007) proposed that nursing students need to understand the stages of honeymoon, conflict, and reintegration to be prepared to identify times of crisis in their own professional development, as well as that of peers. Duchscher (2009) defined a transition shock model to represent the process experienced by new nurses moving into practice. Through structured nursing curricula, students can anticipate the role transitions that occur during their educational program and after graduation.
According to Gardner, Avolio, Luthans, May, and Walumbwa (2005), an authentic leader develops self-knowledge through an evaluation of one’s values and personal experiences and the presence of positive role models as “pivotal forces in the leader’s personal growth and resulting self-awareness” (p. 348). Self-knowledge and self-awareness support an authentic leader’s ability to align values with intentions and actions (Avolio & Gardner, 2005; Shamir & Eilam, 2005).
LeDuc and Kotzer (2009) used the Nurses Professional Values Scale-Revised (Weis & Schank, 2009), which measures professional nursing values based on the American Nurses Association’s Code of Ethics for Nurses (2001), and found that experience is not essential in the development of professional values. It is through socialization experiences, such as self-assessment exercises, mentoring experiences, and role modeling, that nursing students acquire their own professional values. A more recent study by Iacobucci, Daly, Lindell, and Griffin (2012) explored the relationship among professional nursing values, self-esteem, and ethical decision making in nursing students. Those authors found a positive relationship between nursing students’ professional nursing values and their individual levels of self-esteem.
Nursing Leadership and Patient-Centered Care Courses and Seminars
As part of a curriculum redesign for a baccalaureate nursing program, faculty created a series of three structured Nursing Leadership and Patient-Centered Care (NLPCC) courses in the junior and senior years that included biweekly small-group seminars led by full-time faculty. These seminars provided students with structured time for self-reflection and discussion to reconcile and synthesize classroom theoretical concepts with clinical practice learning experiences. The purpose of this study was to evaluate the undergraduate NLPCC courses and seminars on students’ perception of professional values, socialization to the professional role, and dimensions of authentic leadership.
Each NLPCC course is 3 credit hours that also includes a corresponding 1-hour seminar. The first NLPCC course (NLPCC I) in the series is offered during the first semester of the junior year. This course focuses on the theory and skills necessary for effective professional communication. In addition, this first course outlines the importance of utilizing those skills to achieve interpersonal, therapeutic, and interprofessional relationships that contribute to patient-centered care. The second NLPCC course (NLPCC II) is offered during the second semester of the junior year. This course concentrates on the development of leadership skills and gaining the essential knowledge surrounding contemporary nursing topics. Current regulatory, political, legal, economic, and ethical issues and implications for interprofessional patient-centered care are analyzed. The final course in this series, NLPCC III, is offered in the second semester of the senior year. This course focuses on the development of leadership and management knowledge and skills for the professional nurse in current health care organizations. Content includes managerial practices for delivering nursing care, organizational design and effectiveness, change implementation, quality management and measurement, fiscal resources, and staff development.
The NLPCC seminars were designed to provide students in a small-group setting (maximum of 12 students) with the opportunity to meet biweekly over the course of the semester at each curriculum level to address specific topics related to socialization to the profession of nursing. This allowed students to further self-reflect and synthesize classroom content with clinical experiences, thus providing a unique and supportive student learning environment. Each seminar had a defined goal, a self-awareness exercise that would stimulate personal reflection on an array of values and challenges, and a guided activity facilitated by faculty to foster open dialogue and application to nursing practice. Concepts included articulation of the nursing role, interpersonal skills development, intra- and interdisciplinary collaboration, advocacy, ethical decision making, diversity and inclusion, and conflict resolution skills. By developing these competencies, nursing students will be better prepared to manage clinical, peer, and interdisciplinary daily challenges.
The seminars further provide an opportunity for faculty to mentor and role model therapeutic communication, facilitate students in their critical thinking, and support problem solving for any concerns that students might have. By providing a safe and confidential setting to explore teachable moments, students discuss the concerns and challenges they may be experiencing. These seminars are consistent with the nursing program’s mission to promote responsible, ethical, self-reflective individuals who are committed to serving the public with high integrity.
Within the leadership seminars, professional leadership attributes are examined through the use of self-reflective activities and open peer discussion. Exploration of individuals’ values, beliefs, and behaviors is encouraged. Professional relationship issues that may impact one’s ability to gain confidence in a leadership role are identified and discussed in the context of the clinical setting. Factors related to broader cultural and social norms are incorporated to promote integration of leadership by nurses at the bedside and within the context of interdisciplinary collaboration and patient-centered care. The seminar coordinator (N.M.B.), who is an expert in psychiatric mental health nursing and leadership, provided preliminary and ongoing training for all faculty in group facilitation and content. A collaborative process for the evaluation and revision of all seminars was completed at the end of each seminar. Input was sought from students, seminar faculty, and leadership course faculty.
Design and Measurement
A mixed-methods design was used, which involved administering two surveys to the students at the start of the junior year and the end of their senior year and two qualitative questions that were administered to the students after the second-semester junior year and again after the second-semester senior year. The two surveys used were (a) the Authentic Leadership Self-Assessment Questionnaire, a proven reliable and valid 16-item, 5-point Likert scale that examines self-awareness, internalized moral perspective, balanced processing, relational transparency, and overall authentic leadership scores (Walumbwa, Avolio, Gardner, Wernsing, & Peterson, 2008) and (b) the Nurses’ Professional Values Scale–Revised, a psychometrically based 26-item, 5-point Likert scale instrument derived from the American Nurses Association’s Code of Ethics for Nurses and designed to measure nurses’ professional values (Weis & Schank, 2009). Verification of the reliability and validity of this instrument was completed, and it was determined that it accurately measures professional nurses’ values and professional socialization (Weis & Schank, 2009).
The students in the pretest–posttest group, recruited as new juniors, had three semesters of participating in the professional socialization seminars as part of the NLPCC courses in the new curriculum. This group also responded to two qualitative questions about their self-reflections on the biweekly seminars. The students were asked to:
- Provide examples (at least three) of discussions from the seminar that have assisted you in better understanding the professional role of nurses.
- Describe examples (at least three) of how seminar topics apply in the clinical setting.
The research study was submitted and approved by the college’s institutional review board. The study consent was reviewed with the students, and written consent was obtained prior to survey administration. Volunteers were recruited from all first-semester junior students (N = 96) in the undergraduate nursing program. Eighty-nine first-semester junior students completed the pretest survey, for a response rate of 93%.
The data from the Nurses’ Professional Values Scale–Revised, the Authentic Leadership Self-Assessment Questionnaire, and the qualitative questions were collected confidentially using Qualtrics online survey software. Survey data were downloaded into SPSS®, version 20, software for analysis. A dependent samples t test compared pretest and posttest means from the Nurses’ Professional Values Scale–Revised and the Authentic Leadership Self-Assessment Questionnaire.
Members of the research team reviewed the identified concepts and emerging themes from the students’ responses. An analysis of the concepts and themes further synthesized their relationship to aspects of the developing professional role. At the completion of the study, both sets of qualitative analysis findings were compared for consistency in themes and identification of potential outcomes that correlated with NLPCC courses and seminars.
Results and Discussion
The research team examined the NLPCC treatment by comparing the means of the Nurses’ Professional Values Scale–Revised and the Authentic Leadership Self-Assessment Questionnaire administered at the start of the junior year and at the second-semester of the senior year. This analysis revealed no significant improvement in self-reported professional nursing values and authentic leadership over the time period. However, analysis of the qualitative responses revealed evidence that the NLPCC intervention had positive effects.
The junior students in their second semester showed a growing awareness of the professional nursing role and responsibilities beyond the bedside. Themes included the importance of patient and professional advocacy, ethics, safety, communication, conflict management, patient-centered care, leadership, and accountability. These students began to demonstrate a concrete understanding of basic day-to-day nursing skills for success to be a “good” nurse, with an emerging sense of understanding responsibilities beyond the bedside (Table A; available in the online version of this article).
Themes of the Nursing Leadership and Patient-Centered Care Course Identified From J2 and S2 Students’ Comments Related to Two Qualitative Survey Questions
The same students in their second senior semester showed a greater awareness of the realities of practice and a growing sense of readiness and empowerment to embrace the professional role of an RN and their role in managing and influencing the quality of care. Themes from the senior students’ reflections included skill development for conflict resolution, ethical decision making, advocacy, professional role development, and communication (Table A). At the end of the second senior semester, the students demonstrated a consistent integration and emerging reconciliation for the differences between what is learned in school and what is effective in the workplace. Role integrity was an overarching theme, as the students assimilated the steps in understanding, creating, and maintaining the professional nurse role. Leadership at the bedside, practice collaboration, and cultural competence were dominant themes.
Although the authentic leadership survey is a reliable instrument, its use for nursing students who have not had actual nurse leader experience may have negatively impacted their ability to respond to the questions. Also, the junior and senior NLPCC seminars over three semesters used several faculty, which may lead to differences in the process and content delivery.
Understanding the factors that impact nursing students’ socialization to the profession of nursing is critical to enhancing the success of future nurses as they transition to a challenging health care work environment. Due to the design of the NLPCC courses, with the purposeful inclusion of content from the Quality and Safety Education for Nurses (QSEN, n.d.) competencies, the socialization of students to the nursing profession assists students to prepare for the provision of quality care. With a focus on patient-centered care as one of the QSEN competencies, students learn to value not only skill development (knowledge and skills) but also socialization (attitude) to the profession (QSEN, n.d.). These recommendations support the need for ongoing research to contribute to the development of educational best practices, not only for skills development but for nursing students’ socialization transition to the professional practice of nursing.
This study evaluated three NLPCC courses and faculty-led, biweekly, small-group seminars on strengthening nursing students’ perceptions of the role of nursing through more effective socialization and the provision of safe quality care. Although the quantitative results were not significant, the qualitative results demonstrated a growing sense of student awareness for the role of the professional nurse in advocating beyond the bedside. Through role modeling, scripted conversations, and focused dialogue, the infusion of the knowledge, skills, and attitudes from the QSEN patient-centered care, teamwork, and collaboration competencies allowed students to hone their socialization skills prior to entering the work-force. Structured nursing leadership courses across the curriculum, which include small faculty-led group seminars, can provide the mentoring and development of leadership and socialization competencies to assist students toward successful transition to the role of a professional nurse.
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Themes of the Nursing Leadership and Patient-Centered Care Course Identified From J2 and S2 Students’ Comments Related to Two Qualitative Survey Questionsa,b
|Theme||Question #1||Question #2|
|Patient and Professional Advocacy||“The discussion we had regarding political activism helped to reinforce the idea that nurses have opportunities to make improvements.”||“…how to advocate for patients. How to advocate for ourselves.”||“Advocating for patients made me better understand what that actually means.”||“…[it is] important to keep in mind that the patient is the most important person in the situation.”|
|Ethics||“We have an ethical responsibility as nurses to the patient, the profession, and to ourselves. This really made us think.”||“…being provided with ethical dilemmas and working through them as a group.”||“…gave me a better understanding of ethics and how it is incorporated into the nursing profession.||“We are all going to face challenges as new grads…to face moral challenges and [the] need to deal with them in ethically appropriate ways.”|
|Safety||“We discussed ways to communicate interprofessionally and how doing so will give us better patient outcomes.”||“How important maintaining patient safety is at all times.”||“We talked about hand-off reports and how these are especially important in ensuring patient safety.”||“I often refer back to what we learned when uncomfortable in a situation with a patient or another employee, whether it be a safety issue or conflict issue: how to respond and the appropriate actions to take.”|
|Communication||“The concept of effective communication is of importance when providing care to patients so that nothing is misinterpreted.”||“…how to act in an interdisciplinary approach…. It helped me to think about ways to better communicate with other team members.”||“…being able to listen to the patient and hear the subtext.”||“I use the interpersonal skills and active listening I learned everyday with coworkers and patients.”|
|Conflict||“…resolving conflict among coworkers and how to approach that person directly then going up the chain of command [as needed].”||“We also talked about ways to approach issues when they are in conflict with our own set of beliefs.”||“We discussed conflict management and how we can defuse conflict without it blowing up into an issue but rather a conversation that should be addressed.”||“Conflict is discussed a lot during seminar…. It is important that we feel comfortable dealing with it in a professional manner.”|
|Role Development||“We were able to brainstorm different ways of describing our profession, which further reinforced the credibility of what we actually do as nurses.”||“…how we might find it hard to advocate for our patient as a brand new RN—this discussion probably better prepared us for the clinical setting.”||“…good ways to learn from a nurse who has experience….things to expect in the real world.”||“Seminar topics…have all been reflective of my experiences. I have learned…to be a professional and passionate nurse.”|
|Patient-Centered Care||“Nurses must use other members of the health care team in order to provide quality patient-centered care.”||“The discussions around confidentiality and patient-centered care form the backbone of my clinical practice.”||“[The] patient was the focus of the care— we are here to benefit the patient, not ourselves.”||“We can bring what we have experienced in [the] clinical setting and debrief on them in seminar—talk about what went well and what could have gone better.”|
|Leadership||“Our discussion about professional nursing organizations helped us to realize that our responsibilities extend beyond the bedside.”||“…qualities that make you a good leader.”||“How to get our voices heard and make changes in the hospital was demonstrated when I went to a couple different meetings.”||“Leadership is a vital characteristic of a nurse.”|
|Accountability||“The discussion we had regarding accountability and examples my teacher gave were helpful and made me think how I want to be accountable…so my coworkers, patients. and everyone will trust me and know I am competent.”||“Evaluate our own sets of beliefs and how they impact our decision making.”||“I witnessed a situation in which the nurses were not doing what should have been done and going to the charge nurse was what was needed and if I hadn’t had that seminar, then I wouldn’t have known what to do.”||“…understanding professional responsibilities and scope of practice.”|
|Workplace Culture||“The topic that really helped me…would be the horizontal violence discussion—it taught me and gave me a preparedness for the workplace.”||“How to follow the chain of command.”||“Being able to work as a team and collaborate effectively creates a safer environment.”||“Health care is a team pursuit, one must be able to speak effectively to other members.”|
|Self-Care||“As we discussed the possible problems that can arise in the hospital environment, we discussed ways in which nurses can be an advocate for themselves.”||“Strategies to promote self-health to avoid burnout and provide the best possible patient care.”||“Being confident—without confidence in yourself you won’t get anywhere.”||“Standing up for oneself as a nurse is very important in order to make the best decisions for our patients.”|
|Current Professional Issues||“We discussed the importance of being an active nurse. We have many opportunities to join professional organizations that get involved politically and allow us to have the rights and protections that we deserve as a profession.”||“Aid in providing better patient- centered care—aid in developing strategies in identifying self-worth and contribution to discipline.”||“Laws that are passed directly affect nurses, such as the nurse-to-patient ratio. The fewer patients a nurse is responsible for, the lower the risk of error…more time can be spent with the patient assessing and caring for their needs.”||“Importance of autonomy in nursing practice—evidence-based care and how it helps improve patient satisfaction.”|