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THESIS

This is to certify that the
dissertation entitled
Professional Nurses and The
Externship EXperience:

A Descriptive Study

presented by
Linda Nicholson Grinstead

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MSU I. An Affirmative Action/Emu OpportunIty Inflation
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PROFESSIONAL NURSES AND THE
EXTERNSHIP EXPERIENCE:
A DESCRIPTIVE STUDY
By

Linda Nicholson Grinstead

A DISSERTATION

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY

Department of Educational Administration

1995

ABSTRACT
PROFESSIONAL NURSES AND THE
EXTERNSHIP EXPERIENCE:

A DESCRIPTIVE STUDY
By

Linda Nicholson Grinstead

During the most recent nursing shortage health care agencies devised a
number of strategies to attract nurses. One of the most significant strategies
was the Offering of summer externships. These programs were designed
primarily for nursing students who were between the junior and senior years in
a nursing program. The agencies saw the programs as a way of potentially
attracting future graduates and the students saw them as a way of gaining
valuable work experience while getting paid for their services. An additional
goal of the externship experience was to help bridge the gap between the
idealism of nursing school and the reality of the workplace.

In 1986, the American Association of Colleges Of Nursing published

‘l-. 0 0 ‘-=-_Io. I‘ ° I. <0! 0 '0‘ Clo. I- 'Ioutlining
professional socialization outcomes deemed necessary for the baccalaureate
prepared nurse. This study describes the externship experience and the
professional socialization that occurs within it.

Several previous studies had examined internships or preceptorships for
which students received academic credit. There was a lack of empirical

evidence demonstrating whether students in non-credit externships were

becoming socialized to the professional role in part as a result of the experience.

The purpose of this study was to'examine the perceptions Of new
graduate nurses regarding their socialization to the professional role.
Comparisons were made between those nurses who participated in a summer
externship program as students and those who did not.

Data were collected through a mailed survey sent to Spring, 1991,
graduates of baccalaureate nursing programs in Michigan. Of the 225
respondents, 63 percent had participated in an externship program. Data
analysis indicated that externs engaged in activities that were directly related
to published professional socialization outcomes and, as newly registered
nurses, scored significantly higher on a professional attitude inventory.

These findings support the value of an externship for nursing students.
Evaluation of nursing curricula and modification of existing programs is needed
in order that every student is assured of an experience that will assist in

meeting the professional socialization outcomes.

Copyflghtby
LINDA NICHOLSON GRINSTEAD

1995

Dedicated to
my husband Bill

and children Paul and Nathan

ACKNOWLEDGMENTS

This study could not have been completed without the guidance and
support of many people.

As chairperson of my guidance committee, Louis Hekhuis was readily
accessible and thoughtfully supportive. His kind, patient manner was
encouraging and appreciated. The other members of my committee, Eldon
Nonnamaker, Marvin Grandstaff and Betsy Becker provided significant direction
throughout my graduate studies.

For technical support, the computer expertise of Cindy Coviak was
invaluable. The assistance with data entry provided by Lisa and Kristy Standen
was appreciated.

A special thanks to the faculty and staff of the Kirkhof School of Nursing
at Grand Valley State University who suffered through occasional distractions
and continually offered support and encouragement. Colleen Smitherman
deserves special recognition for her careful, thoughtful analysis and editing of
the dissertation.

An extra measure of gratitude is reserved for my mother, Edna May
Nicholson, who continually stressed the value of education and my sister, Kay

vi

Zeaman, who listened to me and sustained me through the peaks and valleys.
My husband's love and support throughout graduate school motivated me
when nothing else did. His infinite patience in sharing his expertise in designing
the survey instrument and mastering the intricacies of word processing was
appreciated. Finally, many thanks to my children, Paul and Nathan, who not
only spent one summer stuffing envelopes and licking stamps but offered me

the understanding and encouragement needed to complete the study.

vii

TABLE OF CONTENTS

Chapter One ........................................... 1
Introduction ....................................... 1
Problem Statement .................................. 3
Significance of the Study .............................. 4
Purpose of the Study ................................. 5
Assumptions ...................................... 6
Research Questions .................................. 6
Limitations of the Study ............................... 7
Definition of Terms .................................. 7
Summary ......................................... 8

Chapter Two ........................................... 9
The Nature of Socialization ............................. 9
Professional Socialization ............................. 10
Professional Socialization of Nurses ...................... 12
The Externship Experience ............................ 13
Summary ........................................ 16

Chapter Three ......................................... 17
Methodology ..................................... 1 7

The Population ............................... 17
The Sampling Technique ......................... 18
Data Collection Procedures ....................... 19
Data Analysis ................................ 21

Chapter Four .......................................... 23
Analysis of Data ................................... 23
Introduction ...................................... 23
The Mailed Survey ................................. 24

Part I: Demographic Data ........................ 24
Part II: Summer Nurse Externships ................. 27
Part III: Professional Attitudes .................... 35
Research Questions ................................. 38

viii

Research Question One .......................... 38

Research Question Two ......................... 40

Research Question Three ........................ 42

Research Question Four ......................... 44

Chapter Five .......................................... 48
Summary, Findings and Recommendations ................. 48
Summary ........................................ 48
Summary of Findings and Conclusions .................... 50
Recommendations .................................. 55
Recommendations for Health Care Agencies ........... 55
Recommendations for Schools of Nursing ............. 58

Implications for Further Research ....................... 61
Reflections ....................................... 63
Appendix A ........................................... 65
Appendix B ........................................... 72
Appendix C ........................................... 73
Appendix D ........................................... 77
LIST OF REFERENCES ................................... 78

ix

LIST OF TABLES

Table 1 Generic Baccalaureate Nursing Programs in

Michigan Included in Study ....................... 18
Table 2 Gender and Age of Respondents ................... 25
Table 3 Ethnic Background and Marital Status of Respondents . . . . 26
Table 4 Pregraduation Summer Employment of Respondents ..... 27
Table 5 Opportunities Provided During Externships ............ 29
Table 6 Most Beneficial Aspects Of Externship Experience ....... 32
Table 7 Least Beneficial Aspects of Externship Experience ....... 34
Table 8 Comparison of Mean Scores of Respondents

on Professional Attitude Inventory .................. 39
Table 9 Characteristics of Respondents .................... 41

Table 10 Relationship Between Outcomes of Professional
Socialization and Scores of Respondents on
Professional Attitude Inventory .................... 45

LIST OF FIGURES

Figure 1 Professional Attitude Scores - Superordinate Purpose ....... 36
Figure 2 Professional Attitude Scores - Critical Attitude/Thinking ..... 36
Figure 3 Professional Attitude Scores - Compassion .............. 37

Figure 4 Professional Attitude Scores - Total ................... 38

xi

Chapter One

Introduction

In 1987, with enrollments in schools of nursing decreasing and the demand
for registered nurses increasing, the Secretary's Commission on Nursing was
formed by Health and Human Services' Secretary, Otis R. Bowen. During the
following year, this 25 member panel made a thorough assessment of the
shortage of nurses. These findings led to the development of 16
recommendations and 81 strategies designed to alleviate present and future
shortages which were issued in the Commission's 531839523.

The Commission's determination that the shortage was primarily a result of
increased demand as opposed to a contraction of supply served as a justification
for intense recruitment efforts being expended by employers. Nursing recruiters
were sent farther afield with promises of sign-on bonuses, free tuition
assistance and free courses to help new graduates prepare for the licensing

examination.

2

The majority of these efforts were short-term solutions to meet the
immediate staffing needs of agencies. They did not directly address the long-
term issues brought forth in the Commission's recommendations.

The Commission believed that failure on the part of health care agencies to
fully recognize the professionalism of nurses had contributed to problems in
recruiting and retaining nurses. Therefore, at least a third Of the
recommendations found in the ElnaJ_B_e_p_Qn addressed issues of
professionalism: decision making, impact on self regulation, professional image
and career development. In 1983, the first reports of an innovative strategy
which would address the twin concerns Of recruitment and professionalism
began to surface in the literature. Harkins, Schambach, & Brodie (1983) and
Hartin (1983) reported on summer nurse extern programs in two Georgia
medical centers. This was followed the next year by Fire, Bozett, & Dearner
(1984) and Allison et al. (1984) who described their programs in Oklahoma and
Mississippi, respectively.

These programs were designed primarily for the participation of nursing
students during the summer preceding their last year in nursing school. The
agencies saw the programs as a way of potentially attracting promising future
graduates and the students saw them as a way of gaining valuable experience
in their chosen profession while getting paid for their services.

An additional goal of the externship experience was to help bridge the gap

between the idealism of nursing school and the reality of the workplace. This

3

was addressed by providing seminars where students could openly express
their concerns and plan appropriate actions to deal with the disparity
expeflenced.

Kramer (1974) described this difficult transition from student to graduate
as "reality shock." She found that, because of reality shock, new graduates
frequently became disillusioned and left the profession. Two studies (Corwin,
Taves, & Haas, 1961; Kramer, McDonnell, & Reed, 1972) attributed the
attrition from nursing practice to inadequate socialization. Socialization is the
process by which members of the profession acquire the knowledge, skills and
values necessary for group membership. When nurses are not recognized for
the abilities and contributions that they bring to the profession, or if they do not

feel a part of the profession, they tend to leave.

Emblemitatement
Nursing education literature reveals very little about the professional
socialization process that occurs in externship programs which take place
outside the nursing curricula. A number of studies have reported on the
socialization of students in preceptorships or internships for which they received
academic credit (ltano, 1987; Dobbs, 1988; Olson, 1984). Others have
evaluated the impact of externships on clinical competence (Scheetz, 1989;

Myrick and Awery, 1988).

4

With the increasing popularity of summer externships among nursing
students it is imperative that nursing educators gain an understanding of how
the experience affects the student for several reasons. There may be a need to
modify the nursing school curriculum, the teaching methods, or both based on
the students' experiences. Educators need to know how externships are
affecting the professional socialization of their students so that they can
continue and build on the process when the student returns for the final year of
schooling. If students are appropriately socialized into the profession, it seems
clear that the rate of attrition as professionals will diminish.

As more health care agencies offer externships, Often with little or no input
from schools of nursing, the composition of the experience can vary widely.
How nursing schools adapt to the wealth of experiences brought back by
students may be crucial to the school's existence.

While most agencies report that externships have proven to be an effective
recruitment strategy, no empirical data exists to demonstrate whether students
are in fact becoming increasingly socialized to the professional role by the

experience. This, then, is the focus of the study.

5.1. ['5'

A two-year study conducted by the American Nurses Association (ANA)
clearly demonstrated that "a significant, serious, and sustained shortage of

nursing personnel continues to threaten our nation's health care delivery

5

system" (McKibbon, 1990). It pinpoints the year 1986 as the starting point of
the most recent shortage and seeks to answer the question as to why it
continues into the 19905.

The ANA report dismisses enrollment declines and exodus from the
profession as major causes of the current shortage. It reinforces the
Commission's findings of increased demand. It calls for "targeted, focused
remedies . . . in order to alleviate the nursing shortage in the 19905 and help
prepare the nation for the far greater demands predicted for nursing care in the
21st century" (p. xi).

Recommendation 15 found in the flnaLBeppn of the Secretary's
Commission on Nursing calls for the need to support research concerning "the
effects of nurse compensation, staffing patterns, decision making authority, and
career development on nurse supply and demand" (p. 48). Clearly, there is a
need for a careful examination of how nurses are not only educated but
socialized into the profession.

Eumsuflhefijudx

A variety of summer nurse externships have been described in the nursing
literature. Conclusions reached regarding the benefits of such programs are
primarily based on information gathered from students who received academic

credit for their work.

6

This study has a dual purpose. The first is to examine the externship
experiences of recent nursing graduates and compare those experiences to the
outcomes of professional socialization.

The second purpose is to compare demographic data and the perceived
socialization of recent nursing graduates who completed a non-credit summer
externship with those who did not. The socialization of both groups is
measured by scores on a professional attitude inventory.

Assumptions
This study is based on the following assumptions:

1. Nurses who elect to participate, as students, in a summer externship
program are not significantly different from those who do not.

2. The responses of the respondents to the research instruments will
accurately reflect the activities of the summer externship programs.

3. The goal of socialization to the professional role is common to all
summer externship programs.

4. Professional attitudes measured in graduate nurses are measurably
influenced by summer work experiences while nursing students.

Bosoarohfiuestions

In the population of registered nurses who graduated from baccalaureate

nursing programs in Michigan in the Spring of 1991 and who are licensed in

Michigan:

7

1. DO nurses who participated in summer student externship programs
hold different attitudes regarding professionalism than nurses who did not have
externships?

2. What demographic differences are there between nurses who
participated in a summer student externship program and those who did not?

3. How do recent graduates perceive their summer externship experience
as contributing to their professional socialization?

4. What aspects of the externship experience relate to professionalism?

I"' ['5'

This is a study of nurses' perceptions and is limited to:

1. The degree to which the survey instrument accurately reflects the
experiences of the participants.

2. The frankness and honesty of the participants responding to the
questions.

1. Summer nurse externship program - a non-credit work-study
experience offered to students during the summer between the junior and senior
years of a nursing program and under the direction of a health care agency.

2. Non-externship experience - employment within the health care field
which has no structured learning opportunities or any employment outside the

health care field.

8

3. Professional socialization - the interactive process by which an
individual integrates a professional role into the self concept through the
acquisition and internalization of the requisite knowledge, skills, values,
attitudes and norms of the profession (Jacox, 1978; McCain, 1985; Moore,

1970).

Summary

This is a descriptive study to examine the professional socialization Of
baccalaureate nursing students which occurred during summer externship
experiences between the junior and senior years of a nursing program. The
study compares the professionalism scores (on Stones Health Care Professional
Attitude Inventory as adapted by Lawler) of recent graduates who participated
in summer externship programs with those who did not. The study describes
some of the activities Of the externship experience. Lastly, it examines the
perceptions of nurses who completed a summer nurse externship program
about how and whether that experience met the professional socialization
outcomes as outlined in the American Association Of Colleges of Nursing
document, -I-. . . -.- «I. I- ' I. -.-I . 'o: o'I.
Nursing. It is believed that this information will enhance the nursing faculty's
understanding of the process that presently occurs during the externship

expenence.

Chapter Two
II II I S . I' .

The study of socialization has arisen from the disciplines of anthropology,
psychology and sociology (Hurley-Wilson, 1988). Out of these various
traditions have come a number of definitions. The concept as defined by
sociologist Q. G. Brim (1966), encompasses the basic elements of the process.
He states that socialization is "the process by which individuals acquire the
knowledge, skills and dispositions that make them more or less able members
of their society." This process continues throughout one's life. Socialization
has also been defined in terms of learning social roles which prepare individuals
for adult occupational, marital and parental roles.

Prior to the mid-19605, socialization was primarily viewed as a passive
process. Since that time, it "has come to be viewed as an interactional and
reciprocal process in which the person being socialized and socializer are
mutually influenced" (Hurley-Wilson, 1988, p. 75). This process is enhanced
by the acquisition of language which in turn affects the learning of role

behaviors.

10

Among sociologists, a common theoretical approach used is that of social
learning theory. By the processes of observation and vicarious learning, the
individual will identify with a particular group and model that group's behavior
if it has been and continues to be appropriately reinforced (Bandura, 1969,
1977). Members of the group are prepared to perform adult social roles that
will maintain the group as a whole. The outcomes of the process are dependent
upon each individual's ability to learn the behaviors appropriate to the
acquisition of a specific role.

E i . | S . I' .

Professional socialization can be seen as an extension of adult socialization.
Although all preprofessional individuals go through a similar process of
socialization, they cannot be considered as a homogeneous group. Instead, the
socialization process involves taking a heterogeneous group of beginning
students and progressively molding them into a more homogeneous group with
respect to the knowledge, values, attitudes, behavior, and skills that they will
have following socialization (Lum, 1978).

Learning a technical language and developing a professional self-image are
two characteristics of professional socialization. Exposure to many agents of
socialization such as clients, professional colleagues, other health professionals
and fellow students also affects the process (Lum, 1978).

Jacox (1978) discusses the process of professional socialization in terms of

three criteria for professionalism: specialized education, service orientation, and

11

autonomy. She stresses that the process of professional socialization does not
begin when the individual enters the professional school but much earlier when
the decision is made to join a particular occupational group. She sees the
characteristic of autonomy as derived from the other two. Through autonomy,
members of a profession have control over their own functions in the work
setting.

Cohen (1981) and Lum (1978) examined the goals and characteristics of
professional socialization and concluded that developing and integrating a
professional self-image into all other life roles is an essential component of
professional socialization. The student must learn the technology and language
of the field and internalize the culture to which he or She is exposed.

Cohen (1981) proposed a developmental model of professional socialization
that parallels the cognitive stages of childhood. It was drawn from studies on
the development of cognition in children and is based on the stage theory of
child development of Harvey, Hunt, and Schroeder (1961). A developmental
approach to the study of professional socialization has also been supported by
Leddy and Pepper (1985), Simpson (1967) and Blase and Pajak (1982).

Cohen proposes four stages of the professional socialization process. She
titled these stages Unilateral Dependence, Negative/Independence,
Dependence/Mutuality and Interdependence. Students progress at their own
rate through each stage but "must experience each stage in sequence to feel

comfortable in the professional role" (Cohen, 1961 , p.16).

12

In Stage I of Cohen's model, the student accepts concepts from external
sources without question. In Stage II the student begins to question concepts
presented to him and to free himself from external controls. During Stage III the
student begins to think more abstractly and objectively. This stage "marks the
beginning of empathy and commitment to others" (Cohen, 1981 , p.18). By the
end of Stage IV, the individual is able to synthesize abstract concepts, and
exercise appropriate judgment in sometimes contradictory situations. These are

the hallmarks of a professional.

EI'IS'I" [II

The study of socialization of nurses has been approached in a variety of
ways. However, Conway (1983) in her review of the literature related to
socialization, identified a lack of a consistent conceptual view to guide such
research.

The classic professional socialization studies found in the literature are those
by Davis and Olesen (1964) and Olesen and Whittaker (1968). They, along
with Cohen and Jordet (1988) and Crocker and Brodie (1974), found that
nursing students increase their professional role conceptions and reject lay,
bureaucratic images of nursing as they progress through their educational
experiences. For Oleson and Whittaker, the core of professional socialization

was in the fusion of person, situation, and institution.

13

In a three year longitudinal study of nursing students progressing from the
sophomore year through the senior year of their education, Stein (1978) found
that students perceived themselves as more autonomous as they neared
graduation. She examined how values and attitudes changed with academic
and clinical experience. Although their need for nurturing lessened as they
progressed through the program, there continued an unresolved conflict
between the ideal professional image developed in school and the realistic one
encountered in nursing practice.

While these studies offer evidence that professional socialization for nursing
is a developmental process, none were found that attempted to measure the
professional socialization that took place as part of the student's participation
in a non-credit summer nurse externship. Most seemed to assume socialization
occurs only in teacher directed academically focused experiences.

II E | . E .

Although there are no studies describing or evaluating non-credit
externships, several have examined preceptorships and internships taken for
credit. These terms, preceptorship and internship, are used interchangeably in
the literature and the experiences described are similar to the externship
experiences explored in this study. The major differences between
preceptorships and internships and the externships described here are the

allocation of academic credit and remuneration for hours worked.

14

Another difference among the aforementioned experiences concerns
control. Those which provide academic credit are primarily designed by schools
of nursing and ultimately under their control although they may or may not have
faculty present during the experience itself. The externship experience
explored in this study is completely within the control of the health care agency
and provides no academic credit. Therefore, the amount and quality Of
structured learning experiences based on specific behavioral objectives can vary
widely.

Hovey (1990) reported on a preceptorship taken as an elective by nursing
students who had completed their junior-level clinical nursing courses. From a
content analysis of evaluations completed by 35 students and their preceptors,
she concluded that the experience had contributed to the professional
socialization of those students. "Increased confidence" in the performance of
psychomotor skills, physical assessment and recording of data was most often
cited as the greatest benefit.

Clayton, Broome, and Ellis (1989) studied the relationship between a
preceptorship experience and role socialization as graduate nurses. They
compared students who were paired with a preceptor with those who
participated in a traditional faculty supervised clinical experience. Their findings
supported their hypothesis that working with a preceptor, as opposed to a

faculty member, enhances the transition from student to graduate nurse.

15

Anecdotal evidence of increasing clinical proficiency and confidence through
summer experiences was reported by Fire, Bozett, and Dearner (1984), Harkins
(1983), Hartin ( 1983), Suess (1982), and Whelan (1982). Olson, Gresley, and
Heater (1984) found no significant differences on the professional development
of students who participated in an elective eight week internship when
compared to those who did not.

Scales, Alverson, and Harder (1993), in a quasiexperimental study,
examined the nursing performance of students before and after a five week
preceptorship. Their findings supported the preceptorship experience as a
means of developing a more clinically competent graduate nurse.

A number of studies have been conducted to examine the role that
preceptorships play in a student's education. As generally defined,
preceptorships offer students the opportunity to work under the supervision of
staff nurses as part of their educational program. The goals are similar to
externships: increased confidence and competence in the delivery of health
care. However, Itano, Warren, and lshida (1987) found no significant difference
in role conceptions between participants and non-participants of the program.
Dobbs (1988) examined senior preceptorships as a means of promoting
anticipatory socialization to the working role. Her study supported the program
as an effective strategy to increase the beginning competency of new

baccalaureate graduates.

16

Summon

Professional socialization is viewed as a developmental process. Summer
externships are designed to support the professional socialization of nursing
students as demonstrated by those studies reviewed here. Therefore, the
externship should facilitate the student's movement through that process so
that he/she is better prepared to face the realities and responsibilities of his/her

first position as a professional nurse.

Chapter Three

Methodology

In this study, the researcher examined the perceptions of new graduate
nurses regarding their socialization to the professional role. Comparisons were
made between those nurses who participated in a summer nurse externship
program as students with those who did not. In order to do this, a survey was
sent to a sample of registered nurses who had graduated between January 1
and June 30, 1991. They were asked to share demographic data as well as
their perceptions of their summer nurse externship experience and their own

professional socialization.

Iboliooulation
The population consisted of baccalaureate-prepared nurses licensed in

Michigan who were in their first year of employment since graduation.

17

18
II S I' I I .

The sample consisted of a group of Spring, 1991 graduates of eleven
generic baccalaureate nursing programs in Michigan (Table 1) who passed the
licensing examination in July, 1991 and became licensed in Michigan.

From the cross-referenced lists provided by the schools of nursing and the
Michigan Department of Licensing and Regulation, 348 individuals were

identified and all were sent the survey instrument.

 

 

Table 1

I 3 I Io'o-IIIIII-II III a
School Location
Grand Valley State University Allendale
Hope-Calvin Colleges Grand Rapids
Lake Superior State University Sault Ste. Marie
Madonna University Livonia
Michigan State University Lansing
Northern Michigan University Marquette
Oakland University Rochester
Saginaw Valley University University Ctr.
University of Detroit - Mercy Detroit
University of Michigan Ann Arbor

Wayne State University Detroit

19
WES

A pilot study was conducted using ten December, 1991, BSN graduates
who were not members of the study sample. A cover letter explained the
study and the pilot procedure. All ten surveys were returned by the date
requested. Therefore, no follow-up letters were necessary. Comments were
requested but none were received. No revisions were made to the cover letter
or to the survey instrument. The pilot sample may have been favorably biased
toward the researcher as all of the members of the sample were known to the
researcher. This may account for the lack of comments received.

The survey instrument sent to the subjects of this study consisted of three
parts. Part I, Demographic Data, was concerned with information such as the
gender, age, ethnic background and marital status of the respondents. In Part
II, Summer Nurse Externships, the respondent who participated in a summer
externship experience was asked to indicate the degree to which he/she agrees
or disagrees with 13 statements describing his/her externship experience. Five
of these statements included outcomes of professional socialization as defined
by the American Association of Colleges Of Nursing in its 1986 report,

‘I- o o ‘°_$-_I'. I‘ ' 0.- -.0I 0 0‘ 0|- L 'I(see
Appendix B) as well as other statements describing various externship and
preceptorship experiences as found in the literature. It was followed by two
open ended questions requesting their perception of the most and least

beneficial aspects of the experience.

20

Finally, in Part III, Professional Attitudes, the respondents were asked to
express their attitudes toward three aspects of professionalism: a superordinate
purpose, critical attitudes/thinking, and compassion for the needs of the
client/public. This was achieved through the use of a portion of Stone's Health
Care Professional Attitude Inventory as modified for nursing by Lawler (Lawler,
1988; Ward and Fetler,1979). It was based on work by Dumont (1970) who
saw the "new face of professionalism" as responding to constantly changing
environments and social change. The original inventory incorporated the
additional aspects of consumer control, indifference to credentialism and
impatience with rate of social change. The questions in these areas were
considered to have minimal relationship with the professional socialization goal
of externships and therefore, were not included.

The Professional Attitudes section consisted of 20 five-point items in a
Likert scale format (strongly agree--strongly disagree) pertaining to health care
professionals and delivery systems. The instrument was self-administered and
took approximately 10 minutes to complete.

Other instruments were considered before Lawler's version of Stone's
Health Care Professional Attitude Inventory was selected. One instrument
seriously considered was the Professional subscale from Corwin's (1961)
Nursing Role Conception Scale. However, Corwin's instrument appeared to be
more useful in measuring professional role dissonance which was not the focus

of this study. Stone's instrument was determined to be a better choice and had

21

a better level of reliability. The alpha for the total Stone inventory was reported
to be .73 (Lawler, 1988).

A list Of the Spring, 1991 graduates was obtained from the eleven schools.
These names were matched with a list of nurses newly registered in Michigan
during the summer months Of 1991 as provided by the Michigan Department
of Licensing and Regulation. A three part survey packet (see Appendix A) was
mailed tO each individual in the population.

Each packet mailed to the respondents included 1) a cover letter explaining
the study and assuring confidentiality by the researcher 2) the three part survey
instrument 3) a stamped return envelope and 4) a stamped return postcard so
respondent could request survey results under separate cover.

Follow-up letters were sent at the end of two weeks to those individuals
whose response was absent or incomplete. Additional packets were sent two

weeks after the follow-up letter as needed.

QataAnalxsis

Descriptive statistics were used to analyze the data gathered by the survey
instrument comparing participants and nonparticipants in nurse externship
programs. Demographic data were used to determine the similarity Of the
groups. Data were crosstabulated using the program, SPSS (Norusis, 1990).

Standard procedures for testing were used in the analysis of data.

22

The data gathered in Part II rating the externship experience (by those who
participated in one) were analyzed to determine means and frequencies.

The scores on the professional attitude inventory (Part III) were compared
between participants and nonparticipants. Ratings on the three subscales of the
inventory were examined for significant differences between the groups. T-
tests were calculated. Depending on the F-value and its associated two-tailed
probability, the pooled variance estimate was utilized when the variances were
similar and the separate variance estimate was utilized when the variances were
significantly different. Alpha level for all testing was .05.

The responses to the Open-ended questions regarding the most and least
beneficial aspects of the externship experience of the respondent were sorted

and categorized by frequency of the type of response.

Chapter Four

AnollsimoLData

thoduction

The purpose of this study was to examine the externship experience of
recent nursing graduates and to compare the perceived socialization of those
graduates who completed a non-credit summer externship as students with
those who did not. Spring, 1991, nursing school graduates of Michigan
colleges and universities were surveyed one year after graduation.

The content of this chapter will be organized in two ways. The data will be
reviewed in the order that they appeared on the survey. Demographic data are
described first, and a description of the externship experience follows. Finally,
a summary Of the responses received on the Professional Attitude Inventory
(Part III) is included. In the second half of the chapter, each research question

will be addressed individually.

23

24

Part I: Demographic Data

Respondents were asked their gender, age, ethnic background, marital status
and type of employment position held during the summer between their junior
and senior years in nursing school. Two questions, type of nursing education
completed and date of graduation from nursing school, were asked as a means
of assuring that the responses were from the target population.

Of the 348 surveys mailed, 225 completed surveys were returned for a
return rate of 64.7 %. Nine surveys were returned unanswered by the Post
Office due to insufficient or inaccurate addresses.

Ninety-three percent of the respondents were female (n = 209). This sample
is typical of the graduating classes at that time nationwide (Bednash, Berlin, &
Haux, 1991). More than half of the respondents were between the ages of 20

and 27 years (see Table 2.)

 

 

 

 

25
Table 2
GondoLondAgeoLBosoondontS
Gender N % Age in Years N %

Male 16 7.1 20-23 89 39.6
Female 209 92.9 24-27 71 31.6
28-35 36 16.0
36-45 26 1 1.6
46 & over 3 1.3

Ninety-three percent listed their ethnic background as white. The remainder
listed their background as one of the minority groups or as "other". This last
category included subjects by country of origin (Ethiopia, Pakistan) or those who
checked more than one category (Black/Asian, Asian/ Indian). Forty-four
percent of the respondents were married at the time they completed the survey

(see Table 3.)

26

Table 3

 

 

Ethnic Background N % Marital Status N %
White 209 92.9 Married 99 44.0
Black 6 2.7 Single 1 17 52.0
American Indian 1 0.4 Divorced 6 2.7
Asian 3 1 .3 Separated 1 0.4
Hispanic 1 0.4 Widowed 2 0.9
Other 5 2.2

Of the total 225 respondents, 63 % (n=141) had participated in an

externship program between the junior and senior year of their nursing school

program. Of these, 66 participated in an externship at the agency where they

were eventually hired after graduation.

One subject participated in two

externships and later accepted employment at one of the agencies (see Table

4).

27

Table 4
Emgtaduotionfiommofimoloxmontotflosoondonts

 

 

Variable N %
Externship at employing agency 66 29.3
Externship at non-employing agency 76 33.8
Work study with academic credit 7 3.1
Health care employ. w/O learning opportunity 51 22.7
Employment outside health care field 17 7.6
Other 21 9.3
Totals 238 * 105.8 *

* Totals equal more than the number of respondents and more than 100% due to
holding of more than one position by some subjects.

Part II: Summer Nurse Externships

Eighteen activities associated with externships were listed and respondents
who had participated in an externship were asked to indicate the degree to
which they agreed or disagreed with a statement about each activity in respect
to how it described their particular externship. All 141 subjects who had
indicated they had had an externship completed this section. Their responses
ranged from a high of 93.6% (n = 132) to a low of 23.4% (n =33) who either

agreed or highly agreed with the statement as it described their experience.

28

As indicated in Table 5, the opportunities most frequently provided by the
externship experience included mastery of assessment skills, an identification
with the nursing profession and mastery of technical procedures. Those
activities provided for less than half of the respondents included seminars to
discuss problems in role transition, medication administration and class
instruction of 10 hours or more. Several respondents noted that medication

administration was one activity that externs were not allowed to perform.

29

Table 5

D "E'IID'E I'

 

 

N %
Assessment 1 32 93.6
Identification with nursing profession 129 91.5
Technical procedures 128 90.8
Recording 126 89.4
Time management 126 89.4
Link bet. motivation & dev. of prof. behavior 120 85.7
Meeting psychosocial needs of families 1 18 83.7
Speciality area Of interest 108 76.6
Mentor/Preceptor 1 07 75.9
Internalize values of professional nurse 106 75.2
Experience on more than one shift 102 72.3
Critical thinking 98 69.5
Syllabus/Orientation manual 96 68.1
Appropriate postgraduation employment 87 62.1
Experience on more than one unit 74 52.5
Class instruction of 10 hours or more 69 48.9
Medication administration 62 44.9
Seminars on role transition 33 23.4

N212 n=147

30

In this section of the survey instrument respondents were also asked two
open-ended questions. They were asked to name the most beneficial and least
beneficial aspects of the externship experience. In reviewing the responses
received, several themes emerged.

Eight respondents left the question regarding the most beneficial aspect of
the externship experience blank. As indicated in Table 6, the most frequently
cited benefit, by far, was the opportunity to improve skills through "hands on
experience." Forty-four percent (n = 63) referred directly to this one aspect of
the experience. The five specific skills areas noted most often were:
organization/time management (n =20), technical skills (n =12),
communication/nurse client interaction (n =1 1), assessment (n = 5), and
documentation/charting (n = 2).

The next most frequently cited benefit of the externship (n = 63) relates to
the improved skill attainment assumed to be inherent in the experience.
Nineteen respondents stated that their particular externship experience helped
prepare them for the "real" or "actual" world of the registered nurse. An
additional fifteen respondents stated that it eased the transition from the role
of student to registered nurse. Another thirteen respondents spoke directly to
their socialization to the professional role. Through increased interaction with
professional nurses, one respondent stated, the most beneficial aspect was
"being able to assimilate the professional nurse role-being a part of the health

care setting and functioning as a nurse."

31

Other benefits listed by the respondents were the opportunity to apply theory
to practice, the opportunity to explore an area of interest, the opportunity to
work closely with one mentor, increased self-confidence and improved

performance in school (see Table 6).

32

Table6
H E ["II [E I' E .

 

 

N %
Improved skills/hands on experience 63 44.7
Preparation for "real" world 19 13.5
Eased transition from student to RN 15 10.6
Socialization to professional role 13 9.2
Application of theory to practice 7 5.0
Exploration of area of interest 6 4.3
Opportunity to work with one mentor 5 3.5
Increased confidence and responsibility 5 3.5
Improved school performance 4 2.8
Opportunity to work on more than one unit 4 2.8
Classroom activities 2 1.4
Other" 10 7.1
[More n= 741
* Included benefits of: experience without pressure of grading,

money, development of employment opportunity, eased
transition to specific agency or shift, provided View of ”how
nursing should not be ".

33

In response to the question of what was the least beneficial aspect of the
externship experience, 36 % (n=51) of the subjects either left it blank or
responded "none" or "nothing."

In regard to the least beneficial aspect of the externship experience, the
major theme to emerge from the responses related to role expectations and/or
restrictions. Eighteen respondents cited limitations placed on opportunities to
perform such skills as administering medications, hanging intravenous fluids,
caring for critically ill clients and taking physician's orders as the least beneficial
aspect of their experience. Some respondents added that they recognized there
had to be some limitations placed on them as they were, as yet, unlicensed
personnel.

Twenty-one respondents related, occasionally in pointed comments, that they
were frequently utilized in other ways than expected in the extern role. Terms
used to describe their unanticipated functions were aide, orderly, unit assistant,
nurse extender, and helper. Also mentioned was their use as "cheap labor"
when they were "dumped on" by registered nurses. Six specifically disliked
being "counted as staff." They saw the role of the extern as being an
educational one where they would not be considered in the staffing needs of the
unit. Other aspects listed as least beneficial were lack of one specific
preceptor assigned to them alone (n =1 1), lack of classroom/seminar activities

(n =8), negative attitudes of staff (n = 6), lack of variety/work on one unit only

34

(n=6), lack of structure to the program (n=5), and interference with

school/lack of time to study (n =4). A summary is presented in Table 7.

Table7
I E [HM [E l' E .

 

 

N %

Utilization in role other than extern 21 14.9
Limitations placed on role 18 12.8
Lack of one assigned preceptor 1 1 7.8
Lack of classroom activities 8 5.7
Negative attitudes of staff 6 4.3
Experience on only one unit/lack Of variety 6 4.3
Lack of structure to program 5 3.5
Interference with schoolwork 4 2.8
Insufficient salary 3 2.1
Other" 1 6 1 1 .3

[1th n=141

* Included aspects of: stress of unit, conflict between real and

ideal, not placed in area of interest, midnight shift assignment,
rotation to more than one unit, lack of professionalism of staff,
length of program.

35

Part III: Professional Attitudes

In this section of the survey all subjects were asked to respond to twenty
statements about today's health care professions and health care delivery
systems. They were asked to indicate the degree to which they agreed or
disagreed with each statement.

Questions relating to the three subscales covered by the instrument were
intermingled throughout the survey. Questions 1, 5, 8, 11, 13, and 16
compose the subscale "superordinate purpose." Dumont (1970) defines this as

the "principles that order and direct (sic) professional lives. Questions 2, 3,
7, 10, 12, 15 and 18 compose the subscale "critical attitude/thinking" which
refers to the professional's willingness to search or question the evidence and
possible alternatives in any situation. Questions 4, 6, 9, 14, 17, 19 and 20
compose the subscale "compassion." It assesses the level of dedication and
sensitivity toward the care of others which is such an integral part of the
professionalism of nurses.

Scores were computed on each subscale as well as a total professional
attitude score for each respondent. The means from those who had
participated in an externship were then compared with the means of those who
had not.

The six questions from the subscale "superordinate purpose" had a possible

range of scores from 6 to 30. The actual scores of all subjects on that subscale

36
ranged from 14 to 27 with a mean score of 20.92 and a mode of 22.0. As
expected, the scores followed a relatively normal distribution (see Figure 1).

Professional Attitude Scores

 

o..... Hm— .
IIIsuirIIIImainnuamn
Soon

Figure 1 Professional Attitude Scores - Superordinate Purpose

For the seven questions from the subscale critical attitude/thinking, the
possible range of scores was from 7 to 35. The actual scores of all subjects on
that subscale ranged from 16 to 31 with a mean score of 22.87 and a mode of

24.0. Again, they followed a fairly normal distribution (see Figure 2).

Professional Attitude Scores

 

III‘I1.19202121232425232720293031
lou-

Figure 2 Professional Attitude Scores - Critical Attitude/Thinking

37

The compassion subscale score was derived from seven questions and,

therefore, had a possible range of 7 to 35. The actual range was from 17 to 33

with a mean score of 23.49 and a mode of 24 (see Figure 3).

Professional Attitude Scores

   

Figure 3 Professional Attitude Scores - Compassion
The total professional attitudes score, derived from all 20 questions and
encompassing all 3 subscales had a possible range of 20 to 100. The actual
scores for all subjects ranged from 55 to 79 with a mean of 67.29 and a mode

of 65 (see Figure 4).

38

Total Professional Attitude Scores

 

55555755503031uuussusneaumnnnunnnnn
Score-

Figure 4 Professional Attitude Scores - Total

Besoatohfluostionflno

Do nurses who participated in summer student externship programs hold
different attitudes regarding professionalism than nurses who did not have
externships? In order to answer this question t-tests were used to compare the
mean scores of the two groups.

First the mean scores on the subscales were compared. Scores for the two
groups were quite similar but subjects who had participated in a summer
externship did score slightly higher on all three subscales.

With the desired alpha level set at .05, the separate-variances formula was
utilized to compare the two groups. Table 8 presents the means and standard

deviations for the two groups on the three subscales and the total score. Mean

39
scores were significantly higher in the externship group on only the
superordinate purpose subscale.
The total professional attitudes score of the two groups were compared.
A qualified significant difference was found between the scores Of the two
groups since the resulting probability was .049. This cautiously but

affirmatively answers the first research question.

 

 

 

 

 

Table 8
.
WWW E . I i . I I

Subscale Group N M SD t p

Externship 141 21.31 2.50
Superordinate 2.99 .003
Purpose

Non-externship 84 20.22 2.62

Externship 141 22.90 278
Critical Attitude/ .20 .845
Thinking

Non-externship 84 22.82 2.72

Externship 141 23.5L3 2.81
Compassion .30 .767

Non-externship 84 23.42 2.70

Externship 141 F780 5.10
Total Score 1.99 .049

Non-externship 84 66.42 4.71

40
Basoamhfluestionlm
What demographic differences are there between nurses who participated
in a summer student externship program and those who did not?

Characteristics of the two groups can be found in Table 9.

41

 

 

Table 9
El . . i E |
Externship Non- Total
Participants Externship
Participants
Variable N % N % N % x2 p

Gender 1.18 .28
0 Male 8 5.7 8 9.5 16 7.1

0 Female 133 94 76 91 209 93

Age 1 1 .55 .02
0 20-23 63 45 26 31 89 40

0 24-27 48 34 23 27 71 32

0 28-35 17 12 19 23 36 16

0 36-45 11 7.8 15 18 26 12

o 46 + 2 1.4 1 1.2 3 1.3

Ethnicity 8.45 .13
0 White 133 94 76 91 209 93

o Black 3 2.1 3 3.6 6 2.7

o Am.lndian 0 0 1 1.2 1 0.4

0 Asian 3 2.1 0 0 3 1.3

0 Hispanic 1 0.7 0 0 1 0.4

o Other 1 0.7 4 4.8 5 2.2

Marital Status 7.80 .10
0 Married 57 41 42 50 99 44

0 Single 80 57 37 44 1 17 52

o Divorced 4 2.8 2 2.4 6 2.7

o Separated 0 0 1 1.2 1 0.4

o Widowed 0 0 2 2.4 2 0.9

While there was a greater percentage of females in the externship group
(94.3%) than in the non-externship group (90.5%) no significant difference was

found in regards to gender.

42

Subjects who participated in a summer externship experience tended to
be younger than those who did not. There was a significant difference found
between the two groups.

No significant differences were found in regards to ethnicity or marital
status. All values were calculated using the Pearson chi-square statistic.
Bosoatobflnestionlhtoe

How do recent graduates perceive their summer externship experience as
contributing to their professional socialization? Five questions (1, 2, 6, 9 8t 13)
in Part II of the survey instrument (see Appendix A) related directly to the

outcomes of professional socialization as outlined by the American Association

of Colleges of Nursing in its 1986 report, MW!
EducationjoLELotossjonaLNuLsm (see Appendix 8). Responses to these five

questions will be examined in order to answer this research question.

When asked whether their externship experience provided them with a
linkage between their motivation for entering nursing and the development of
professional behavior, 85.7 % answered affirmatively. Just four subjects (2.8
%) disagreed with the statement (see Appendix C).

A majority of the subjects agreed that the externship experience provided
them the opportunity to master the skills of the nursing profession. However,
there was some variation among their perception of the six skills specifically

listed.

43

Mastery of the Skill of assessment was given the highest ranking of all
the skills. One hundred thirty-two (93.6 %) agreed that they had gained this
skill while four (2.8 %) disagreed. Mastery of technical procedures (90.8 %)
was the next most common accomplishment followed by recording (89.4 %),
time management (89.4 %), working with families' psychological needs (83.7
%I and medication administration (44.9 %).

The respondents were provided with somewhat less opportunity to
develop critical thinking skills. Ninety-eight respondents (69.5 %I responded
positively to that measure of professional socialization. Nineteen respondents
(13.4 %) expressed a lack of opportunity in this area. Interestingly, all of those
who stated that their externship failed to provide a linkage between their
motivation for entering nursing and the development of professional behavior
also stated that they were not provided opportunities to develop critical thinking
skills.

Three-fourths (75.2 %) of the respondents believed they were able to
internalize the values of the professional nurse during their externship
experience. Nine (6.4 %I believed they were not able to do this. These were
evenly distributed between three age groups: 20-23, 24-27, and 36-45.

An identification with the nursing profession was a part of the externship
experience for 91.5 % of the respondents. Just three persons (2.1 %) did not
find this to be true. Two were in the age group 36-45 and one was in the 24-

27 age group.

44

Of the 28 respondents who stated that their externship did not provide
opportunity in one or more of the areas identified as outcomes of professional
socialization, all but one were female. All but two listed their ethnic background
as white. Approximately half were presently employed in the agency where
they had their externship. Most of these respondents were between the ages
of 20 and 27 although nearly half of the externs in the 36-45 year old category
rated their externship as not providing opportunities in at least one of the areas
identified as professional socialization outcomes. Proportionally, the number Of
younger nurses who responded negatively was much less.

In summary, the nurses who participated in a summer externship

experience found it to contribute positively to their professional socialization.

Besoarchfluostioniour
What aspects of the externship experience relate to professionalism? To
determine what relationships, if any, exist, the frequency of some of the
activities of the externship (Appendix A, Part II) was correlated with the
subscale and total scores received on the professional attitude inventory
(Appendix A, Part IN). More specifically, questions 1,2,6,9 and 13 in Part II
listed activities which were outcomes of professional socialization as stated in
‘l- o o '9‘ -_I0. I. ‘ i ,0, --I I 0‘ III I_ 'I(See

Appendix B). It is the correlation of these activities with the scores on each of

45

the three subscales as well as the total professional attitude score that will

address this final research question.

The relationships between the five outcomes of professional socialization

and the subscale and total scores on the professional attitude inventory were

examined using Pearson's correlation coefficients. Table 10 summarizes the

results.

 

 

Table 10
E‘IOI Io 3‘ I“I'_ Oll’ o '0‘ III 0 -.0l
i... 0‘ o 3' III-.‘I II’O‘ III AI 0‘ I ‘I II
Superordinate Critical Attitude / Compassion Total Score
Purpose Thinking
r p r p r p r p
Linkage between
motivation for entering
nursing and
development of
professional behavior -.10 .24 .16 .06 .15 .08 .1 1 .17
Mastery of skills of the
nursing profession
assessment -.06 .48 .06 .52 -.01 .90 —.02 .85
recording -.10 .24 .09 .28 -.04 .66 .01 .92
working with
families' needs -.11 .20 .02 .86 -.01 .88 -.06 .51
technical procedures -.08 .35 .01 .94 .15 .07 .04 .62
medication admin. -.07 .45 .04 .65 .08 .36 .03 .74
time management -.15 .07 -.05 .58 .07 .38 -.07 .43
Opportunities to
develop critical
thinking skills -.12 .16 -.04 .66 .08 .35 -.04 .63
lnternalization of the
values of the
professional nurse -.08 .36 .00 .97 .02 .79 -.04 .65
Identification with the
nursing profession -.22 .01 -.06 .47 .11 .20 -.08 .33

46

The frequency with which the externship experience provided a linkage
between the respondent's motivation for entering nursing was not significantly
related to any of the scores on the professional attitude inventory. When the
six skills which had the potential for mastery within the externship were
correlated with the three subscales and the total professional attitude score no
significant relationship was found.

The correlation of the frequency with which respondents were allowed
opportunities to develop critical thinking skills with the scores on the
professional attitude inventory also demonstrated no significant relationship.

Correlation of the frequency with which the respondents were able to
internalize the values of the professional nurse during the externship with the
professional attitude scores demonstrated no significant relationship.

The only significant relationship demonstrated was the correlation
between the respondent's identification with the nursing profession and the
score on the subscale of superordinate purpose. A significance of .01 was
noted. When correlating this same outcome of professional socialization with
the remaining two subscales, critical attitudes/thinking and compassion, or with
the total professional attitude score, no significant relationship was
demonstrated.

The lack of any demonstrated significant relationships can be accounted
for in a number of ways. The subjects in this study were quite similar and

therefore the strength of the correlations would decrease. When the instrument

47

was tested for reliability unacceptable levels were obtained (see Appendix D).
Therefore, the one significant finding was most likely due to chance.

To summarize the findings related to research question four, it appears
that very little of the externship experience related to professionalism as
measured by the professional attitude inventory. It was possible to demonstrate
a link between just one aspect of the experience, identification with the nursing
profession, and one measure of professionalism, the holding of a superordinate
purpose. With all other activities there was no clearly demonstrated relationship
to professionalism. the lack of demonstrated reliability of the instrument played

a major role in the lack of significant findings.

Chapter Five

5 El IE I'

Professional socialization involves a wide range of formal and informal
processes. From their formal educational program, students begin to acquire
the knowledge and skills necessary for their chosen profession. Informally
students begin to overcome their prior stereotypes and accept new beliefs,
values and attitudes as they come in contact with other professionals. This
exposure assists the novice with the development of his/her own professional
self-image (Cohen, 1981; Lum, 1978).

Upon examining the professional socialization of nursing students one is
struck by the incongruence in the socialization processes between those
occurring in the university setting and those occurring in the practice settings
which students choose upon graduation. Kramer (1972, 1974) has written
extensively about this phenomenon and utilized the term "reality shock" to
describe the new graduate's reaction to the experience of this incongruence.

48

49

Inadequate professional socialization has been found to be a factor in nurses
abandoning the profession (Corwin, Taves, & Haas, 1961).

In an attempt to gain an understanding of the "essential knowledge,
practice, and values for the education of the professional nurse", the American
Association of Colleges of Nursing established an Essentials Panel to explore
those issues (AACN, 1986). Among the findings released in their final report
were five outcomes of the socialization process.

In response to the growing body of data acknowledging the incongruence
between the socialization of school and work, hospitals and universities set up
a variety of programs designed to ease the transition and accommodate the
growing need for nurses as well. These are described in the literature as
internships, preceptorships or externships with each having both unique and
overlapping characteristics with the other.

The focus of this study is the summer externship program defined as a
non-credit work study experience Offered to students during the summer
between the junior and senior years of the nursing program and under the
direction of the health care agency. Specifically, the study examined the
professional socialization of new graduates by use Of an adapted version of
Stone's Health Care Professional Attitude Inventory. A comparison of
professional attitude scores was made between those graduates who had

completed a summer externship program and those who did not.

50

Spring, 1991, graduates of baccalaureate programs in Michigan were
surveyed. Two hundred twenty-five or 64.7 % surveys were returned. In
addition to demographic data, respondents were asked to provide information
regarding the activities of their particular externship experience. The frequency

of these activities was correlated with the specific outcomes of professional

socialization as outlined in the AACN document, Essentialsfljollegund
!!"E|'[EI'II|'-

As was expected, the majority of the respondents were Caucasian,
female and in their twenties. Approximately, half were single. Sixty-three
percent (n =141) had participated in an externship program. Overwhelmingly,
their experiences in the externship were described in positive terms. Benefits
of getting "hands on experience" and preparation for the "real" world were
frequently cited. Criticisms were primarily related to their use in functions

other than anticipated in the extern role.

I.
-
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-

Nurses who participated in a summer externship program as a group
scored higher in all three attitudes surveyed: superordinate purpose, critical
attitudes/thinking, and compassion. However, a significant difference was

found only in the area of superordinate purpose. When the total scores on the

51

attitude inventory were compared, a significantly higher mean was found by
those who had an externship experience.

While a difference in the area of critical attitudes/thinking was expected,
the fact that there was none may mean that those respondents who
participated in an externship actually developed opposing attitudes. That is,
they began to model their behavior after their preceptor and carry out nursing
activities simply because that is how it was always done and not because they
had considered all possible alternatives in any given situation. With repeated
exposure to some situations, the respondent may have begun to rely more on
past experiences and less on the need to think critically.

Compassion is one attitude which does not appear as developmental in
nature as some of the others. Compassion for others is often what draws
students to the nursing profession initially. It would be understood that externs
would come to the experience with a sensitivity for the needs of their clients.
Therefore, it is not overly surprising that no difference was seen between the
two groups.

Since a superordinate purpose forms the foundation of one's professional
life, it seems reasonable that experiences that enhance one's professional
identity such as an externship would also solidify the base on which that
identity rests. The externship is seen as a "real world" experience and it often

reinforces the fact that the individual has made the right career choice.

Ale Q‘Il" 10].. ' ‘l ’ v. ‘ l’ ' 9‘ A“!

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I. ‘ I I0 0110-. '0. 'I -_ .llll‘ .I‘ ‘. ‘ I I- o H. -.II III. I0 ' I I-
dithotZ

No significant differences were found between the groups in regards to
gender, ethnicity, or marital status. A significant difference was found in
regards to age. The respondents who participated in an externship were
youngen

Since the two groups were quite similar in all aspects except for age, it
could be postulated that the Older student possibly had more family
responsibilities and was not able to participate. As some of the written
comments indicated, a number of the older students were already employed in
the health care field as licensed practical nurses, respiratory therapists, etc. and
therefore, they preferred to continue in those roles for the summer.

II
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I

‘. ‘ I I0 ‘.0‘ ‘l ‘ -. 0| ° I! o l‘ 0 0 ‘ 01-. o " - 'I7

Five statements relating to outcome measures of professional
socialization were embedded in a listing of externship activities. An analysis of
these statements revealed that a majority of nurses perceived the externship to
contribute positively to their professional socialization. The outcome most
closely associated with their actual experiences was that of mastery Of the skills

of the profession.

53

Much of the literature regarding externships focused on skill acquisition
as one of the main goals of the experience (Myrick & Awrey, 1988; Scales,
Alverson, & Harder, 1993; Scheetz, 1989; Whelan, 1982). Therefore, this is
not a surprising result. Mastery of skills is also a very concrete outcome and
probably more easily understood by the respondents. The remaining four
outcomes are less easily defined and recognized and their achievement more
subfle.

Proportionally, a greater number of older nurses reported that the
externship experience did not provide opportunities related to professional
socialization outcomes than was expected. While their expectation of skill
acquisition seemed to be fulfilled, their internalization of values and professional
identification was not. For many in this age group, nursing may have been a
career change. It may take longer for someone with a greater range of careers
and experiences to accept the values of a new profession than for the individual
who is entering into his/her first career.

3' ‘v. IQ.‘°I 0. Alt!" 0 l“.‘ll".9“l“-."
E . l' ?

When the frequency of the professional socialization activities of the
externships were correlated with the scores received on the professional
attitude inventory, no significant relationships were found except in one

instance. Nurses who reported that the externship experience provided them

54

with an identification with the nursing profession also scored significantly higher
on the superordinate purpose subscale.

One would expect to find a relationship between the activity of
developing critical thinking skills and the subscale which measured critical
attitudes/thinking but this was not found. This may reflect on the way those
questions were phrased as they may not have been seen as relating to critical
thinking.

With the exception of the relationship noted above, it appears that little
of the externship experience relates to professionalism as measured by the tool
in this study.

Overall, the major conclusion to be drawn from this study is that those
subjects who had an externship experience as students did engage in activities
that were directly related to published professional socialization outcomes and
they achieved higher professionalism scores as graduates than those who did
not have an externship. One variable that could have affected the results is the
time lag between the externship experience and the completion of the survey.
For most respondents the time span was approximately two years and their
perception of the externship experience could have been altered due to the lack
of recall of such events. Additionally, their experiences during their last year in
their nursing program and their first year of employment could have altered their
professional attitudes and the resulting scores. If professional socialization is

seen as a developmental process, those two years of time cannot be ignored.

55

One respondent added a note at the end of the survey stating, "I am currently
employed in the military. I got a great deal of experience as a nurse extern, but
nothing compares to my military experience. I have grown more as a

professional this past year than I ever thought possible."

Bmmmendatims

Since the data from this study were collected, changes have taken place
in the health care industry and the nursing profession. In an effort to reduce
costs, most health care agencies have either eliminated or sharply limited the
number of externship students that they accept each summer. As health care
agencies shift to hiring more unlicensed personnel and less registered nurses,
the externship experience is no longer viewed as the necessary recruitment tool
that it once was. As agencies become more sophisticated in costing out the
services provided by these various types of personnel, the staffing mix will
continue to fluctuate and change.

Based on the review of the literature and the results of this study, the
following recommendations are offered to health care agencies and schools of
nursing.

B | . E II I | E g .

1. Health care agency administrators should consider establishing an
externship program at their institutions if they do not have one at this time or

if agencies have eliminated the externship program, consideration should be

56

given to reinstating it. Overwhelmingly, the respondents credited the externship
program with easing their transition into the registered nurse role, reducing their
stress level and improving their overall skill level. This should have an impact
on decisions made by human resource managers. One respondent noted,

The externship program I was involved with allowed me the opportunity
to develop and cultivate my nursing skills and style. It provided an arena
to practice and apply all the knowledge acquired in the classroom without
all the pressures and responsibilities of a professional RN. I cannot
imagine making the transition from a student to a professional without
first participating in an externship program.

This can be contrasted with a note attached to one survey from a
respondent who had not participated in an externship. He stated,

If you are only surveying people who are currently working as nurses,

don't include this one. I didn't pass probation on my first nursing job.

I've been looking for another nursing job ever since. It's been a year now

and I'm almost ready to give up looking.

The cost of orienting a new employee is enormous and the value of the
externship especially as a recruitment/retention tool is obvious. Most
orientation programs of major employers are tailored to the needs of the new
employee and costs increase with the need for longer programs. Laschinger and
MacMaster (1992) suggest that externship-like experiences may reduce
orientation needs for new graduates because of their increased clinical
competence. Presently no empirical data exist that determine the point at

which the cost of an extended orientation outweighs the cost of an externship

for an individual. Since there are no guarantees that a nurse extern will be

57

employed after graduation, the externship allows the agency to closely examine
a new nurse before offering him/her permanent employment.

Another area of concern and expense for employers is stress and burnout
among employees. Several respondents specifically mentioned these two
concerns because they were either presently experiencing them in their job or
were seeing evidence of them in their colleagues. Several respondents saw the
externship experience as a time where "stress was controlled" allowing them
to gain experience which helped decrease their stress level later as a new
graduate.

2. Coordinators of externship programs at health care agencies should
evaluate their present programs.

The following suggestions for change have been derived from the
comments received from those who had participated in an externship. It is clear
that nurse externs want and need a structured program which allows them to
function in the extern role. One respondent who felt she had not been utilized
in the intended role of the extern stated, "I was basically an aide who charted."

Each extern should be assigned to one preceptor who has also been
prepared for his/her role. The preceptor should have a positive attitude toward
the profession and have an understanding of the extern's learning needs. One
respondent noted that, "Some preceptors tried to share twenty years of
knowledge in a three month externship. Too much, too fast. Better to keep it

simple and concentrate on the extern's needs." A study by Pond, McDonough,

58

and Lambert (1993) supported the premise that the best preceptor is one who
has spent two or three years in the work setting as they are most likely to
"connect" with students and meet their learning needs. More clinically
advanced nurses "perceive situations 'whole' and often find it difficult to
communicate the steps that go into their decision making."

The experience that nurse externs most desired but often did not get was
the administration of medications. The legal aspect of using unlicensed
personnel for that task was the most often cited reason. Since 44.9 % of the
participants were allowed to administer medications it seems that the
complexities of the procedure could be managed legally and safely so that all
externship participants could have that particular experience.

Most externs expressed a need for more structured classes and seminars
where they could focus on issues related to professionalism (i.e., role change,
accountability, role expectations, legal issues, ethical issues, and stress
management).

B I . l S | I l [I .

1. Nurse educators should re-evaluate the curriculum of the
undergraduate nursing program at their institution as it addresses a) the AACN
outcomes for professional socialization and b) the clinical experience
component.

While most educators appear to subscribe to the AACN outcomes, there

does not always appear to be a structured plan for seeing that they are being

59

met. Two educators, Davis and Barham (1989), note that these socialization
outcomes are "most likely to be realized" when schools of nursing and health
care agencies collaborate in providing appropriate learning opportunities. It is
generally assumed that simply by associating with faculty and registered nurse
colleagues in clinical agencies for four or more semesters, the student will
integrate the values and beliefs of the profession. Specific strategies need to
be addressed so that each student will have met the outcomes at graduation.

Respondents in the study frequently noted what they perceived as the
inadequate amount of time spent in the clinical area within their undergraduate
programs. One called it "grossly inadequate." Another said, "The externship
provided the clinical experience needed to survive post-graduation that was not
available in school." Still another noted that the clinical assignments given in
school were too limited and unrealistic and the externship allowed her to "work
with a realistic patient load." Patton and Dowd (1994) suggest that "students
should be exposed to a more realistic view of nursing in every clinical course."

The number of clinical hours that students experience have decreased
since the days when most students attended a hospital controlled school of
nursing (Olesen and Whittaker, 1968). The belief is that a firm theory base
along with limited clinical experience is preferable to repetitious clinical
experiences and limited theoretical content. The battle over the proper balance
between theory and clinical practice and the perceived inadequacy of clinical

experience by nursing students continues to rage (Blanchard, 1983; Scheetz,

60

1989). A curriculum based on measurable outcomes and a framework that
allows an integration of activities is a starting point. Faculty will need to
continually re-examine the issue in light of their own curricular goals.

2. Nurse educators should actively seek creative, innovative teaching
methods to improve the balance between theory and clinical practice while
addressing the issue of professional socialization of students.

Time and resources are precious commodities for students and faculty
alike and they become the basis for credit allocation, tuition costs, and faculty
salaries. Many schools have addressed the dual issues of clinical experience
and professional socialization outcomes by incorporating an internship within the
course of study for each student (Dobbs, 1988; Itano, Warren, 81 lshida, 1987;
Myrick & Awrey, 1988; Scheetz, 1989). Within these experiences the student
generally works with a preceptor, carries a more realistic assignment, and
receives academic credit. lt evens out the experiences of each student in the
program and prepares them for the "real world" of employment as a registered
nurse.

To enhance the clinical experience and give students valuable problem
solving opportunities, a number of computer and video programs allowing
interactive exchange are currently available and the number is growing rapidly
(Bolwell, 1993). These and other simulation activities could prove to be

valuable adjuncts in preparing students for post-graduation employment.

61

Faculty should not underestimate their own value in the educational
process. It was interesting to read one respondent's note. It said, "I think it
was very helpful to work with an RN and see some of the problem solving that
they had to do. It is very beneficial to watch someone troubleshoot." Perhaps
faculty need to be more active in verbalizing how they are problem solving
situations to students when they are with them during clinical experiences. This
would in turn help students in developing their own critical thinking skills and
would enhance the quality of the limited time spent in the clinical area.

One respondent noted that in her externship she "learned day to day
aspects of nursing not taught in the classroom." This raises the question of
why these "day to day aspects" are not being addressed. Is it possible that
faculty and health care agency personnel need to better collaborate so that the
new graduate is prepared for his/her first job and does not experience the
extremes of "reality shock" as described by several of the respondents.

lmnlicaflonsjoLEuuheLBmamb

Through the findings of this study information has been added as to the
nature of the externship experience and its impact on a select number of
participants.

To further study the impact of externships on the post-graduation
employment of nurses a serious examination of the effect of externships on the
time and cost of orientation programs needs to be undertaken. Until their

benefits are proven monetarily it is doubtful that their value will be recognized.

62

As the supply and demand of nurses fluctuates, so too will the development of
such programs without empirical evidence to support them. While no one has
proven that externships are the best method of giving students the realistic
experiences they need, no one denies the value of hands-on experience.

To study the process of professional socialization in nurses a longitudinal
study would be an advantageous design. One could choose subjects as
students and continue the study at one, five, and ten year intervals post-
graduation. Participation in an externship is but one variable to have an effect
on the professional identity of each graduating nurse. The impact of specific
role models, academic programs or prior work experience could also be
examined within this design.

Revision of the instrument used in this study is necessary in order to
improve its reliability. Although it was found to be reliable when used in its
form as modified by Lawler (1988) it was not found to be so in this study (see
Appendix D). As the health care industry changes, the wording or focus of
some of the items may need to be changed in order to improve clarity. For
example, item 13 (Appendix A, Part III) relating to primary care would most
likely be answered differently today than it would have been in the 19805.
There is a much greater emphasis on educating primary care providers today

than in the past.

63
Reflections

The two open-ended questions and the anecdotal notes added to the
survey instrument provided some of the most intriguing data collected. When
reviewing the respondent's answers to what was "least beneficial" regarding
the externship experience, rather interesting observations were made. Many
respondents left that question blank while others were quite outspoken in their
remarks. When some of the remarks related specifically to the respondent's age
and how they felt they had been treated because of it, a closer inspection was
made between age and response.

What seemed to emerge were comments that paralleled the respondent's
own adult socialization level. One of the youngest respondents stated,

I worked in a very busy Metro Detroit ER on 3-1 1 shift. The stress
was incredible. I was not twenty-one years old so my preceptors
(who reduced their stress at the bar) did not know how to help
me. I ended up getting very sick because my resistance to illness
was so low. Right now I'm at that same stress level - two years
later.

Those in the middle of the age groupings commented frequently on the
"lower standard of professionalism" that they saw or the "lack of willingness
of staff to help teach and support developing nurses." One stated, "I felt like
cheap labor - no one wanted to see me develop as a professional." The nurses
who were oldest commented on the "lack of interpersonal relationships" with

one stating, "Only two of my instructors seemed to acknowledge that older

students might have a different perspective on things."

64

While each respondent seemed to want his/her own needs recognized,
those at either end of the age range seemed to feel their needs were unique.
This may say something about how educational programs are aimed toward the
"average" student and are not addressing the needs or those who do not fit that
profile. On the other hand, it could reflect the personal socialization of adults.
Just as their professional socialization was at different levels, so also was their
personal socialization. While the younger student focused on the level of
confidence and security he/she was experiencing, the older student was
expressing more concerns regarding relationships. The former was more
centered on the self while the latter was looking to reach out and involve
others.

Educators and health care agency administrators need to reflect on these
comments and pay greater attention to the personal and professional
socialization of their students and employees. Collaboratively, creative
strategies can be developed that will decrease the stress and burnout and

ultimately enhance the lives of students and employees.

APPENDIX A

PROFESSIONAL NURSE SURVEY

Appendix A

PROFESSIONAL NURSE SURVEY

This survey is designed to determine the attitudes of recent graduate nurses

toward their professional role. WM If you wish
to comment on any of the questions, please use the space in the margins or at
the end of the survey.

Thank you for your participation.

Earn: Demographic Data

Please check one answer for each question.

1 . Gender

D1 Male
D2 Female

2. Age

D1 20-23
D2 24-27
D3 28-35
D4 36-45
D5 46 and older

3. Ethnic Background

D1 White

D2 Black

D3 American Indian
D4 Asian

D5 Hispanic

D6 Other

 

4. Marital Status

D1 Married
D2 Single
D3 Divorced
D4 Separated
D5 Widowed

65

 

66

5. Nursing Education
What is the highest level you have completed?

D1 Associate Degree in Nursing
D2 Diploma in Nursing
D3 Baccalaureate Degree in Nursing

6. Date of Graduation From Nursing School

D1 1990 or earlier
D2 January 1, 1991 - June 30, 1991
D3 July 1, 1991 or later

7. Pregraduation Employment
In which of the following did you participate during the summer between your junior and senior
years of nursing school?

D1 Nurse externship program at the agency where you are presently employed. This is
defined as a non-credit work study experience which was under
the direction of the health care agency.

D2 Nurse externship program at an agency other than the one at which you are
presently employed. This is defined as a non-credit
work study experience which was under the direction of the
health care agency.

D3 A structured work study experience for which you received academic credit.

D4 Employment within the health care field which had no structured
learning opportunities.

D5 Employment outside the health care field.

D6 Other (describe)

 

 

 

If you participated in a summer nurse externship program, please complete p911] Part II and Part "I.

If you did not participate in a summer nurse externship program, please gmjt Part II and go on to part III.

 

67

(£311: Summer Nurse Externships

Please read each statement. Then, utilizing the response scale on the right, indicate the degree to
which you agree or disagree with each statement in respect to how it describes the summer nurse
externship in which you participated by checking the appropriate box.

a
o
g a
O: .2
q Q
S, a § S
.5. g s e s
. . . w é” a, a: «‘3
The summer externship experience pro vrded:
1 . A linkage between my motivation for entering nursing
and the development of professional behavior ......... m a In a [a
2. Mastery of the following skills of the nursing
profession:
a. assessment ..................... a a a Q a
b. recording ....................... m a a a a
c. working with families' psychosocial needs a a a a a
d. technical procedures ............... a a a D a
e. medication administration ........... a a a a a
f. time management ................. D a a [a a
3. A syllabus and/or orientation manual containing
specific behavioral objectives ..................... a a a a a
4. Classroom instruction of ten hours or more ........... a a a a a
5. Seminars to discuss problems in role transition ......... In [a a a a
6. Opportunities to develop critical thinking skills ......... m a a a a

68

Strongly Agree

Agree
Neutral
Disagree

The summer externship experience provided

(continued):
7. Experience on more than one unit of the agency ........ a a E a
8. Experience on more than one shift ................. u a [a D
9. lnternalization of the values of the professional nurse . . . . a a a a
10. Opportunity to interact with one prearranged a a a a
mentor/preceptor .............................
11. Opportunity to work in nursing specialty that was matched
with my area of interest ........................ a a a u
12. A post graduation employment position that was congruent
with my philosophical beliefs about professional nursing a a a a

13. An identification with the nursing profession .......... a [a a a

14. What do you consider to be the most beneficial aspect of the externship experience?

Strongly Disagree

 

EIEIBEIEIEIEI

 

 

15. What do you consider to be the least beneficial aspect of the externship experience?

 

 

69

RAM: Professional A ttitudes

This inventory contains a series of statements about today's health care
professions and health care delivery systems. These statements are not
intended to elicit a right or wrong answer but to collect your perceptions of the
accuracy and/or validity of each statement.

Please read each statement. Then indicate the degree to which you agree or
disagree with each statement by checking the appropriate box at the right.

Health care professionals, for the purpose of this inventory, include all registered
nurses who function as a member of the health care team. Health care delivery
systems are those mechanisms and strategies designed to facilitate the delivery
of health care to the consumer.

. i.
0 a
K
a. In
st '5
:- >.
s a E a
t g S g: c
o a a o
«’3 ‘” '2 is 55
Statements: ' ‘ * - -
l. The potential for a financially secure position is a
major reason for pursuing a career in the health care
professions ................................. D a a a [a
2. Students in the health care disciplines should be
expected to emulate or model the role to their
instructors .................................. a a a a [a
3. Students in the health disciplines should incorporate
the philosophy of their educational program into their
practice .................................... [a a a a a
4. Policies based solely on scientific methodology are
most appropriate for the resolution of society's
health care problems ........................... a a a a [a
5. Health care professionals such as nurses generally

are impersonal and scientifically oriented ............. a a a D a

7O

Statements (continued):

6. Health care professionals generally fail to show
adequate interest in the health needs of consumers .....

7. Criticism of health care practices and procedures by
persons outside the profession is usually
acknowledged and acted upon by health care
professionals ................................

8. Education programs for health care professionals
spend more time preparing students for careers in
research and/or teaching than for careers as
practitioners ................................

9. Health care teams tend to become so busy
coordinating care that they lose sight of patient
needs .....................................
IO. Priorities for the consumer of human and material

resources in the health care professions are best
achieved through centralized decision-making ..........

1 1 . The desire for a position of status should be
accorded little importance as a reason for pursuing a
career in the health care professions ................

12. Special economic interests have too often had a
negative influence on public health legislation .........

13. Training greater numbers of health care professionals
to deliver primary care is one alternative that will be
beneficial in meeting the long-term health needs of
society ....................................

14. Health care is currently available to people at
differing income levels on a selective basis ...........

15. Health care professionals have developed adequate
self-evaluation of procedures and techniques in the
delivery of health care ..........................

Strongly Agree
Agree

Neutral

Disagree
Strongly Disagree

‘l

71
8
8 s»
k
In .2
S o
>~ >.
B.- s Q s.
c E E a. c
O Q Q
5‘; e? z ‘6’ a?
Statements (continued): ~ .. .
16. Societal class and social distinctions should be of no

importance in a health care setting ................. D a a a a

17. The health care professional such as a nurse should
be concerned solely with clinical practice and not

with social change in his community ................ In a a a a

 

18. Nursing educators are considered alternate rather
than ultimate sources of information for their

students ................................... D I2 3 a a

19. The existing forms of health care delivery systems
allow professional personnel to efficiently deliver
health care services to meet the needs of individual

consumers .................................. m [a a a a

20. When cost accounting and systems research
techniques are applied to health care, it can be
concluded that the health care needs of some

citizens have not been adequately served ............ m a a a [a

Thank you for participating in this study.
Please return this form by July 21, 1992 in the enclosed self-addressed stamped envelope to:

L. Grinstead, RN, MN
3418 Devon Dr. NE
Grand Rapids, MI 49546

APPENDIX B

AACN SOCIALIZATION OUTCOMES

 

Appendix 8

American Association of Colleges of Nursing Socialization Outcomes
A linkage between the individual's motivation for entering nursing and the
development of professional behavior.

A nursing perspective and related critical-thinking and problem-solving
skills.

Mastery of the knowledge and skills of the profession.

lnternalization of the values, traditions, and obligations of the
professional.

Identification with and commitment to the profession.

AACN

E 'l [Ell I!!' .
El . l E l . Ill .
(1986,p.3)

72

 

APPENDIX C

FREQUENCY TABLES OF THE PROFESSIONAL NURSE SURVEY

.aw

 

Appendix C

Frequency Table of Part II of Professional Nurse Survey

A linkage between my motivation for entering
nursing and the development of professional behavior

Mastery of the following skills of the nursing profession:

a. assessment .....................
b. recording .......................
c. working with families' psychosocial needs
(I. technical procedures ...............
e. medication administration ...........
f. time management .................

A syllabus and/or orientation manual containing
specific behavioral objectives .....................

Classroom instruction of ten hours or more ...........

Seminars to discuss problems in role transition .........

Opportunities to develop critical thinking skills .........

Experience on more than one unit of the agency ........

Experience on more than one shift .................

lnternalization of the values of the professional nurse . . . .

73

; SUong/y Agree

76

61

51

70

24

72

45

34

13

3O

29

38

25

Agree

56

65

67

58

38

54

51

35

20

68

45

64

81

Neutral

16

12

21

29

11

23

17

25

24

26

28

15

36

52

15

43

25

Disagree

SUongly Disagree

19

19

31

15

1O

10.

11.

12.

13.

74

Opportunity to interact with one prearranged mentor/preceptor

Opportunity to work in nursing specialty that was
matched with my area of interest ..................

A post graduation employment position that was congruent
with my philosophical beliefs about professional nursing

An identification with the nursing profession ..........

Strongly Agree

61

45

56

Agree

50

47

42

73

Neutral

10

19

25

Disagree

21

10

23

Strongly Disagree

00

10.

75

Frequency Table of Part III of Professional Nurse Survey

The potential for a financially secure position is a major

reason for pursuing a career in the health care professions .

Students in the health care disciplines should be expected

to emulate or model the role to their instructors ........

Students in the health disciplines should incorporate the

philosophy of their educational program into their practice .

Policies based solely on scientific methodology
are most appropriate for the resolution of

society's health care problems ....................

Health care professionals such as nurses generally are

impersonal and scientifically oriented ...............

Health care professionals generally fail to show adequate

interest in the health needs of consumers ............

Criticism of health care practices and procedures by
persons outside the profession is usually acknowledged

and acted upon by health care professionals ..........

Education programs for health care professionals spend
more time preparing students for careers in research

and/or teaching than for careers as practitioners ........

Health care teams tend to become so busy coordinating

care that they lose sight of patient needs ............

Priorities for the consumer of human and material
resources in the health care professions are best achieved

through centralized decision-making ................

Q

Strongly Agree

11

32

16

Agree

103

79

114

15

14

66

56

63

38

Neutral

41

70

49

57

17

69

37

40

81

§

8

a

Q

x

§ 3.

a t

.a g

o a:
51 2
50 14
27 3
127 23
85 126
144 49
77 5
99 17
103 10
83 20

#_‘u‘
. s

.._-.F-—II-m
d_ ".‘p

‘5‘...

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

Ir

76

The desire for a position of status should be accorded
little importance as a reason for pursuing a
career in the health care professions ................

Special economic interests have too often had a negative
influence on public health legislation ................

Training greater numbers of health care professionals
to deliver primary care is one alternative that will be
beneficial in meeting the long-term health needs of society

Health care is currently available to people at differing
income levels on a selective basis ..................

Health care professionals have developed adequate
self-evaluation of procedures and techniques
in the delivery of health care .....................

Societal class and social distinctions should be
of no importance in a health care setting .............

The health care professional such as a nurse should
be concerned solely with clinical practice
and not with social change in his community ..........

Nursing educators are considered alternate rather than

ultimate sources of information for their students .......

The existing forms of health care delivery systems
allow professional personnel to efficiently deliver health

care services to meet the needs of individual consumers . .

When cost accounting and systems research techniques
are applied to health care, it can be concluded
that the health care needs of some citizens

have not been adequately served ..................

reverse scored items

b
a
Q
8
\
a a
.9. *
a» Q
' 18 92
' 27127
* 20116
* 21 105
3102
‘ 88 86
3 4
* 27 90
6 57
" 64121

Neutral

45

58

44

39

48

15

39

42

24

Disagree

61

12

40

44

67

23

122

53

93

11

Strongly Disagree

15

84

11

21

APPENDIX D

STATISTICAL RELIABILITY OF PART III
OF THE PROFESSIONAL NURSE SURVEY

Appendix D

Statistical Reliability of Part III of the Professional Nurse Survey

Subscale StandaLthemflnha
Superordinate Purpose .16
Critical Attitude / Thinking .22
Compassion .31
Total Score .32

77

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American Association of the Colleges of Nursing. (1986). EssentiaLLQchllege
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Bandura,A (1969). Social learning theory of identification process. In D. A.

Goslin (Ed. ), liandbookoLsocializationJheQnLandmeamh

Bandura, A. (1977). W. Englewood Cliffs, NJ: Prentice-
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Bednash, 6., Berlin, L. E. &Haux, S. C. (1991). mm

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Blanchard, S.L. (1983). The discontinuity between school and practice. Nursing
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Blase, J. J., & Pajak, E. F. (1982). Teaching, the loss of innocence, and the

psychological development of a professional self. WM,
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Bolwell. C. (1993). W (5th ed.).

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