UNDERSTANDING CHINESE NURSING STUDENTS’ PROFESSIONAL SOCIALIZATION EXPERIENCES AND PROFESSIONAL IDENTITY DEVELOPMENT By Qing Xia A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of Higher, Adult, and Lifelong Education – Doctor of Philosophy 2022 ABSTRACT UNDERSTANDING CHINESE NURSING STUDENTS' PROFESSIONAL SOCIALIZATION EXPERIENCES AND PROFESSIONAL IDENTITY DEVELOPMENT By Qing Xia Chinese hospitals face high nurse attrition constantly despite the Chinese nursing education system graduating a half-million students. Many leave the profession as soon as they graduate, and those who stay in the nursing profession hold ambivalent feelings about their nursing identity. This study examines undergraduate Chinese nursing students' professional socialization experiences in American and Chinese hospitals to illuminate how the hospital experiences affect nursing students' professional identity development. In addition, I employed narrative inquiry to explore the participants' stories in this study. This study is guided by Cohen's (1981) three- sphere framework for nursing students' socialization and professional identity development (cognitive, interactional, and personality sphere) emphasizing students' experiences in the interactional sphere. This study focuses on understanding how Chinese nursing students' professional socialization experiences in hospitals shape their professional identity and self-concept. The study's participants' narratives revealed stark differences between their experiences in the American hospital and Chinese hospitals. The American hospital experiences were generally positive, while the participants' experiences in Chinese hospitals were negative. The negative experiences profoundly impact Chinese nursing students' professional identity and make them uncertain about their future in the nursing profession. The study's findings provided insights into what Chinese students learned during their experiences in the American hospital, which challenged their previous understanding of nursing and care and inspired them to provide humane, compassionate, and innovative care to patients. The participants' experiences in the Chinese hospitals revealed that the most salient professional socialization, hospital experience, was more than less ideal. In addition, the students encountered numerous challenges from burnout, unfriendly peer nurses, patients and their families, and poor leadership. Furthermore, the study illuminated one of the root problems for China's high nurse attrition rate, the Chinese College Entrance Exams, and its admission policies that recruit students to study nursing involuntarily. I concluded by offering a sociocultural lens to study Chinese nursing students' professional socialization and identity development. I further provided suggestions for practice to improve nursing students' recruitment, support nursing students' mental health, and collaboration between tertiary hospitals, nursing colleges, and researchers. In addition, I suggested applying a transformative learning lens in studying nursing education abroad programs in future research. Also, more research with qualitative methodology is needed to learn about the nuanced Chinese nursing students' professional socialization and identity development to understand better the challenges that the students face and facilitate meaningful reforms in nursing education. Copyright by QING XIA 2022 This dissertation is dedicated to Julie and Jennifer. Thank you for always believing in me. To the Chinese nursing students I met, thank you for inspiring me. v ACKNOWLEDGMENTS I embarked on the journey of doctoral degree studies after working in higher education for more than two decades. I love my work and love learning. I endured unexpected challenges as a full-time employee and a doctoral student: a new job in the earlier year of my study and the COVID-19 to complete. I would not be able to achieve my doctoral dream without encouragement, support, care, and love from my family, friends, and colleagues. I want to give my heartiest thank you to my biggest supporters over the past six years. I must first thank my family members for everything they have done for me over the past six years. My younger daughter Jennie always cheered me up and made me feel she was OK when I spent my weekends reading and writing instead of spending time with her. She knew I had to do my work. It is hard for me to imagine what we might have missed during the six years of her growth from a child to a teenager. My elder daughter Julie spent her time reviewing my writings and provided critique and input. She was my stand-by editor for many years. My partner's unconditional understanding and support meant a great deal to our family and me. I must thank my dissertation committee members for their support and encouragement during the years, Professors John Dirkx, Dongbin Kim, Fei Sun, and Steven Weiland. In addition, I want to thank my advisor Prof. John Dirkx for his guidance and insights before and during my dissertation research. Dr. William Cunningham, director of the Institute for Global Health at MSU gave his unwavering support to me for pursuing my doctoral degree after I started a new position in the organization. I must thank the McLaren Great Lansing Hospital for supporting international nursing students and giving them opportunities to observe in the hospital. The Chinese students’ experiences in the US made my dissertation possible. vi Finally, I often think about my late parents, who left this world many years ago. They left their children with a legacy of kindness, unselfishness, hard work, and perseverance. The fond memories of their love and dedication to their children and families, my mother's passion and love as a teacher and a lifelong learner have continually propelled me in my life. I believe they would be proud of me. I know I could not have made it without all of you; thank you. vii TABLE OF CONTENTS LIST OF TABLES .................................................................................................................... xi LIST OF FIGURES ................................................................................................................. xii Chapter 1: Introduction ...............................................................................................................1 Statement of the Problem ........................................................................................................2 The Research Question ............................................................................................................4 Statement of Significance ........................................................................................................6 Summary.................................................................................................................................7 Chapter 2: Literature Review.......................................................................................................8 Chinese Nursing Education Background..................................................................................9 A Brief History ....................................................................................................................9 Nursing Education System ................................................................................................. 12 Traditional Chinese Medicine (TCM) and Nursing ............................................................. 13 Nursing Regulations........................................................................................................... 14 Internationalization of Nursing Education ............................................................................. 15 International Collaboration in Nursing ............................................................................... 16 Bilingual Education in Nursing .......................................................................................... 17 Nursing Student Recruitment................................................................................................. 17 The Chinese National College Entrance Exam: Gao Kao （高考） .............................. 18 Nursing Profession’s Low Social Status in China .................................................................. 19 Professional Identity and Development ................................................................................. 21 Teachers’ Professional Identity .......................................................................................... 22 Medical Students’ Professional Identity ............................................................................. 22 Professional Identity Development in Nursing ....................................................................... 23 Caring as the Core of Nursing Identity ............................................................................... 24 Diversity in Nursing Professional Identity Literature .......................................................... 25 International Dimensions of Nursing Professional Identity .................................................... 26 Nurses’ Self-Concept, Public Image, and Professional Identity .......................................... 26 Chinese Nursing Students’ Concepts of Professional Identity ............................................. 28 Socialization to Professional Nursing .................................................................................... 30 Nursing Students’ Professional Socialization ..................................................................... 31 Nursing Students’ Professional Socialization in a Global Context ...................................... 33 Education Abroad for Nursing Students................................................................................. 36 Chinese Nursing Students’ Education Abroad Experiences ................................................ 38 Theoretical Framework ......................................................................................................... 38 Cohen’s Three-Sphere Model............................................................................................. 39 A Note on the Theoretical Framework ................................................................................ 42 Summary............................................................................................................................... 43 Chapter 3: Research Methods .................................................................................................... 44 The Context of My Study ...................................................................................................... 45 viii The Impact of COVID-19 .................................................................................................. 46 Researcher Positionality ........................................................................................................ 47 My Education and Job Background .................................................................................... 48 My Relationship with the CEUTCM .................................................................................. 48 My Relationship with the Summer Program and the Chinese Nursing Students .................. 49 Research Methodology .......................................................................................................... 51 Pilot Study ............................................................................................................................ 52 Data Collection ..................................................................................................................... 57 Participant Recruitment...................................................................................................... 57 Participant Interviews ........................................................................................................ 58 Data Analysis ........................................................................................................................ 59 Coding Scheme .................................................................................................................. 59 Trustworthiness.................................................................................................................. 60 Limitations ............................................................................................................................ 61 Summary............................................................................................................................... 62 Chapter 4: Embarking on the Nursing Journey .......................................................................... 63 Participants in the Study ........................................................................................................ 63 Hong .................................................................................................................................. 64 Angie ................................................................................................................................. 65 Lily .................................................................................................................................... 65 Yanni ................................................................................................................................. 65 Gina ................................................................................................................................... 66 Lia ..................................................................................................................................... 67 Lynn .................................................................................................................................. 67 Anna .................................................................................................................................. 68 First Steps in Nursing ............................................................................................................ 68 How Did Participants Enter Nursing? ................................................................................. 69 Efforts to Transfer Out of Nursing ......................................................................................... 77 Summary............................................................................................................................... 78 Chapter 5: Findings at the US Hospital: Seeing Is Believing...................................................... 80 Why This Program? .............................................................................................................. 81 Nursing Methods for Mental Health ...................................................................................... 83 Humanitarian Care in Nursing ............................................................................................... 84 Respect for Nurses and the Nursing Profession ...................................................................... 88 Reflections on American Hospital Experiences ..................................................................... 90 Why Nursing is Respected in American Hospitals? ............................................................... 90 Specialized Job Responsibilities ............................................................................................ 92 Summary............................................................................................................................... 93 Chapter 6: Findings: Experience in Chinese Hospitals and Beyond ........................................... 95 Daily Routines, Physical Challenges, and Irregular Learning in Hospitals ............................. 96 Interaction with Nurse Educators, Nurses, and Patients ....................................................... 102 Nurse Educators as Exemplary Masters of Techniques ..................................................... 103 Discouragement from the Nurses ..................................................................................... 105 Patients’ Attitudes toward Nurses..................................................................................... 108 ix Forming Professional Identity and Self-concept................................................................... 111 Leadership’s Understanding, Trust, and Treatment of Nurses .............................................. 115 The Lack of Leadership Understanding and Support......................................................... 115 The Lack of Interprofessional Understanding from Doctors .............................................. 117 A Wavering Professional Identity ........................................................................................ 118 Summary............................................................................................................................. 121 Chapter 7: Discussion, Recommendations, and Conclusion ..................................................... 122 Theoretical Implications ...................................................................................................... 123 Experiences in Relation to Cognitive Sphere .................................................................... 124 Experiences in the Personality Sphere .............................................................................. 125 A Sociocultural Lens for Chinese Nursing Students’ Professional Identity Development . 127 How Students’ Experiences Impact Their Professional Identity Development ..................... 130 Nurse Teachers’ Personal Connection with Students ........................................................ 130 Disconnections between Hospitals and Nursing Colleges ................................................. 131 “Caring” as Expressed among Chinese Nursing Students ................................................. 132 What Kind of Learning Happened at the Great Lakes Hospital? ....................................... 133 Other Contributors to Chinese Nursing Students’ Professional Identity Development .......... 135 The Lack of Leadership in Hospitals ................................................................................ 136 Other Factors Keeping Nursing Students in the Profession ............................................... 138 COVID-19 and Nurses' Image .......................................................................................... 139 Implications for Practice and Research ................................................................................ 140 Provide Early Education on the Nursing Profession ......................................................... 141 Improved Communication between Hospitals and College Nursing Programs .................. 141 Support Education Abroad ............................................................................................... 142 Future Research ............................................................................................................... 143 Conclusion .......................................................................................................................... 145 APPENDICES ........................................................................................................................ 147 Appendix A: Participant Invitation Letter ............................................................................ 148 Appendix B: Participant Consent Statement ........................................................................ 149 Appendix C: Interview Protocol .......................................................................................... 151 Appendix D: Reflection on Data Collection via Zoom Meetings.......................................... 152 REFERENCES ....................................................................................................................... 153 x LIST OF TABLES Table 4.1 Participant Demographics (at time of interview) ....................................................... 65 xi LIST OF FIGURES Figure 1.1 Cohen’s three-sphere framework ...............................................................................7 xii Chapter 1: Introduction For many students entering nursing programs in the US, nursing is an exciting, respected profession through which they can serve humanity and pursue a career (Carter et al., 2019; Cohen, 1981). College students in China, however, often have markedly different experiences of nursing education. Several studies on Chinese nursing students’ professional identity and commitment to nursing have indicated students in undergraduate programs tend to have a low sense of professional identity and commitment to the nursing profession. Scholars have found this problem to be worse among senior nursing students (Chen & Zhang, 2015; Hao, Niu, Li, Yue, & Liu, 2014; Zhang et al., 2015; Zhao et al., 2011), and that it even extends into graduate- level nursing programs (Guo et al., 2018). Consequentially, nurse attrition and staff shortages in hospitals have become significant problems in China (Eddins et al., 2011; Hao et al., 2014; You et al., 2015). As nursing requires the development of a professional identity through professional socialization (Castledine, 2003; Cohen, 1981; Maginnis, 2018; McGinnis, 2018), an early conceptualization of what a nursing profession or career entails and internalization of professional identity in nursing education may contribute to students’ future success and the future of the nursing profession (Zhang & Petrini, 2008). Professional identity and professional socialization (or professionalization) are intricately connected to and intertwined with adult life. Professional socialization has been defined as “a part of learning for the adult to adapt to new roles” and “the learning of expectations associated with a role one expects to enter in the future” (Anderson & Taylor, 2004, p. 110). Yet, because professionalization is a lifelong social and psychological process, professional identity formation does not stop after one initially learns a new role (Crigger & Godfrey, 2014). Socialization is fundamentally reflective and “involves self-conscious human beings seeing and reacting to the 1 expectations of others” (Anderson & Taylor, 2004, p. 92) and matching their values and beliefs, which are influenced by societal and personal factors (Maginnis, 2018). Professional identity is how individuals present themselves in a group and is therefore a fundamental aspect of being a professional. It is ultimately the outcome of a professionalization or socialization process, and includes professional, educational, social values, and behaviors that distinguish one professional from another (Maginnis, 2018). Statement of the Problem Nurse shortages are a global problem. In 2014, the World Health Organization (WHO) and the World Bank calculated a global shortage of nine million nurses and midwives (Drennan & Ross, 2019). Furthermore, in China, a 2011 study showed China had a shortage of five million nurses (Eddins et al., 2011). In 2013, the ratio of nurses to 1,000 people in China was 2.04 (Yang & Nan, 2015). By 2017, that number increased to 2.3, while hovering at 11 and 11.1 in Japan and the US, respectively (Drennan & Ross, 2019). China has undergone rapid economic development, urbanization, and an increasingly aging population (National Health Commission of PRC, 2016). Accompanying health care demands have only intensified the need for nurses in hospitals, community care, geriatric care, hospice, and more. Given its incubation of soon-to-be professionals, the Chinese nursing education system is the pipeline that provides nursing staff to various healthcare sectors. The system has dramatically increased its capacity in the past decade. There were 2.05 million registered nurses in 2010, a number that reached 3.24 million in 2015 (National Health Commission of PRC, 2010; 2016). However, this increase in the number of nursing personnel in Chinese healthcare has been accompanied by a persistently high nurse attrition rate across the country. Studies show that, among level-three hospitals (the highest level), the nurse attrition rate is between 6%-20% (Chen 2 & Li, 2018). In some healthcare organizations, the attrition rate is as high as 30% (Tian, 2011). These numbers demonstrate the widespread nature of the issue and point to several reasons why Chinese nurses are leaving the profession. The most common factors include but are not limited to: low levels of professional identity; low income, high levels of professional risk, high stress, low job satisfaction, inequality and imperfection in the healthcare system, low social status, and workplace violence against healthcare workers (Han, 2017; Feng et al., 2017; Mai et al., 2016; Shao et al., 2017; Tian, 2011; Tian et al., 2020; Yang & Nan, 2015; Yun et al., 2010). For years, the Chinese government and other healthcare organizations have attempted to intervene in nurse attrition. At the macro-level, the government published plans and guidelines for improving nursing quality, management, nurses’ safety, remuneration, and financial benefits. At the meso-level, hospitals have tried to improve working environments, provide trainings and professional development, promotion opportunities, and financial incentives. Hospitals have also begun to streamline management systems, establish fair nurse evaluations, and release nurses from non-nursing related duties (Chen & Li, 2018; Han, 2017; Mai et al., 2016; Tian, 2011). Additionally, in its most recent nursing development guidelines, the Chinese government mandated healthcare organizations provide nurses with mental health support and personal care (Bureau of Medical Administration, 2020). In 2016 through 2020, the government proposed another significant intervention: addressing and changing traditionally negative depictions of nurses in public media. Materially, this has meant government support for and investment in media productions that positively promote nursing. However, China is a vast country with a diverse spectrum of regional economic, social, and cultural differences. Whether these efforts will be effective depend on local governments and the healthcare systems’ capacity, ability, and willingness to make changes and improvements. 3 Many Chinese undergraduate nursing students begin their careers by either following the Chinese higher education admission system or by listening to their parents’ or friends’ opinions and recommendations (He et al., 2017; Tian, 2011; Wang & Li, 2016; Zhang et al., 2019; Zhan et al., 2015). The majority of these students do not enter nursing programs willingly or because it is their professional aspiration. Rather, they feel they are stuck with the nursing profession and do not have other options. Many nursing graduates thus do not stay in nursing long after graduating from college. Among the nurses who quit the profession, those who held baccalaureate degrees had the highest drop-out rate in Chinese hospitals (Han, 2017; Mai et al., 2016; Tian, 2011; Yang & Nan, 2015). This phenomenon has further exacerbated nurse shortages and prevented the reliable delivery of advanced, high-quality nursing (You et al., 2015). Indeed, getting nursing students to accept and commit to the profession has been incredibly challenging for the Chinese nursing educational system, as students have little interest, knowledge, or aspiration to be a nurse when starting their college careers. The Research Question Until the 1980s, nursing education in China consisted of only secondary-level training programs. Developing advanced nursing programs became part of a national plan in the 21st century, prompting curricular reform based on the US and UK models (Anders & Harrigan, 2002; He et al., 2019; National Health Commission of the PRC, 2011). One of the plan’s mandates was to encourage higher education institutions in China to establish nursing student exchange programs aimed at the “mastery of technology related to the business of healthcare, education, and management” (He et al., 2019, p. 2). The learning goals of these international programs were meant to expand nursing students’ horizons by facilitating learning of advanced nursing knowledge and technology and improvement of foreign language skills (Yue & Wu, 4 2013). There may, however, be unintentional consequences to Chinese nursing students’ participation in these international programs, particularly regarding how they understand their professional nursing identities. Yet, to date there has been no discussion about professional identity in the scant studies on Chinese healthcare students’ international experiences. To address this gap, the current dissertation study critically explores the role of the participation in a study abroad program in an American hospital in shaping Chinese nursing students’ sense of professional identity. I then compare their American experiences to the students’ clinical experiences in Chinese hospitals. I specifically examine how students experience these programs in terms of the professional socialization and identity development. Given Chinese nursing students’ low sense of professional identity and tenuous commitment to nursing, professional socialization opportunities like these in the US may be critical for international learning programs. My study is therefore centered on eight Chinese nursing students’ professional socialization experiences in an education abroad program at a hospital in America, and their experiences during their clinical internships in China. Using Cohen’s (1981) framework of three-sphere nursing students’ professional identity development, I analyze participants’ interview data to determine whether they obtained a deeper understanding of the nursing profession and whether the hospital experiences improved their sense of professional identity. See Figure 1.1 for a visualization of the interrelated nature of Cohen’s three spheres of nursing socialization and professional identity development. Two overarching research questions drive this study: Does a short-term study abroad program provide nursing students with professional socialization experiences, and do they have any influence on Chinese nursing students’ sense of professional identity? How does Chinese 5 nursing students’ international experience compare to their clinical internship experience in China in terms of professional socialization and identity development? The related questions are: o How does participating in the eight-week study abroad program in nursing affect Chinese undergraduate nursing students’ understanding of their nursing identity? o How do students characterize professional socialization in the eight-week program? o Does the experience in a US hospital have a long-term effect on Chinese nursing students’ careers in China? o What are Chinese nursing students’ clinical internship experiences in China? Statement of Significance My study will provide a deeper understanding of Chinese nursing students’ sense of professional identity and their perspectives on professional socialization through education experiences abroad and in China. The findings may help educators examine and implement learning designs and outcomes pertinent to nursing students’ professional identity development. This study is therefore important for several reasons. First, research on short-term Chinese nursing students’ overseas experiences is scarce. I was only able to locate one paper on this topic, but it lacked discussion on nursing students’ professional identity development and socialization. Second, the qualitative research methodology used in this study is unique among similar studies on Chinese nursing students’ professional identity. Although many papers have been published on this topic in Chinese, few have used a qualitative methodology (Yue & Wu, 2013). This may be because most Chinese researchers are alternately trained to take quantitative approaches to such issues (Wang & Geale, 2015). Consequently, almost all existing quantitative studies on Chinese nursing students’ professional identity development have yielded similar results and generic recommendations for nursing educators and administrators. In other words, 6 these studies limit what is possible to know in this regard because they usually do not delve into the personal lived experiences of Chinese nursing students. My study offers insights into students’ experiences through a comparative lens that may be useful to nursing educators and hospital administrators. In particular, the data can help stakeholders understand what students think about their profession and their lives, and why nursing students make certain decisions about their careers at a personal level. Third, the outcome of this study may provide valuable information for study abroad nursing programs, particularly in the areas of program design and program content. Identifying a program’s goals and the pedagogy required to facilitate desired learning outcomes can especially benefit students from the Global South studying in developed countries. Summary In this chapter, I introduced the problems of nursing shortages and nursing education in China, as well as the low levels of professional identity among Chinese nursing students and their potential contributions to the high nurse attrition rates in Chinese hospitals. I presented the research questions driving this study and the study’s significance and contribution to international nursing student exchange education and general nursing education in students’ home countries. In the following chapter, I review scholarly literature relevant to my study and present the theoretical framework. Cognitive Interactional Personality Sphere Sphere Sphere Figure 1.1 Cohen’s three-sphere framework 7 Chapter 2: Literature Review The literature review in this chapter is organized based on subjects related to my research questions. Recall from Chapter 1 that the overarching research questions are: Does a short-term nursing study abroad program provide professional socialization experiences to students, and do they have any influence on Chinese nursing students’ sense of professional identity? How does Chinese nursing students’ international experience compare to their clinical internship experience in China in terms of professional socialization and identity development? The related questions are: o How does participating in the eight-week study abroad program in nursing affect Chinese undergraduate nursing students’ understanding of their nursing identity? o How do students characterize professional socialization in the eight-week program? o Does the experience in a US hospital have a long-term effect on Chinese nursing students’ careers in China? o What are Chinese nursing students’ clinical internship experiences in China? To answer these questions, we must better understand the factors that influence Chinese nursing students’ experiences in study abroad programs and how these experiences affect their socialization in nursing and in developing a professional identity. For example, it is necessary to examine how Chinese nursing programs recruit students and the significant role of the Chinese College Entrance Exam (高考 Gao Kao) in determining nursing students’ college lives and future careers. Given this, I first analyze the literature on the background of Chinese nursing education and explain the internationalization of nursing education. I then explore existing scholarship on nursing student recruitment, professional identity development, professional identity 8 development in nursing, the international dimensions of nurses’ professional identities, and socializing students into the nursing profession. I conclude with a discussion on nursing students’ education abroad and present my theoretical framework for analyzing my data. Taken together, the sections of this chapter constitute a comprehensive and nuanced picture of Chinese nursing education and suggest a method of analysis relevant to addressing the issues of nurse attrition and drop out mentioned in Chapter 1. Chinese Nursing Education Background As changes and reforms have occurred in nursing education at all levels over the years, the background of the Chinese nursing education system is layered and complex. I begin unpacking these layers with a brief history of the nursing education system, traditional Chinese medicine (TCM) and nursing, and nursing regulations. I then discuss the Chinese National College Entrance Exam (Gao Kao), which determines nursing students’ college and professional careers. Understanding Gao Kao and how students may be assigned to study disciplines they are not interested in, such as nursing, may contribute to later nurse attrition and dropout. A Brief History Modern nursing was introduced to China by Western missionaries (He et al., 2019). The first formal nurse training program was established in 1887 at the West Gate Hospital in Shanghai by American nurse, Elizabeth McKechnie (Wang & Huang, 2007; Wong & Zhao, 2012). American influence on the Chinese nursing profession has been profound and far- reaching. Individual American nurse educators, nurses, missionaries, and private American foundations significantly contributed to the early development of the profession in China (Xu et al., 2000; Wang & Huang, 2007). For example, missionary hospitals were the major providers of nursing education until 1933, when the Chinese nationalist government established the first 9 government nursing school (Xu et al., 2000; Wong & Zhao, 2012). By the time the communist government took over China in 1949, there were 183 nursing schools and 32,800 nurses in China. Nursing education was regarded as vocational education and most teaching materials were either a direct translation from English books or the original English texts themselves (Wong & Zhao, 2012; Yan et al., 2014). From 1949-1965, nursing education in China primarily of a two- to three-year period of vocational training. During this period, 300,000 nurses were trained by various nursing schools. However, the Chinese Cultural Revolution disrupted all education in China from 1966-1976, including that of nursing education, which resulted in a closing of all nursing schools during this time. The Cultural Revolution was a decade of political and cultural campaigns launched by Mao Zedong, chairman of the Chinese Community Party (CCP) and China. Mao’s death in 1976 declared the end of the most devastating era in modern Chinese history. The Cultural Revolution has been described as “10 years of catastrophe,” “10 years of turmoil,” and “10 years of civil unrest” by media, historical documents, researchers, and literature. In 1981, the CCP published “Resolution on Several Historical Issues of the Party Since the Founding of the People’s Republic of China.” A particular focus in the “Resolution,” centered on reviewing the lessons of the “Cultural Revolution,” characterizing it as “initiated by the leader (Mao Zedong) mistakenly” and “give the party (CCP), the state and all ethnic groups civil unrest that brought serious disaster to the people” (Wilson Center, 1981). The Cultural Revolution was a complicated decade marked by disastrous upheavals in Chinese political and civic life. China became “the world turned upside down” (Francis, 2021; Kraus, 2012) and “a bomb site” (Agelasto & Adamson, 1998). In terms of education, all schools were closed. Many students, particularly middle-school and college students, became “Red 10 Guards” for Mao. They followed his call to rebel against anyone in authority and perpetuate violence against teachers and professors, who he labeled as “Ox demons and snake spirits,” or those he deemed to be taking the capitalist road (Chen, 2020; Davin, 2013; Righter, 2021). The Red Guards instigated a reign of terror on school campuses: Teachers were vilified, defenestrated, rusticated or murdered, as the Confucian bond of loyalty between students and mentors was ruptured. Campus became the local point for revolutionary action with proletarian politics in command; classrooms were abandoned for a number of years. University entrance examinations were discontinued, with preference for admission given to those with proletarian backgrounds. Academic pursuits were condemned as bourgeois and divorced from reality and students undertook farmwork and other labor. (Agelasto & Adamson, 1998, p. 2) In the two decades after the Cultural Revolution, Chinese education began returning to normality. During this time, higher education in China recovered and pursued reconstruction and reform along with that of the economy (Agelasto & Adamson, 1998; Zhu & Lou, 2011). After the Cultural Revolution, nursing schools resumed teaching but remained at the vocational level until 1979. It was not until after the 1980s that tertiary-level nursing programs were established, followed by postgraduate nursing education in the 1990s (Xu et al., 2000; Wong & Zhao, 2012). In the last two decades, nursing education in China has rapidly expanded, especially at the undergraduate level. By 2007, there were 862 secondary programs, 307 advanced diploma programs, 201 baccalaureate programs, 52 master’s programs, and four doctoral programs in China (You et al., 2015). In 2006, all Chinese nursing programs together graduated almost 192,000 students. The number of graduating students rose to over 510,000 by 2012, almost a three-fold increase. However, only 7.7% of these students held baccalaureate degrees (You et al., 11 2015). By 2015, less than 15% of the 324,000 registered nurses in China had earned baccalaureate degrees (Jiang & Han, 2019) and research has further verified a significant loss of nurses with advanced training in the Chinese healthcare system (Han, 2017; Mai et al., 2016; Tian, 2011; Yang & Nan, 2015). Moreover, there is a marked imbalance between nursing programs and nurses across China, as most nurses are concentrated in urban areas. This exacerbates the shortage of quality nurses not only for cities, but also for more remote and rural areas (You et al., 2015). Accordingly, the current nursing education system does not reflect the multiple levels of healthcare needs that have come with the rapid social and economic development of China. Nursing Education System The current Chinese nursing education system is a combination of three diploma programs: three-year secondary diploma programs, three-year advanced diploma programs, and tertiary-level nursing programs. The three-year secondary diploma programs recruit students aged 15-16 years old who have completed the nine-year general education criteria to join. The advanced diploma and tertiary-level programs recruit high school graduates who have completed the 12-year general education program in China. The tertiary level of nursing education generally takes 4-5 years. Graduates of these three program levels are eligible to take the National Nursing Licensure Examination (NNLE) to be a registered nurse. However, research shows the NNLE’s pass rate is low—especially for secondary diploma programs—indicating issues of quality in nursing education and training (Wang & Zhao, 2012; You et al., 2015). For instance, the program curriculum was largely based on medical education; only in recent years has the design of baccalaureate nursing curriculum transitioned from biomedical to a nursing-oriented model (Eddins et al., 2011; Wong & Zhao, 2012). Additionally, other curricular and pedagogical 12 problems exist. “The sage on stage,” or faculty centered learning is still the most prevalent teaching method in nursing education (Lu & Kitt-Lewis, 2018; Zhou et al., 2016). Additionally, there are discrepancies between teaching and hospital practice (Eddins et al., 2011), a lack of humanities courses (Li et al., 2005), delayed onset of clinical practice in nursing curriculum (i.e., only in senior year), problem-based learning (Chen et al., 2019), and a lack of active learning. Despite these lingering challenges, some Chinese nursing educators have tried to reform their teaching and make improvements. For instance, educators have experimented with student centered teaching (Clarke, 2010), integrating spiritual care into baccalaureate programs (Yuan & Porr, 2014), facilitating clinical experience earlier in curriculum (Yin et al., 2001), exploring new teaching and learning models (Chen et al., 2019), and research on a core competence model for baccalaureate nursing graduates (Yang et al., 2013). Traditional Chinese Medicine (TCM) and Nursing At the time of this study, the nursing student participants were studying nursing at a Traditional Chinese Medicine (TCM) university. TCM has existed for more than 3,000 years and is used to prevent and treat physical and mental illness in China. The main therapeutic methods of TCM consist of acupuncture, moxibustion, cupping, and herbal medicines. However, before the establishment of the People’s Republic of China in 1949, the country did not have TCM hospitals or clinics. TCM healthcare was instead practiced by individuals and TCM knowledge was passed on through apprenticeship. Today, TCM plays a central role in healthcare delivery in China. It accounts for around 40% of all healthcare services and is used to treat approximately 200 million patients annually (Park et al., 2012). There are currently 25 TCM universities in China that educate TCM medical professionals, including nurses, and TCM has been quickly advancing via new developments in science and technology. TCM education has particularly 13 begun integrating Western medicine and nursing science into traditional techniques and methods of teaching and practice. Nursing science characterized by TCM is generally referred to as “TCM nursing” and is an indispensable branch of the nursing profession in China. Many nurses trained in TCM nursing work in the fields of primary nursing, geriatric nursing, hospice care, community care, and family nursing (Hao et al., 2011). It is important to note here that the China National Nursing Development Plan of 2016-2020 identifies TCM nursing as a key strategy for strengthening the healthcare system. Nursing Regulations The development of nursing education is regulated, guided, and supported by the government. In 1993, the Ministry of Health issued an Administrative Regulation for Nurses in China requiring those graduating from vocational level health schools and tertiary nursing programs to pass the National Nurse Qualification Examination (NNQE). By 2008, the new Nurse Ordinance took this step further for professional licensing requirements. Instead of allowing nurses to practice nursing without first passing the NNQE, the new Nurse Ordnance extended the NNQE requirements to all nursing students, regardless of education level, before allowing them to practice nursing (Wong & Zhao, 2012). The nursing program accreditation body, the Instructional Committee for Nursing Education of the Ministry of Education (ICNE), was established in 2007. Since issuing the new requirements, all full-time nursing education programs must be reviewed and approved by the committee. A new Nurse Act was also introduced in 2008 to support further development in nursing that stipulates legalities for nursing practice, the definition of nursing, and nurses’ rights in China (Wong & Zhao, 2012). 14 Internationalization of Nursing Education The internationalization of higher education in China has been a trend since the 1980s and has especially intensified in the past two decades. Internationalization1 means opening Chinese higher education institutions to the outside world. The Chinese government invested in various initiatives to support international activities, including student and faculty exchange programs, which is most common among many higher education institutions. Indeed, international exchange and collaborations are necessary for Chinese higher education to meet the demand for talent required to achieve economic and social development (Zhu & Lou, 2011). To this end, Chinese universities have established collaborations with international partners to send students on study abroad programs and to establish programs for international students to Chinese campuses. Within the context of this ebb and flow of international student mobility, the US is the number one study abroad destination for Chinese students. According to the Institute of International Education (IIE), China has been the largest resource in sending students to the US for a decade (IIE Open Doors, 2019). In 2018 and 2019, nearly 370,000 Chinese students were studying in undergraduate, graduate, non-degree, and temporary work programs in the US (IIE Open Doors, 2019). However, the scale of Chinese nursing students’ participation in study abroad programs is largely unclear, as there is not an organization like IIE tracking students’ international education mobility in China. 1 International activities include joint degree programs, collaborative research projects, recruiting international students to study in China, establishing Confucius Institute in many countries to teach Chinese and promote cultural learning and public diplomacy, sponsoring Chinese students to study abroad for degrees, bringing western universities to China, and using English to teach selected courses (Larbi et al., 2020; Liu & Lu, 2019; Ministry of Education of the PRC, 2001; Ministry of Education of the PRC, 2004; Tan, 2009; Wang et al., 2021; Xi & Rowlands, 2021; Zhu & Luo, 2011). 15 International Collaboration in Nursing The Chinese government encourages nursing programs to strengthen international collaborations with other countries at both the academic and professional practice levels and to pursue personnel training as well as mastery of technologies related to the business of healthcare, education, and management (National Health Commission of the PRC, 2011). As mentioned in Chapter 1, Chinese nursing education has been greatly influenced by American nursing, such that the first nursing programs in the country were established by American missionaries. Even now, Chinese hospitals use textbooks, curriculum, and pedagogy based in American nursing to train nurses (Anders & Harrigan, 2002; He et al., 2019; Wong & Zhao, 2012). Accordingly, many scholars have compared the American and Chinese nursing education systems, curriculum, and pedagogies for learning purposes (Kalisch & Liu, 2009; Li et al., 2005; Lu & Kitt-Lewis, 2018; Xu et al., 2019). International collaboration in nursing programs include student exchange, short-term study abroad for Chinese nursing students, faculty visits and exchange, and international faculty teaching in Chinese universities. The Chinese government plays an important role in financially supporting these collaborations (Zheng et al., 2016). For example, each nursing student who participated in my research received about $5,000 in scholarships to make the exchange possible. Without this support, many students would not be able to make the trip. Indeed, Chinese nursing programs are eager to identify international partners and collaborate in developing viable exchange programs (Xu et al., 2001). For Chinese universities, short-term education abroad is a key venue for university internationalization. Students learn advanced nursing knowledge, medical technologies, foreign languages, and engage diverse cultures. These programs usually run between 3 to 12 weeks. Chinese nursing students have 16 welcomed study abroad opportunities because they can couple nursing education with experience at overseas hospitals and improve their language learning (He et al., 2011). However, critics have observed that international nursing partnerships are usually a “one-way knowledge transfer” due to China’s dependence on Western nursing science and the relative lack of creativity in Chinese nursing sciences. As such, critics have further highlighted the potential for TCM and TCM nursing to reciprocally offer new perspectives and knowledges to Western health sciences (Chen, 2001; Xu et al., 2001; Eddins et al., 2011; Zhao et al., 2016). Bilingual Education in Nursing Bilingual teaching in English is a phenomenon promoting the internationalization of Chinese higher education in the 21st century. In 2001, the Ministry of Education (MOE) required universities to offer bilingual (English) instruction in 5%-10% of the total number of undergraduate courses within three years in an effort to better serve economic globalization and accelerate the improvement of advanced technology (MOE of the PRC, 2001). As a result, Chinese universities started offering bilingual courses on various subjects, including nursing. Another reason for the surge of nursing courses in English is the introduction of an international bilingual exam, the International Qualification Exam in China (CGFNS International 2003). The exam was adopted in 2003 by the Commission of Graduates of Foreign Nursing Schools (CGFNS) and is conducted exclusively in English. However, as some English terms in the exam questions are difficult for many Chinese examinees, bilingual teaching is necessary to prepare nursing students for the CGFNS International exam (He et al., 2011). Nursing Student Recruitment Nursing student recruitment has been a consistent challenge for Chinese medical universities because those wanting to study healthcare-related majors try to avoid nursing due to 17 the lack of nursing knowledge and its stigma as a low status profession in Chinese society (Feng et al., 2017). In China, nursing is characterized by low pay, hard work, and requiring less intelligence. Additionally, many consider nurses to be servants. Most Chinese students thus enter undergraduate nursing programs not by choice, but instead by way of the National College Entrance Exam (Gao Kao) admission system, which assigns students to study nursing. For example, among the 14 Chinese nursing students who visited Midwest University in 2019, only one actually wanted to study nursing as her first choice. Chinese researchers call this phenomenon the “reversed profession/career choice” (逆向择业), meaning the profession chooses the person rather than the person choosing the profession (Eddins, et al., 2011; Smith & Yang, 2017; Wong & Zhao, 2012). Research has demonstrated that the “reversed profession/career choice” is a key contributor to nursing dissatisfaction and the high drop-out rates in Chinese hospitals (Tian, 2011; Wong & Zhao, 2012). Chinese scholars have therefore criticized the Gao Kao and called for reforms to prevent the system from hindering the implementation of a better, more just process of talent selection to meet the needs of rapid social development in China (Zhu, 2015). The Chinese National College Entrance Exam: Gao Kao （高考） To better understand the lack of a sense of professional identity among Chinese nursing students, it is necessary to understand the Chinese National College Entrance Exam, Gao Kao, how it affects college admissions, and its role in students’ professional identity development. Higher education in China requires students to participate in the exam for college admissions each summer. The Gao Kao is a notably complicated testing system. In the past, all students took the same tests offered by the MOE regardless of school locations. Since 1987, the MOE has mandated students take three national tests: Chinese, mathematics, and foreign language. They 18 must also take tests provided by their individual provinces and municipalities on subjects including history, social studies, geography, chemistry, physics, and biology. Students have the choice to take either STEM or humanities-oriented tests depending on their academic aspirations (Chen, 2019). To millions of Chinese students and their parents, Gao Kao is a battle, and they must do their best to compete for admission to the top colleges and their intended majors. The terms most used to describe the Gao Kao are “life-determining” and “only-score- based” (Zhu, 2015). This is because students can only take the exam once a year and universities use Gao Kao scores as their only criteria for admission. Universities thus have cut-off scores to determine whether a student has scored high enough to attend. The most elite Chinese universities require significantly higher cut-off scores than others. Even if a student’s Gao Kao score makes the cut-off and the university accepts them, they may not necessarily get into their intended major. Cut-off scores vary across universities based on the number of applications received, student scores, and which majors students apply for. For instance, students who apply for admission to a medical university with a major in clinical medicine may be assigned to study nursing if their Gao Kao score is lower than the clinical medicine major’s cut-off score. In medical universities, clinical medicine is usually more competitive, while nursing is one of the least competitive. When students are forced into nursing programs without intention and preparation, they may feel resistance and resentment for their lack of agency. Nursing Profession’s Low Social Status in China Scholars have shown that the nursing profession in China is generally perceived to be lower in social status than other professions, which in turn contributes to a low sense of professional identity and high turnover rates among nurses in China (Feng et al., 2017). Currently, no survey exists on how Chinese people regard the nursing profession in Chinese 19 society. More recently, the Chinese government has issued guidelines on treating the nursing profession with respect by promoting the provision of benefits, training, and career development to better provide for nurses’ mental health and improve their public image and working environments (Bureau of Medical Administration, 2020; National Health Commission of PRC, 2016). That the government must intervene in this way is a significant indicator of the dire conditions nurses face and foregrounds prevalent problems that demand urgent attention and actionable change and reform. Feng et al. (2017) concluded that the nursing profession’s low social status is subjective and therefore entwined with nurses’ job satisfaction. They found nurses’ subjective social status did not exert a significant direct effect on nurses’ turnover rates, but that it did have a significant indirect effect on job satisfaction, which can lead to turnover. Subjective social status (SSS) has been defined as an individual’s perception of his or her place within a given social hierarchy (Jackman & Jackman, 1973). Individuals employ objective socioeconomic indicators, such as income and occupation, to reflect their SSS. Non-economic indicators, such as respect, reputation, feeling of financial security, and education also contribute to SSS (Singh-Manoux, Adler, & Marmot, 2003). Many Chinese nurses and their family members likely subscribe to the belief that nurses have low social status in Chinese society as measured by SSS indicators: low income (Chen et al., 2015; Jiang & Han; 2019), gender-based stereotypes (Jiang & Han, 2019; Liu, 2010), low education levels, most registered nurses have associate degrees and only 15% of the work force hold a bachelor’s degree2 (Jiang & Han, 2019), are perceived to be lower skilled by patients (Cao et al., 2008; Tzeng, 2006), the lack of public understanding and unfavorable 2 According to Buerhaus et al. (2017), in 2015, 38% of registered nurses in US nurse workforce had a bachelor’s degree and 15% had graduate degrees, while in China, only 15% of registered nurses had undergraduate or post graduate education (Jiang & Han, 2019). 20 public image in various societies (Cabaniss, 2011; Glerean et al., 2017; Holroyd et al., 2002; Takase et al., 2006). Professional Identity and Development As professional identity is a key part of self-identity in adulthood, it is critical that people have a sense or perception of professional identity to effectively establish themselves in an organization or social group (Anderson & Taylor, 2004). According to Beijaard et al. (2004), professional identity is not stable, and thereby contains different, shifting meanings based on the specific area of a profession and the environment in which one is situated. Professional identity is thus a complex and dynamic equilibrium, wherein professional self-image is balanced with a variety of other roles. Maginnis (2018), for instance, has posited that professional identity includes professional, educational, and social values and is essentially distinguished from one profession to another. Scholarship on professional identity has often focused on specific areas and defined professional identity development in relation to those areas. In addition, when defining professional identity, researchers have typically used vague language (e.g., “self- image”) to describe how one perceives their adequacy and satisfaction in performing an expected role, as well as to describe their sense of being a professional practitioner and member of a profession in terms of attitudes, beliefs, and standards (Trede et al., 2012). To better understand what constitutes professional identity in nursing, this study is grounded in the experiences of students in training and illustrates different attributes and qualities for different professional identities. In the next section, I present two examples to illustrate how professions differentiate in the process of forming professional identities, such as teachers and doctors. These two cases show the unique nature of professional socialization in different fields, and there is no single format to replicate to each other. 21 Teachers’ Professional Identity In researching the literature on teachers’ professional identity formation, Beijaard et al. (2004) found most viewed their teacher identity as an ongoing multifaceted and dynamic process of integrating the “personal” and “professional” aspects of becoming and being a teacher. These aspects included history, culture, society, psychology, and day-to-day working environment. The researchers further identified several sub-identities within professional identity that may align and conflict with each other (p. 113). Beijaard et al.’s (2004) three major findings regarding teacher identity formation are as follows. First, professional identity formation was a process involving the triangulation of various knowledge sources, such as teaching, human relations, and subject sources. Notably, it was important for teachers in training to learn and reflect on how they have been influenced by their families, environments, cultures, traditions, etc. Second, teachers were more effective at developing a sense of professional identity when engaged in the communication and sharing of ideas with other teachers through “dialogue” (p. 114). Third, the authors found mandating uniformity and conformity could threaten teachers’ professional identity formation because it negates the notion of the authentic, ambivalent self. This assertion is particularly relevant to the US and other developing societies, where schools are situated in environments and communities characterized by differing racial and socioeconomic conditions. Teacher socialization and professional identity formation therefore encompasses a range of elements of teachers’ environments and contexts. Instead of imposing a single, uniformed professional identity, one’s identity as a teacher should be nurtured to reflect the nuances and fluidity of multi-layered social corporeality. Medical Students’ Professional Identity Like Beijaard et al. (2004), Goldie (2012) and others have drawn similar conclusions 22 regarding medical students’ professional identity development (Cote & Levine, 2002; House, 1977). Goldie posited “medical student” is one of an individual’s many identities. How individuals represent their identities affects their relationships with said groups, such as those between patients and other healthcare professionals. As a result, medical students may perceive their membership in multiple groups in terms of “in-group” and “out-group.” In “in-group” contexts, a medical student shares the same primary identity with others. Goldie (2012) specifically found medical students who were more inclusive with their in-group membership were more open to change, less likely to be influenced by power, and tended to value social justice and were non-judgmental in dealing with patients. Goldie also found a medical student’s identity can be an asset, whether tangible or intangible. Tangible assets included social class, gender, prior degree(s), and membership to clubs, which can function as passports into social and institutional spheres. These tools were crucial for students in “impression management and the micro-politics of identity negotiation (p. 645). Intangible assets included strengths, self-esteem, a sense of purpose, critical thinking abilities, and the ability to self-actualize. It was found that strong intangible assets could offset a lack of tangible assets. Goldie further asserted identity dissonance may lead to failures in life. This finding is crucial to consider how much identity dissonance occurs to nursing students as they struggle to figure out their future and life and what ramifications they may face if they fail to commit themselves to the nursing career after years of training and efforts. Professional Identity Development in Nursing The field of nursing has significantly developed over the last 30 years of the 20 th century and the first decade of the 21st century, particularly in relation to nursing professionalization, including nursing education, nursing theory, and nursing practice (Hoeve et al., 2014). Until the 23 late 1960s, a “good nurse” was identified as one who conformed to the so called “Nightingale ideal” (i.e., one who behaves in a ladylike manner and is dependent on doctors, trainers, school, and hospital administrators). The ideal defined a nurse’s role as that of a handmaiden to a physician (Chambers & Subera, 1997; Cohen, 1981). Importantly, handmaidens are not considered professionals. Although the meaning of the word “handmaiden” has historically varied, its submissive, subordinate connotation has remained constant. Nevertheless, giving care is the core function of the nursing profession (Arreciado Marañón & Isla Pera, 2015; Cohen, 1981; Rhodes et al., 2011; Zamanzadeh et al., 2014). In healthcare, the concept of giving care has evolved to include providing/showing compassion and empathy to patients, which research shows can effectively improve patient-centered care, care quality, and better treatment outcomes (Fogarty et al., 1999; Moss et al., 2019; Oates et al., 2000, Patel et al., 2019; Trzeciak et al., 2019). Caring as the Core of Nursing Identity According to the American Association of Colleges of Nursing (1998; 2008) and the National League for Nursing (2007), “caring” is a fundamental value of nursing. In regard to the meaning and quality of caring, Shultz (2009) has described nursing education as pivotal to transforming caring from a personal characteristic into a professional “identity of caring.” Other scholars have argued caring is a requisite for the development of critical thinking (Benner & Wrubel, 1989; Benner, 2000; Benner et al., 2009). Stowe’s (2006) investigation of curriculum design in nursing education, for instance, concluded nursing education’s efforts to “impact a more consciously caring individual for our society is invaluable” (pp. 127-128). In general, scholars have put forth caring as including a scope of cognitive and practical elements, such as struggle, discovery, hope, humility, and spirituality (Purnell, 2009). The evolution of caring 24 begins with the personal characteristic of nurturing, proceeds to an assimilated sense of caring in the nursing profession, and results in empowered caring. In this final stage, nurses realize nursing interactions support caring connections within an interprofessional healthcare delivery system (Falk-Rafael, 1996), indicating empowering caring is enabled by both knowledge and experience. Beyond to the fundamental value of caring as a prominent component of a nurse’s professional identity, the American Association of Colleges of Nursing (AACN) (2008) has specified “the inherent values of altruism, autonomy, human dignity, integrity, and social justice are fundamental to the discipline of nursing” (p. 4). As for undergraduate level generalist nursing practice, the association mandates that: The baccalaureate-graduate nurse is prepared to practice with patients, including individuals, families, groups, communities, and populations across the lifespan and across the continuum of healthcare environments. The baccalaureate graduate understands and respects the variations of care, the increased complexity, and the increased use of healthcare resources inherent in caring for patients. This definition of undergraduate nursing education is rather at the macro level and a high goal to achieve. It emphasizes life-long learning and critical thinking as nurses keep growing in knowledge, skills, and strengthening their professional identity. It also expands nurses’ realm of work beyond temporary hospital and clinic settings to the lifespan and various communities. Diversity in Nursing Professional Identity Literature The literature on nurses’ professional identity development is diverse but encompasses major perspectives (Arreciado Marañón & Isla Pera, 2015). One highlights the importance of constructing a sound identity as a nursing professional, particularly as it pertains to ethics, moral 25 development (Crigger & Godfrey, 2014; Ranjbar et al., 2017), and caring (Falk-Rafael, 1996). The other highlights the reality of a diffused nursing identity. For example, Rhodes et al (2011) has argued nursing professionals and students must change their conceptualizations of nurses from “angels” to competent professionals who are both knowledgeable and caring. The literature has also confirmed the importance of clinical placements in which nursing students can develop student-mentor relationship to develop their professional self-concept as well as reinforce theory through practical learning (Arreciado Marañón & Isla Pera, 2015). International Dimensions of Nursing Professional Identity Internationality is a notable dimension of the research on nurses’ professional identity development. Although many countries have modeled their nursing education curriculums on the UK and US methods, nurses worldwide have developed themselves into professionals with a great deal of knowledge and skills, as witnessed by the creation of nursing protocols and guidelines around the globe (Hoeve et al., 2014). As such, nurses’ professional identity development is inevitably affected by a country’s historical, social, cultural, and economic context. Nurses’ Self-Concept, Public Image, and Professional Identity Popular conceptions of nurses matter not only to the public, but also to nurses and nursing students (Fulton, 2007; Hallam, 2000; Hoeve et al., 2014; Milisen et al., 2010; Takase et al., 2002). A nurse’s self-concept has been defined as information and beliefs nurses have about their roles, values, and behaviors (Takase et al., 2002; Takase et al., 2006). In this way, self- concept refers to the professional self rather than the psychological self. Psychological literature suggests nurses’ self-concept may be shaped by the public’s view of nurses, nurses’ comparisons of themselves to physicians, and professional socialization processes in nursing. However, the 26 most important factor to influence self-concept in this regard is the professional socialization process (Takase et al., 2002). Understanding how popular depictions of nurses and the nursing profession affect nurses’ self-concept and professional identity development is critical. To examine how portrayals of nurses in popular culture and other factors influence nurses’ development of self-concept and professional identity, Hoeve et al. (2014) analyzed and compared studies published between 1997 and 2010 on cultural depictions of nurses around the world. The final selected studies included those from Australia, Brazil, Sweden, USA, Taiwan, Hong Kong, Israel, Japan, and Norway. They found notable discrepancies between nurses’ self-concept and public image. Specifically, they found that stereotypical, inaccurate, and negative images of female nurses on the Internet and in media and entertainment (e.g., prime time sitcoms) caused harm to actual nurses. These negative images can lead to nurses’ job dissatisfaction and low job performance. Traditional sociocultural values in some societies, such as Brazil and China, dominate nurses’ and the nursing profession’s public image, such that nurses are always depicted as female, with low social and professional status, and subordinate to physicians. For instance, in Chinese society, nursing is often seen as a female gendered profession because it is associated with care and nurturing, characteristics that are commonly connected to women. Women are expected to be subservient wives, mothers, and caregivers of their families, assumptions reflective of women’s roles in a traditional, patriarchal society (Holroyd et al., 2002). However, research has also shown a lack of public awareness of nursing professionals’ qualifications. For instance, nurses are trained on rigorous and scientifically based curricula, through which they deliver patient care and interventions that improve healthcare outcomes. For over a decade, scholars have been advocating for the celebration of nurses’ knowledge, creativity, and life-saving 27 problem-solving abilities (Fulton, 2007). Others have similarly pushed for nursing professionals to engage with media and take charge of their images by monitoring, reacting, and correcting inaccurate stereotypes (Cabaniss, 2011). Scholars have also called for a proactive approach to managing nursing stereotypes as a method of addressing global nursing shortages and attrition. Glerean et al. (2017), for example, investigated young peoples’ perceptions of the nursing profession by engaging eight articles on nursing imagery among young people between 15-24 years of age. The articles were selected from an initial database search of 4,705 articles published between 2006 and 2016 and analyzed for how popular perceptions of the nursing profession may influence young people’s career choices. The authors found that, first, young people’s perceptions of the nursing profession were socially influenced by family, teachers, career advisors, and friends. Among these, family played an important role in young peoples’ career choices, including issues relating to family finance and class. Second, media like hospital dramas tended to negatively impact young people’s perceptions of the profession. Third, despite efforts to improve nursing’s image through recruitment campaigns and interventional education programs, popular nursing imagery did not change in the 10-year period between 2006 and 2016. This study and others confirm the urgent need to revise outdated imagery and popular conceptions of nurses and the nursing profession around the world. Without intentional action at all levels of society, young people will continue to internalize negative attitudes, knowledge, and beliefs about nursing, which will further perpetuate nursing shortages and low-quality care. This is especially important given recent generations are more exposed and connected to media than any generation before. Chinese Nursing Students’ Concepts of Professional Identity The scholarship introduced above highlights two major structural problems in present day 28 nursing education. One is the student recruitment process’ reliance on the Chinese National College Entrance Exam, Gao Kao, and the admission policies that come with it. The exam and its policies cause an excess of students to enter nursing involuntarily, which in turn leads to a low sense of professional identity development among undergraduates across school year and gender (Feng et al., 2016; Guo et al., 2017; Hao et al., 2014; Wang et al., 2011). This lack of professional identity has resulted in several related issues, such as stress, low commitment to nursing, high risk of attrition, low self-concept, and low self-esteem before, during, and after college. For instance, Smith and Yang’s (2017) large-scale study of stress among undergraduate nursing students in mainland China found that, of the 1,538 participating nursing students, 698 voluntarily entered nursing, while 840 entered involuntarily (i.e., 45.4% to 54.6%, respectively). They further found the students displayed higher levels of stress than those who voluntarily opted in, particularly in the late stages of study and training. This affirms similar findings in other studies on professional identity development that have also concluded the existence of increased numbers of students with low levels of professional identity and commitment to careers in nursing (Chen & Zhang, 2013; Zhang et al., 2015; Zhao et al., 2011). Moreover, the literature review in this chapter shows that almost all research related to Chinese nursing students’ professional identity development has been quantitative. Quantitative research findings are helpful for seeing the bigger picture and making recommendations for change. However, without qualitative approaches to supplement quantitative findings, we miss out on the nuances and complexities of Chinese students’ situations and are unable to fully grasp how historical, societal, and cultural elements have influenced nursing students’ professional development. For example, although useful for identifying the growing trend of involuntary enrollment in Chinese nursing education programs, quantitative studies like those by Smith and 29 Yang (2017) are unable to provide more detail about the high levels of stress nursing students experience, the kinds of stress students face in different stages of their programs, how students cope, and long-term impacts of said stress. It therefore remains necessary that colleges and educators create better teaching methods and learning environments and improve administration and communication with students (Feng et al., 2016; Guo et al., 2017; Hao et al., 2014; Wang & Zhu, 2006; Wang et al., 2011). There is also a noticeable lack of research on nursing students’ hospital experiences, which means we have limited and insufficient knowledge of one of the most significant factors shaping nursing students’ professional self-concept and identity development (Arreciado Marañón & Isla Pera, 2015). Socialization to Professional Nursing In sociology, socialization is a process by which people learn the expectations of the societies of which they are a part. During the socialization process, roles are learned in accordance with expected behaviors and societal status. Identity and personality are also established during the socialization process. Identity can be both personal and social, while personality is composed of an individual’s consistent patterns of behavior, feelings, and beliefs (Anderson & Taylor, 2004). Professional socialization is thus an essential process of learning the skills, attitudes, and behaviors required to fulfill professional roles (Price, 2009). It is a complex process that not only involves skills, knowledge, and behavior, but also integrates profession culture, values, attitudes, and goals to achieve the effective internalization of these intangible qualities (Zamanzadeh et al., 2014). Scholars have also distinguished between primary and secondary socialization (Berger & Luckman, 1967). In this regard, the socialization process in childhood is considered primary and the subsequent processes a person undergoes to become socialized into wider society, including occupations and professions, are considered secondary. 30 Some scholars, like Jarvis (1983), have concluded secondary socialization is so important that it should be seen as a separate process called tertiary socialization. Nursing Students’ Professional Socialization Professional identity development or formation is a process of professional socialization relevant to nursing. Cohen (1981) has defined it as follows. Professional socialization is the complex process by which an individual acquires the knowledge, skill, and sense of occupational identity that are characteristic of members of that profession. It involves the internalization of the values and norms of the group into the person’s own behavior and self-conception. In the process the person gives up the societal and media stereotypes prevalent in our culture and adopts those held by members of that profession. (p. 14) Cohen goes on to assert that professional socialization has four goals: The student must (a) learn the technology of the profession – the fact, skills, and theory; (b) learn to internalize the profession culture; (c) find a personally and professionally acceptable version of the role; (d) integrate this professional role into all the other life roles. (p. 15) Here, the emphasis is on interactions between novices and professionals during the socialization process. She asserts that, through these interactions, professional socialization is achieved when one integrates knowledge and practice with the values and expectations of both the profession and the public. Cohen thereby illustrates how professional socialization is both the means and end to achieving a viable professional identity in nursing. Theory is an important part of understanding professional socialization. Cohen (1981), for example, used Erikson’s (1977) human development theory and the theory of cognitive 31 stages to analyze nursing students’ professional socialization (pp. 22-27). She concluded college students are at different developmental and cognitive stages and that their development does not always follow a sequence. As such, professional education is a long-term commitment on the part of the individual and indicates the learning curve is not linear. Furthermore, Cohen has warned professional socialization could fail “if students become fixed in resistance and continue to be rebellious,” as students will consequentially either quit or be kicked out school (p. 27). This warning is particularly relevant given the majority of the Chinese nursing students are involuntarily enrolled in nursing programs and struggle through the curriculum (Smith & Yang, 2017). It begs the question: what is nursing education doing at a systemic level to fix the problem? Socialization is essential for exposing nursing students to and immersing them in professional practice (Cohen, 1981; Ewertsson, Bagga-Gupta, & Blomberg, 2017, Price, 2009; Strong, 1989; Zarshena et al., 2014). Becoming a nurse requires the development of professional capabilities, socialization into the profession, and the development of a professional identity (Cohen, 1981; Maginnis, 2018). Professional socialization in undergraduate nursing education is an essential component of the curriculum, as nursing students develop professional identities throughout their college careers. Socializing nursing students is a multi-dimensional, developmental, and iterative process influenced by classroom experiences, clinical practice, and extracurricular elements (Cohen, 1981; Condon & Sharts-Hopko, 2010; Dinmohammadi et al., 2013; Howkins & Ewens, 1999; Lee & Yang, 2019; Price, 2009; Strong, 1989). Clinical education and training are the general methods through which student nurses are socialized into professional roles and acquire the distinct behaviors, attitudes, and values of the nursing profession. Getting such education and training right can maximize students’ 32 professional identity development and the transmission of robust value systems that support and sustain their careers in nursing (Ewertsson et al., 2017; Lee & Yang, 2019). Early hospital experience is now a common practice in nursing education curriculum for the purposes of facilitating the socialization process. Clinical education emphasizes that nursing students watch, observe, feel, and reflect during the experience, which helps reduce the gap between theory and practice. The experience in turn allows students to choose nursing and promotes critical thinking and problem solving (Cohen, 1981; Arreciado Marañón & Isla Pera, 2015). Several key factors determine successful socialization in clinical settings, such as patient communication, effective mentors, role models, group learning, and program planning (Arreciado Marañón & Isla Pera, 2015; Browne et al., 2018; Coram, 2016). Nursing Students’ Professional Socialization in a Global Context Nursing students in different countries undergo various processes to be professionally socialized in nursing. Students thus establish and shape their professional self-concept as nurses within unique social, historical, cultural, and political contexts (Price, 2008). This is especially evident in the findings of a meta-study on early professional socialization and career choice that included 10 peer-reviewed articles based on qualitative nursing data (Price, 2008). A salient theme among the articles featuring nursing student participants from Sweden, Japan, Canada, Australia, the UK, and the US was that nurses and nursing students often experienced “a level of cognitive dissonance” in the “real world” (p. 16). The ideal nursing identity of caring was a clear source of disagreement, as some nurses did not want to be acknowledged as caring, especially when their expertise was overlooked. Some of the studies found more senior and experienced nurses were “uncaring” or “hardened” (p. 16) and that the nurses generally conceptualized caring as a competence instead of a characteristic of compassion (Price, 2008). Relatedly, nursing 33 students often spoke of confrontations with poor nursing role models who did not reflect their ideals, which challenged the students’ belief in caring and the nursing profession. In addition, Price (2008) indicated professional self-concept is influenced by social positioning, or how one identifies and is identified by race, gender, and socioeconomic status. In this way, a nurses’ professional identity is inextricably linked to the perceptions and expectations of others. Other studies have investigated the cognitive dissonance between theory and practice in nursing education via culturally diverse nursing socialization in Western and Eastern countries. In research by Howkins and Ewens (1998) and Thomas et al. (2015), students from the UK constructed their new identities based on their own unique experiences. The authors therefore suggested considering students’ values and beliefs about their education to optimize students’ professional socialization. The UK nursing students also exemplified cognitive dissonance between theory and practice in the environment of their first clinical placement, where they observed intentional and unintentional uncivil behavior in hospital staff. Of these experiences, the students felt a dislocation in status when they were largely treated as workers rather than learners, which caused disillusionment and disappointment. Although the students exhibited resilience in overcoming these challenges, their experiences reveal an enduring issue in nursing education and training that negatively impacts the field as a whole. Although they are westernized democratic societies, South Korea and Japan have deep roots in Confucianism. A prominent characteristic of Confucianism is strict adherence to social hierarchy. Accordingly, interpersonal relationships are mostly vertical in society, among families, and within organizations, and are determined by seniority, job title, and work experience (Jun, 2005; Lee & Yang, 2019). Lee and Yang (2019) found South Korean nursing students tended to suppress their feelings and use passive strategies for coping with the social 34 hierarchies embedded in their clinical settings. As nursing students are at the bottom of the hierarchy in these settings, they struggled to learn how to navigate this role during their clinical placements. To cope with the work culture and improve student-nurse rapport, the South Korean students studied the atmosphere between them and the nurses to get a feel for the nurses’ intentions and respond accordingly and correctly. Lee and Yang (2019) found that, in doing so, the students were able to increase their learning opportunities. Meanwhile, social and professional hierarchies are not as much of a concern for Japanese nursing students, as their professional socialization process is more team-oriented rather than top-down (Condon & Sharts-Hopko, 2010). In Japan, nurses, doctors, and other healthcare professionals tend to work together to deliver patient care. Japanese nursing students and faculty believe a team approach can deliver better patient care than any individual effort. The cultivation of the team-building skills is therefore reinforced throughout nursing education curriculum. Japanese students also pay more attention to patient communication, as they believe it is essential to understand patients’ physical and mental and emotional health. For Japanese students, communication is an important skill or competence for professional socialization. Condon and Sharts-Hopko (2010) also found many Japanese nursing students emphasized critical thinking skills as a crucial competence professional nurses should possess. Here, the critical thinking skills resonate with the American nursing education’s bachelor’s degree holders (AACN, 2008). It defines as “the baccalaureate graduate understands and respects the variations of care, the increased complexity, and the increased use of healthcare resources inherent in caring for patients.” It means that the nurses are equipped with a wide range of knowledge in healthcare and relevant resources and can leverage them to execute the best care for their 35 patients. In addition, it breaks away from the traditional nursing profession image as the subordinates to doctors. Education Abroad for Nursing Students In developed countries, nursing student socialization has expanded to a global scale (Johnso & Stage, 2018; Kako & Klingbeil, 2019; Lee, 2004; Ruddock & Turner, 2007; Ryan- Krause, 2016). Education abroad has generally been defined as an academic experience that allows students to complete part of their degree program through educational activities outside their home countries (Sanz et al., 2018). It has been identified as a high-impact practice by the Association of American Colleges & Universities (AAC&U) and many other scholars (Eyler, 2009; Levin, 2009). A major area of focus in this regard is intercultural competence (Sanz et al., 2018; Twombly et al., 2012). Research has shown participation in education abroad programs seems to have beneficial effects on students’ intercultural competence and self-authorship (Bloom et al., 2017; Fenech et al., 2013; Guan & So, 2016; Kako & Klingbeil, 2019; Moorhead et al., 2014; Philips et al., 2018; Twombly et al., 2012; Witkowsky & Mendez, 2018). Intercultural competence includes but is not limited to: open mindedness and global mindedness, intercultural awareness and sensitivity, knowledge of the relationship between the local and the global, empathy and respect for host countries, appreciation for multiple cultures, and a positive orientation to differences (Twombly et al., 2012). Through intercultural experiences, other educational and developmental outcomes emerge, such as identity development, professional identity formation, language skills, psychosocial or personal development, moral or value development, and holistic development. The scholarship conceptualizes these outcomes as self- authorship (Bloom et al., 2017; Fenech et al., 2013; Guan & So, 2016; Kako & Klingbeil, 2019; Moorhead et al., 2014; Philips et al., 2018; Twombly et al., 2012; Witkowsky & Mendez, 2018). 36 However, some studies have been criticized for a lack of empirical grounding and unclear learning outcomes (Twombly et al., 2012). In the context of nursing, students’ education abroad experiences often reflect their learning of intercultural competence. Multiple case studies of UK and Swedish nursing students’ international experiences in western countries (USA, Sweden, Holland, Spain, Finland, and Denmark) and developing countries (Pakistan and South Africa) have shown nursing students learn the most in culturally diverse areas, particularly in terms of their professional development, values, personal development, and enablers and inhibitors of their learning (Green et al., 2008). Other education abroad projects have shown nursing students’ learning outcomes vary across contexts. For example, Ruddock and Turner (2007) found Danish nursing students developed cultural sensitivity while studying abroad in an eastern European country. Kako and Klingbeil (2019) found American students learned cultural humility and delivered culturally competent care in urban and rural Kenya, and Lee (2004) showed UK nursing students gained personal and professional development in their study abroad programs. A noticeable attribute of the literature on education abroad is the majority focuses on students from the Global North, while only a small subset of literature exists on students from the Global South and their international learning experiences (Bell et al., 2020; Kulbok et al., 2012; Miles et al., 2018). This phenomenon reflects the broader context in which student mobility programs are situated, namely the inequitable geopolitical power relations and the economic imbalance between the Global South and the Global North (Bell et al., 2020). Given this, the multilateral benefits of mutual exchange and reciprocity between developed and developing countries has received little attention in scholarly discourse on internationalization (Miles et al., 2018). 37 Chinese Nursing Students’ Education Abroad Experiences The scholarly literature on Chinese nursing students’ study abroad experiences is extremely scarce in both English and Chinese journals. I found one qualitative study in Chinese language on Chinese nursing students’ learning experiences in Australia (Yue & Wu, 2013). Although the study is based in a year-long program, it provides important insights on Chinese nursing students’ experiences with international education. The study found Chinese nursing students experienced language barriers, differences in teaching and learning styles, and differences in curricular content. In exploring the differences in nursing between the two cultures, participating students were able to deepen their abilities in creative thinking and problem solving. However, the Chinese students also experienced pressure and confusion related to the balance between eastern collectivism and western individualism in nursing practice. The authors noted that, while Chinese nursing students did learn advanced nursing skills in Australia, it is also important for them to maintain Chinese practices that are beneficial to patients. The authors also noted the Chinese nursing students made great progress in intercultural competence, particularly in terms of respect for diverse cultures, open-mindedness, and culturally sensitive care. They concluded Chinese nursing education must make adjustments in the Chinese traditions of social hierarchy and ignoring personal development, and western ideas of individual value and equity. Without integrating western values in the Chinese nursing education system, they cautioned the education system and nursing students’ growth will suffer. Their study, however, is not explicit on how students’ experiences influenced their sense of professional identity or commitment to nursing. Theoretical Framework In this section, I draw on the literature review above to discuss the guiding theoretical 38 framework of my study: Cohen’s (1981) three-sphere model for nursing students’ identity development and socialization. My research focuses on the experiences of undergraduate Chinese nursing students in a short-term study abroad program in the US. I specifically examine their experiences at an American hospital and the program’s potential influence on the students’ professional identity development and professional socialization during, before, and after the program, as the Chinese nursing students inevitably compared their experiences in Chinese hospitals. The experience for students was two-fold in that it was both a professional learning opportunity in the US and a professional socialization experience. To examine data from participant interviews, I draw on Cohen’s nursing students’ identity development and socialization model. I will note here that I understand Cohen’s model was developed in a Western context. However, I believe the model addresses common development issues within the nursing profession, especially regarding the profession’s universal standard of giving care to ailing patients. It is therefore appropriate to apply to my research on Chinese nursing students’ education abroad and professional identity development. Cohen’s Three-Sphere Model Using the lens of professional socialization theory, Cohen (1981) has proposed nursing students’ growth and professional socialization happens in three “spheres” (p. 54): the cognitive sphere, the interactional sphere, and the personality sphere. This model aims to address nursing students’ different development stages and the events and problems they may experience during the nursing identity formation and socialization processes, as well as how faculty should respond to these processes. In her work, Cohen found the nursing education system failed students if the elements in the three spheres did not work as they should. Of this, she explained, “the cause of disillusionment in nursing is rooted in the education system and in problems in the socialization 39 process” (p. 50). For Cohen, nursing students’ failures are thus less a reflection of the individual student and more a reflection of an education system that has failed to adequately prepare and support them. Cohen’s conception of the cognitive sphere encompasses four developmental stages: Dependence, Negative/Independence, Independence/Mutuality, and Interdependence. In the first stage of Dependence, students must accept the theoretical and factual basis of the professional field and rely on instructors’ and mentors’ knowledge. As such, beginning courses in nursing must impart useful knowledge with practical value. Students must also have access to trustworthy relationships with faculty and have opportunities to interact with a variety of faculty, mentors, and practitioners so they can see there are many ways to achieve their professional goals. Early positive experiences and a sense of trust are essential to instilling a sense of confidence in students and for building the foundation upon which they can form the relationships necessary to their success. The second stage, Negative/Independence, is a critical cognitive stage. Here, students start to have questions and even question knowledge and practices in the nursing profession. It can be a difficult time for faculty and mentors as students discover they need to learn new behaviors and discard old ones. Faculty and instructors must therefore be willing to permit and accept student resistance and questioning of the teaching and nursing traditions that may not resonate with students. Cohen advises that, at this stage, a culture of inclusion and tolerance is most “appropriate to encourage students to question not only the theories and facts of the profession but the professional culture and values as well” (p. 35). In the third stage, Independence/Mutuality, students learn the limits of the profession, use their knowledge and skills to identify the most critical information, make predictions, and take 40 action. The best way to grow independence is to provide clinical experience and a supportively structured environment. These support structures should consist of student learning groups as well as faculty and mentors in the hospital. While students learn from each other, faculty should act as a safeguard, encouraging them to work independently and provide the resources necessary for them to do so. During this stage, anticipatory professional socialization occurs. The students begin to change and assume a new status with nursing behavior characteristics, attitudes, and role orientations. Again, a supportive culture and environment is critical at this stage for students to make smooth transitions into the next stage. By the fourth stage, Interdependence, students should be trained and socialized in nursing and should be able to solve problems by working with colleagues and peers. However, when Cohen first published this model 30 years ago, she recognized that her idealized expectation at this stage was not realistic for nursing students because nursing education did not yet support such a level of professional maturity. She hoped future nursing graduates would be able to achieve that status (p. 57). In the interactional sphere, students learn the appropriate manners and conduct of professional behavior in the nursing profession. However, they also encounter cultural norms and barriers that can interfere with their progress. For example, nursing students often realize their knowledge and skills are not as highly regarded and respected as that of physicians and that the public image of nursing is usually negative and stereotypical. The events and problems students encounter in this sphere ultimately affect students across all developmental stages in the cognitive sphere. Finally, in the personality sphere, students observe nursing faculty’s, mentors’, and nurses’ attitudes and dispositions in hospitals. They take these attitudes and behaviors to be the 41 ‘personality’ of the nursing profession. Cohen has critically pointed out that this nursing personality often has characteristics of “authoritarianism” (p. 63), a culture that can severely hinder nursing education and students’ socialization as independent problem solvers. The authoritarian tradition in nursing education ignores students’ individual identities and stresses deference to traditional power structures in healthcare systems among hospital administrators, physicians, nurse administrators, and nurses. Cohen has warned the authoritarian culture in healthcare functions to suppress nursing students’ identity development and thereby causes dismay and disillusionment with the profession. Such a culture can be significantly detrimental to nursing students’ self-concept and personality development. To prevent this from happening, nursing educators should facilitate students’ learning of autonomy and acquisition of professional roles by taking time to work with them through problems instead of just telling them what to do. Furthermore, students also learn to integrate their own personalities and professional nursing roles as they interact and identify role models for themselves in nursing. Cohen (1981) has held that this step is necessary for students to “create a role identity compatible with the demands of the profession and with personal strengths and weaknesses” (pp. 22-23). Overall, nursing students move across the three spheres throughout the processes of their learning and professional growth, and their experiences in one sphere can greatly impact their experiences in others. A Note on the Theoretical Framework It is important to note here that I applied Cohen's three-sphere framework because I felt it necessary for me to do as a novice scholar conducting traditional scholarly research. Some readers, however, felt the framework restricted my study. I considered continuing without the 42 framework, but in the end decided to keep it because it effectively enabled me to discipline and ground my thinking throughout the data analysis and writing processes. Summary In this chapter, I discussed the relevant scholarly literature pertaining to the research questions and conceptual framework to provide background knowledge to understanding Chinese nursing students’ experiences and the challenges they face. Yet, their lived experiences of socialization and development of a professional identity in education abroad programs and learning contexts in China remain notably under-explored in existing scholarship. Keeping in mind that many Chinese undergraduate nursing students enter the nursing discipline involuntarily, their socialization into the profession and their identity development can be particularly challenging. Accordingly, this study advances scholarship on the influence of education abroad programs on nursing students from developing countries, in this case, students from China. In the next chapter, I present my research methodology. Informed by the literature reviewed here, this project was deliberately designed to enrich extant knowledge and theoretical analyses of nursing students’ socialization and identity development in a Chinese context with a particular focus on how education abroad may contribute to these processes. The following chapter lays out the context of my study, my positionality as a researcher, the research design, methodology, and methods employed to analyze the data and answer the research questions. 43 Chapter 3: Research Methods The goal of this study is to provide a nuanced understanding of a short-term study abroad program’s influence on Chinese undergraduate nursing students’ professional identities and socialization into the nursing profession, particularly as they progressed through hospital internships and graduation. In this chapter, I begin by detailing the context of my study and a description of my role as researcher. I then present my research methodology and give an abbreviated explanation of my pilot study, followed by an account of the data collection process and data analysis. I conclude with the steps I took to ensure trustworthiness and a review of the study’s limitations. As previously mentioned, the overarching questions driving this study are: Does a short- term study abroad program provide professional socialization experiences to nursing students, and do they have any influence on Chinese nursing students’ sense of professional identity? How does Chinese nursing students’ international experience compare to their clinical internship experience in China in terms of professional socialization and identity development? The related questions are: o How does participating in the eight-week study abroad program in nursing affect Chinese undergraduate nursing students’ understanding of their nursing identity? o How do students characterize professional socialization in the eight-week program? o Does the experience in a US hospital have a long-term effect on Chinese nursing students’ careers in China? o What are Chinese nursing students’ clinical internship experiences in China? In what follows, I explain how these two research questions, the related questions, and the context of my study impacted my study design, methodology, and methods of data collection and 44 analysis. The Context of My Study In 2016, the College of Osteopathic Medicine (COM) of Midwest University (MU) established a partnership with the China Eastern University of Traditional Chinese Medicine (CEUTCM). American osteopathic medicine and TCM share a common philosophy in that both medical systems take a holistic approach to illness prevention, diagnosis, and treatment. The focus of this partnership is to provide short-term training programs for undergraduate students in CEUTCM nursing and public health programs. The first CEUTCM program that took place in 2017 was three weeks long, a typical length for a short-term study abroad program. Program content included lectures on nursing, public health, American culture, and language, as well as a visit to two local hospitals for professional activities. Each hospital visit lasted two hours. The hospital staff took the Chinese nursing students to various departments, showing them the facility and giving the students a brief introduction of their daily tasks. Students were able and encouraged to ask questions during this tour. Staff members provided English to Chinese translations and vice versa during the visits. In addition to professional site visits to places like nursing homes, the students were also taken on cultural visits to museums and other local events. In 2018, the CEUTCM extended the three-week program to eight weeks to give students more learning opportunities. More importantly, the CEUTCM wanted their nursing students to have hospital observation experience in the US. Our office worked with the Great Lakes Hospital to rotate the Chinese nursing students among 13 departments in the hospital for three weeks. Compared to other CEUTCM nursing education abroad programs in Australia and Japan, the 45 MU program was more attractive because the students regarded the hospital experience as the most valuable piece of their learning of the nursing profession. In the summers of 2018 and 2019, two groups of 24 CEUTCM undergraduate nursing students came to MU and participated in the hospital observation program. As nursing education scholars have shown hospital experience to be essential to nurses’ professional socialization and for professional identity development (Cohen, 1981; Ewertsson et al., 2017; Walker et al., 2014; Zarshenas et al., 2014), the purpose of the three-week program was to help the Chinese students develop a deeper understanding of American nursing and nursing practices. The Impact of COVID-19 The global pandemic disrupted my original research plan for this dissertation. Originally, I intended to use the summer 2020 nursing program as the sample for this study. However, due to COVID-19, the 2020 summer program was canceled. As a result, I had to shift my study sample to the students who participated in the 2018 and 2019 programs. To them, the American hospital experience happened more than one or two years ago, and although they still remembered some details about their time in the American hospital, it seemed many of their feelings and emotions regarding the study abroad program had faded. In this way, the study abroad experience has become a memory on which the students can reflect, connect, and make meaning of their current experiences. The American experience is therefore part of the journey that has shaped the students’ attitudes and behaviors as they continue to learn and practice nursing in China. Moreover, due to strict restrictions on international travel, I was not able to meet the students in person in China and instead had to use Zoom meetings to conduct the interviews for data collection. Merriam and Tisdell (2016) have emphasized that “qualitative research is not a linear, step-by-step process” (p. 191). My 46 conversations consequently lead to the “refinement or reformulation of questions” (p. 191). This was true for me as a researcher, as I had to make adjustments in response to the pandemic and my interviews with participants. I made two key changes to my original research plan. First, I revised my data collection strategies to include all students who visited the US via the 2018 and 2019 summer programs. All students were invited to take part in my dissertation study, including those who participated in the pilot study in the summer of 2019. Second, in response to this adjustment to the research plan, I refined my research protocol to take a more holistic perspective to exploring participants’ lived experiences and how those experiences shaped their professional identity development in China and in the US. The revised research protocol centers on the journey of college nursing students’ professional socialization and their professional identity development. Consequently, my study addresses participants’ professional socialization and professional identity development from wider perspectives (i.e., across their past and present experiences and their hopes for the future). Researcher Positionality Qualitative research is interpretive and, as such, researchers are typically involved in a sustained, intensive experience with participants (Creswell & Creswell, 2018). Such a process introduces “a range of strategic, ethical, and personal issues” in the research (Creswell & Creswell, 2018, p. 183). It is important for me to provide a self-reflective account of myself in relation to the study, especially because the participants and I identify as Chinese and had direct contact during their time at MU. As my biases, values, and personal background shaped my interpretations of the data (Creswell & Creswell, 2018), I took time to reflect and consider various aspects of my own professional and personal identities in this regard. 47 My Education and Job Background My education and work experience in international higher education plays a significant role in my academic and scholarly interests. I was educated in China and came to the US to pursue further education after teaching at a top Chinese university for two years. As an insider, I have an intimate understanding of the fundamentals of Chinese higher education. I also have two decades of experience managing both long- and short-term international visitor programs at MU. The visitors who participate in these programs have included professionals and college students from an array of countries, including China, South Korea, Turkey, Mongolia, and Libya. Although these programs have a curriculum, the programs themselves do not assess learning outcomes due to their non-credit nature. The content of the short-term programs was usually composed of lectures and cultural or professional site visits. Lectures were delivered by faculty and professionals from various fields, and site visits were usually focused on American culture, American life, and histories, such as those presented by museums, schools, government offices, and industries. My Relationship with the CEUTCM The Chinese nursing students’ sponsoring university, CEUTCM, invested full trust in our program and in myself as the program’s architect. I have built trust with CEUTCM over the years by designing and directing four short-term faculty development programs for CEUTCM at MU before the nursing program. The faculty development program was a success and the CEUTCM teachers valued and gave high praise of the program. This successful collaboration evolved into a relationship of mutual trust and confidence in each other. My bilingual language capacity as well as my teaching and administrative work in China further afforded me important 48 cross-cultural advantages in our work as I was able to effectively solve problems and communicate with both my American and Chinese colleagues. My Relationship with the Summer Program and the Chinese Nursing Students The summer program was eight weeks long and composed of two parts. Part one included two components: in-class activities and community engagement. In-class activities were conducted in English and were focused on speaking and writing, lectures on public health, nursing histories, and global health topics. The community engagement activities took students to local community centers and government organizations. There, they participated in organizational actions, a reading club, sports, community dining, packing food for those in need, and presenting topics on Chinese traditional medicine to elders. The goals for the first part of the summer program were to improve the students’ English language skills and to interact with local communities. Overall, the program created mutual learning opportunities for Chinese nursing students and local Americans. For example, the Chinese nursing students delivered presentations on Chinese traditional medicine, physical exercise, and cooking techniques for health improvement to elders at a local community center. Part two of the program was comprised of three weeks of hospital observation. The purpose of this part of the program was for the Chinese nursing students to observe American nurses and other medical staff at work. In this dissertation study, I focus on this three-week hospital experience, particularly in terms of how it affected the nursing students’ professional socialization and sense of professional identity. As program director, I was in charge of curriculum design and coordination between CEUTCM, the hospital, and the MU faculty who taught the English lessons and gave lectures on healthcare and science. I also coordinated with local public health and community organizations 49 and met with the students daily. I attended all lectures and provided support if students had questions or language issues. I went to the hospital with the students every day during their three-week observation experience. One CEUTCM faculty accompanied each cohort to provide support, supervise, and evaluate students’ performances at the end of the program. As I was once an international student myself, I was mindful of providing for the students’ needs and caring for their well-being. I understood the challenges of immersion in a different culture and wanted the students to have quality time learning and living in the US, even if it was for a short period of time. I would describe my relationship with the students as one of mutual respectful. They recognized me as their teacher and felt I was dedicated and responsible based on their observations and direct experience of my service to them during the program. We were thus able to develop a rapport and trusting relationship that also extended to the CEUTCM teachers. These relationships enabled students to share their honest thoughts to my questions during our interviews. Although I capitalized on my insider experience and knowledge of Chinese and American higher education as described above, I worked to address undue influence in my study. Even though I am an experienced educator, I am an outsider to nursing education. Yet, this “outsider” stance was not necessarily an obstacle. In fact, it became an advantage, as I was able to learn from the participants in their own words (Berger, 2015). I was further able to learn about and reflect on the reconstruction of my own professional identity as an educator in healthcare and as a researcher. Through this process, I also learned how nursing students’ identities and the nursing profession’s identity as a whole are formed in the context of Chinese education, healthcare, and society. Additionally, based on my lived experience in both countries, my worldview is shaped by both Chinese and American cultures. Although Western intellectual 50 systems and theories epistemologically and methodologically guided my study, my Chinese background also played a pivotal role in my understanding of the Chinese nursing students’ experiences. Each student navigated their program and nursing career differently depending on their own realities. I therefore sought to examine how they derived meaning from these experiences across various contexts and how their nursing identities were formed and shaped through professional socialization. Research Methodology In this qualitative study, I use narrative inquiry as my research methodology. Narrative inquiry is a qualitative research methodology pioneered and established in the 1980s to 1990s by scholars interested in narratives in diverse disciplines of education, anthropology, psychology, and medicine (Lindsay & Schwind, 2016). Connelly and Clandinin’s (2000) concept of narrative inquiry particularly emphasizes exploration of stories about personal and professional experiences. The authors have suggested that, if people understand the world narratively, it makes sense to study the world narratively. They view narrative inquiry as a collaboration between researchers and participants that takes place across time and space. In this way, narrative inquiry is a way of understanding experience. The collaboration and interactions between participants and researchers are what enable the two parties to tell, retell, and relive the stories of the different experiences that make up people’s lives both individual and collectively. Narrative inquiry has been recognized as a valuable qualitative approach in contemporary healthcare research textbooks (Creswell, 2013). It allows researchers to engage in inquiry with participants and thereby become co-participants in the endeavor (Lindsay & Schwind, 2016). As stories are told and shared, researchers and the participants co-construct emergent knowledge via meanings and significances that, “at once particular and localized, and yet transferrable to other 51 persons and contexts by means of reflective self-inquiry of the audience” (Lindsay & Schwind, 2016, p. 15). Notably, scholars have employed a narrative inquiry methodology in nursing education and practice (Lindsay & Schwind, 2016; Wang & Geale, 2015). They use this methodology to explicate nursing students’ and nurses’ experiences, and to propose policy changes in nursing education, practice, administration, and research. Other scholars have even used narrative inquiry to study nursing identity (Chan & Shwind, 2006; Lindsay, 2006a). The literature review in Chapter 2 shows that current research on Chinese nursing students’ professional identity development is primarily quantitative. It is thus appropriate and necessary to apply a qualitative approach to achieve a more in-depth review of nursing shortages and attrition. Narrative inquiry is a valid and reliable methodology for this purpose. It also provides a useful platform for investigating the multiple realities and social contexts of each student participant, which can lead to greater understandings of nursing socialization and better practices for effectively structuring the development of students’ professional nursing identities in China. At the time of my study, the Chinese student participants had experiences in Chinese nursing education, the study abroad program in the US, and in hospitals in both the US and China. They had reflections and stories to share about how they felt about themselves that ranged from how they entered the study of nursing to how they were socialized into a nursing identity before and after their visit to the US. As a researcher, this was a way for me to structure in the telling and retelling of the students’ stories through their own narratives. Pilot Study An initial pilot study was conducted in July 2019 with approval from the MU Institutional Review Board (IRB). In total, 14 Chinese nursing students in the MU-CEUTCM 52 program participated in data collection. The goal of the pilot study was to find out what the students learned about American nursing practices. Interviews were conducted with four students along with a focus group of seven students. All 14 students also submitted a five-page reflection paper. The interviews and focus group probed the students’ experiences regarding how they started studying nursing, what they learned about American nursing in the hospital, and gave them the opportunity to reflect on what they learned about American culture. The pilot study was important because it not only allowed me to test a part of the protocol, but it further identified nursing identity as the central focus of my dissertation research. Before the pilot study, I was not aware Chinese nursing students faced such significant challenges in developing their professional identities as nurses. I wrongly assumed the students wanted to voluntarily study nursing. To my surprise, I found nursing was the first choice of study for only one of the 14 students enrolled in the nursing program. As a result, this discovery set a new focus for my research: Chinese nursing students’ socialization experiences and professional identity development after a study abroad program in the US. Interviews and focus group were conducted in Chinese and were audio-recorded and transcribed. Each interview lasted from 45 to 60 minutes and the focus group lasted 90 minutes. I also collected a final reflection paper on their American hospital experience from each student. My analysis of the nursing students’ learnings at Great Lakes Hospital resulted in three major themes: (1) students’ confusion around their nursing identity; (2) American nurses’ behaviors; (3) the prospect of being a nurse in China. The nursing students in the pilot study were at the end of their second and third years of study and, as such, were in the early stages of the nursing profession. All had observation experience in Chinese hospitals before joining the education abroad program. Based on Cohen’s (1981) nursing student socialization and identity framework, 53 their experiences in the Chinese and American hospitals were crucial in shaping the students’ professional identities and behavior, as they were able to observe and learn from practicing nurses. I briefly discuss the findings of the pilot study below. There are several factors that make up the students’ confusion regarding their nursing identities. First, only one of the 14 students willingly chose nursing as their college major. Most became nursing students because the Chinese college admission system discussed in Chapter 1 made the choice for them. Some students accepted this reality and tried to study hard to be a qualified nurse, while others rejected the idea of being a nurse and hoped to change their career in the future. Second, all participants were aware of the societal stigmas imposed on nurses and the nursing profession in their home country. As mentioned in Chapter 2, nurses are not considered well-trained professionals in China. Instead, many Chinese people and patients view nurses as low-level healthcare workers whose primary duties are carrying out doctors’ orders, delivering medications, and cleaning up after patients. The students therefore believed their futures would be like what they observed in Chinese hospitals: dealing with a heavy workload and disrespectful patients and doctors. This made it difficult for the students to accept their professional identities as nurses. Finally, for most of the student participants, their identities as nurses were mainly about mastering technical skills and nursing knowledge. The second theme that emerged from the pilot study was the students’ positive observations of American nurses’ behaviors. The students used words like “kind, respectful, enthusiastic, passionate, humanistic, and professional” to describe American nurses’ attitudes and behavior toward patients and their job. The students also noticed two types of behaviors they found particularly salient: American nurses’ passion for patient care and their professionalism, which included their willingness to help the Chinese nursing students. The Chinese students were 54 deeply moved by a few American nurses in particular who they felt showed real care and professionalism by discussing a name for a newborn baby and taking care in communication with patients before starting medical procedures. For instance, some students encountered a nurse named Paul, who had been in the profession for more than 30 years. Paul told the students being a nurse and helping patients was a mission given by God. The students were shocked to meet someone who, after so many years in the profession, was still passionate about nursing. This type of encounter provoked the students to think deeply about nursing and its possibilities. Student Fanny, for example, noted that, even though most Chinese people do not follow a particular religion, she believed “we need some stable beliefs to help build people’s spiritual sustainability and the professional identity of nurses.” Student Yuxin’s reflection on her new perspective of nursing well summarizes how Chinese students may further develop their nursing identities. Yuxin said: This program let me learn more about nursing and know more about myself, my career, and guidance. I think about how to be a good nurse and provide better care for patients. Medical services should be emotional (empathic and compassionate) and let patients feel warm, reflecting the power of healing. Such testimonies evidence that the American nurses at Great Lakes Hospital made an enduring impression on the Chinese nursing students, especially regarding patient care and that there is more to nursing than knowledge and technical skills, like care, empathy, and respect. The third theme that emerged from the pilot study was students’ views of their careers as nurses. Many expressed they planned to advocate for better healthcare in China by improving nursing knowledge and skills or by changing behaviors. Students also expressed the realization that they could develop their nursing careers through specialization, such as those in surgery, 55 geriatric care, and becoming an international nurse in other countries. Student Peilin said her study abroad experience inspired her to dedicate herself to nursing. After participating in the program, she felt more willing to learn, get to know each patient, and give them personalized care in addition to physical treatment. She pointed out that her past experience in the Chinese hospital made her forget how important it was to care for patients’ psychology and mental health. When she observed American nurses talking with their patients, she realized Chinese nurses could do the same but that it would have to be from their hearts. Although Chinese nurses take care of many more patients than American nurses (10+ patients vs. four patients, respectively), she wanted to try to get to know patients, even if their conversations were short. Peilin thought her willing dedication to nursing was the most “precious treasure” of her experience in the US. Student Ming was also impressed by the friendly, inclusive relationship between nurses and patients in the American hospital. Ming was the only male student in the group. He felt such relationships stemmed from nurses’ genuine care for patients and patients’ trust in nurses. Of this, he said, “it is easy to gain authority (in front of patients), but at the same time, it leads to a sense of distance and separation. Therefore, to strive to establish such a relationship seems harder and more important.” Ming went on to explain he had no doubt his experiences would change his career and his life. He now took a more balanced view of each countries’ merits and shortcomings in healthcare and understood there is no perfect solution for Chinese medical problems. However, Ming noted, “I do believe I can try to make things a little better in the future with my experiences here. I think this is why I came here (MU), and that’s why people all over the world come together; to communicate, to share, and to learn from each other so we can try to make the world a little better.” 56 Data Collection As is common in qualitative research, interviews were the primary source of data in my study (Creswell & Creswell, 2018; Glesne, 2011). Interviewing was indeed the most beneficial data collection strategy for my purposes because it allowed me to hear and record students’ stories and experiences in their own words. I specifically wanted to explore Chinese nursing students’ lived experiences of their transition from students to professionals. The interview approach was well suited to my methodology of narrative inquiry because the purpose of said methodology is to understand participants’ experiences and stories from the dimensions of time, space, past, present, and future in the US and China. As a researcher, I interacted with participants and collaboratively explored and interpreted their stories and the meanings they derived from them (Clandinin & Connelly, 2000). The data collection process began with the submission of an online application to the MU IRB. The IRB application included participant information and consent forms for individual interviews. Due to the bilingual nature of my study, the consent forms were issued in both English and Chinese, as shown in Appendix B. In the following section, I describe the procedures employed for data collection in depth. Participant Recruitment At the time of data collection, there were 24 nursing students participating in the MU- CEUTCM program in the summers of 2018 and 2019. All 24 of these students were invited to participate in my study. Some had already graduated from college and were working in hospitals, some were in graduate programs, and some were in their senior year and interning in hospitals. As previously noted, I established a relationship with the nursing students when they visited MU in 2018 and 2019. The personal connections we built then were helpful in recruiting participants for this study (Berger, 2015). I initially reached out to the students and invited them to participate 57 in my study through WeChat and their personal emails. WeChat is a popular social media platform among Chinese speaking people. Consent forms were then distributed among those who opted into the study via email and WeChat to confirm the date and time of our interviews. The interviews were then scheduled on Zoom based on students’ responses. Participant Interviews After recruiting students to participate in the study, I conducted 14 in-depth semi- structured interviews via Zoom. Zoom has become a powerful and popular online communication platform during the COVID-19 pandemic. Its recording function made data collection and analysis easier, as I was able to further identify questions and issues important to my study by reviewing the data from the first round of interviews. I then conducted the second round of follow-up interviews via Zoom. This second round of interviews allowed me to clarify any questions I had from participants’ previous responses and ask new questions that emerged during the process. All interviews were conducted in Chinese, as using the students’ native language eliminated the language barrier and allowed participants to fully express their feelings, thoughts, and ideas. I developed the interview protocol to facilitate participants’ reflection of their lived experiences as they progressed through their nursing careers. The protocol was guided by the study’s research questions and the theoretical underpinning of Cohen’s (1981) three-sphere model of nursing students’ growth, professional socialization, and identity formation. It allowed participants to elaborate on the three spheres of professional development in nursing knowledge, social interaction, and behavior. The interview protocol was semi-structured with open-end questions. Semi-structured interviews were most helpful in this study as they not only gave me flexibility as the researcher 58 to be more responsive to participants and to correct misunderstandings (Yao, 2014), but also because they enabled participants to discuss issues and topics they considered relevant to their experiences as nurses and nursing students. This interview structure further ensured the interviewees were able to tell their stories instead of “being pushed” in certain directions by the interviewer (Berger, 2015). The protocol, as shown in Appendix C, allowed for 45- to 60-minute conversations and each interview was recorded using Zoom and transcribed verbatim. After the first interview, however, the number of my participants dwindled to eight because the others left the study and practice of nursing altogether. Some have moved on to attend graduate programs in public administration, computer science, English and translation studies, and epidemiology, while others have started working for companies and organizations. I decided not to include their data because these students’ nursing careers had stopped right after their graduation, and the data would not serve the purpose of this study. However, this early drop-out phenomenon surprisingly flashed a red light on the nurse attrition problem in China, which can be another research topic for the future. Data Analysis All interviews were conducted in Chinese. The MU Graduate School gave me a small grant to hire an assistant for data transcription. I hired a junior Chinese undergraduate student named John T. at MU. John is a native speaker of Chinese, whose K-12 education was in China. He came to study at MU in the College of Business. John used the Xunfei software to get the machine transcript first and then edited the file manually. I listened to the original recordings and checked the transcripts to ensure the data was accurate. Coding Scheme I started data analysis by assigning a pseudonym to each participant and masked any 59 information that could reveal their identities. Once the transcript was cleaned, I used Excel to organize the data. First, I set up a number of general topic files based on the interview questions, such as how the students were enrolled in the nursing program and students’ hospital experiences in the US. Sub-topics or themes were identified and nested under each general topic. For example, under the US hospital experience topic, subtopics included American nurses’ attitudes, interactions with patients, innovative nursing, humane care, etc. I then grouped the findings into major themes relevant to my research questions. Trustworthiness Trustworthiness refers to the authenticity, credibility, and validity of the research findings (Creswell, 2018; Glesne, 2011). To achieve trustworthiness, “the researcher checks for the accuracy of the findings by employing certain procedures” (Creswell & Creswell, 2018, p. 199). I used multiple approaches to ensure the accuracy of my findings as advised by Creswell (2014) and others (Glesne, 2011; Hesse-Biber, 2006). I first used member checking to determine the accuracy of the results. Member checking is the practice of sending key descriptions or themes to participants for their feedback. There were two components to this process. I sent the transcript to the interviewees to confirm the accuracy of the recording as well as the accuracy of the preliminary findings and themes that emerged from the conversation. I then asked each participant for their input and corrections. Through this process, I was able to ensure what I recorded and interpreted were consistent with what the participant shared with me. Second, I used peer review to enhance the accuracy of the translations and relevant accounts of the findings. I asked another qualified translator, a bilingual doctoral graduate from the same program, to review the Chinese to English translations in my writing. Finally, I paid specific attention to my writing on the data, which included but not limited to “using a rich and thick 60 description to convey the findings” (Creswell, 2014, p. 201). This writing aspect is particularly important to a methodology of narrative inquiry. Writing narrative inquiry research requires researchers to be clear about whose (participants’ or researcher’s) voice arises in the text and “have a sense of audience and a sense of what it is about one’s research text that might be valuable to them” (Cladinin & Connelly, 2000, p. 147). Limitations Identity development and socialization in nursing is a complex phenomenon and my study only explores the tip of the iceberg of Chinese nursing students’ professional identity development and challenges. Accordingly, it has the following limitations. First, all participants were from one university in eastern China, except for one participant who was based in West China Medical University. China is a large country with diverse social and cultural realities and traditions. The participants’ experiences only represented a small part of that. As Glesne (2011) has pointed out, what we come to know “is always partial, always fragmented” (p. 137). Second, there were no male nursing students among the eight participants in this study. This gender imbalance is a reflection of gendered healthcare systems, wherein nursing is feminized and therefore popularly considered to be women’s work. Third, although Zoom made my research possible, zoom meetings have limitations. For example, the sense of space and distance between people and time is distorted by such online platforms. Not every participant handled the virtual meetings and conversations well. Some were more easily fatigued from using zoom and felt their thinking and responses were hampered during the interview. Finally, I am a novice nursing educator without much of a healthcare education background. My perspective is thus limited. However, my education background was a crucial advantage, as it enabled me to examine nursing education from new and critical angles. 61 Summary In this chapter, I discussed my research methodology and methods through a review of my study’s background, my role as a researcher, my experience as an educator, and my positionality in this study. I abbreviated the pilot study and its findings and explained why I employed narrative inquiry as the research methodology. In the research design section, I discussed how I recruited participants and conducted interviews with them, and then explained how data was collected and analyzed. I highlighted how my research design underwent two major changes, namely that data collection shifted to past program participants (i.e., those from the 2018 and 2019 programs) instead of a then-current program in 2020, which was canceled due to the pandemic. The second change was that I expanded the scope of my study to include students’ hospital experiences in China rather than limiting it to their experiences at the American hospital. I concluded by addressing trustworthiness, my strategies for ensuring the accuracy of my findings, and explained the limitations of this research project. In the next chapter, I build off these foundations to elaborate the findings of my study of Chinese nursing students’ professional socialization and professional identity development. 62 Chapter 4: Embarking on the Nursing Journey I began this study with 14 student participants in total. By the time interviews were conducted, however, six of the original interviewees were no longer in the nursing profession, as some had shifted their studies to other areas of the field, while some took jobs unrelated to healthcare. In this chapter, I introduce the remaining eight participants and present their experiences of entering and navigating nursing. I begin by introducing the participants and how they got into college to study nursing, then explore the struggles some faced during their freshman year. Although I only include these eight students’ data in this study, the other Chinese students’ entry into nursing was similar in that they were assigned to the major as opposed to choosing it for themselves. In this way, Chinese students in the nursing profession differ from nursing students in western countries, who often choose to be nurses. The participant stories in this chapter encompass the unique challenges with self, family, and culture Chinese nursing students face as a result of China’s national college exam system, Gao Kao. Participants in the Study Table 4.1 shows participants’ demographic information and stage in their nursing career at the time of my research. Four were graduate students of nursing, two worked in hospitals, and two were senior students. Their backgrounds are important to comprehending their journey through nursing, their aspirations, and their achievements. Among the eight participants, two were from HP city in eastern China, where CEUTCM was located. The rest hailed from Yunnan, Sichuan, Gansu, and Chongqing provinces in western China. Western China’s economy is not as advanced as eastern China’s. As HP city is a metropolis on China’s east coast, it is a magnet for young people who come to pursue their dreams. 63 Table 4.1 Participant Demographics (at time of interview) Participant* Age Gender Year in US Hometown Job Hong 23 Female 2018 Yunnan Graduate Student Angie 23 Female 2018 Sichuan Graduate Student Lia 25 Female 2018 Gansu Nurse Gina 23 Female 2018 HP City Nurse Lily 22 Female 2019 Yunnan Graduate Student Yanni 22 Female 2019 Gansu Graduate Student Lynn 22 Female 2019 HP City Senior Student Anna 21 Female 2019 Chongqing Senior Student * Pseudonyms Hong Hong grew up in Kunming, the capital city of the Yunnan province in southwest China. At the time of data collection, she was in her first year of graduate study in nursing at a different university in HP city. Her goal at the time was to conduct research in clinical nursing and contribute to the improvement of patients’ care environments and healthcare efficiency. She also wanted to learn more about the mental health of healthcare professionals and patients to help enhance occupational happiness. She indicated an understanding that, because of her dreams, she often felt unsatisfied with nursing science and the management systems in academia and hospitals. Although she did not have solutions to these problems, she intended to maintain a positive mindset in making efforts to achieve her goals. 64 Angie Angie came from a small town in the Sichuan province. She left HP city after completing her undergraduate study and enrolled in nursing graduate study at a university in Chengdu, the capital city of the Sichuan province. She was in her first year of study at the time of our interview. Brought up by her grandparents, Angie was a diligent student in school and advanced to a prestigious high school through exams. She was admitted to the CEUTCM and advanced to graduate studies without further exams, where she received numerous awards. Her short-term goals included graduating, publishing articles in high Science Citation Index (SCI) journals, and working in a good hospital. Her long-term goal in the nursing profession was to be a nurse specialist and open her own clinic to conduct wound care. Lily Lily grew up in a small town in the Yunnan province and attended a boarding high school in Qujing city in pursuit of a better academic environment. When she graduated from CEUTCM, she left HP city to pursue graduate study at a university in the Hunan province. She was in her first year of study at the time of our interview. Lily described herself as positive and careful with a strong sense of social responsibility. She was critical in her work and study, identifying problems and finding solutions. As an A student, she received multiple scholarships during her college years and wanted to be a specialized nurse in the future. Her short-term goals were to publish articles, identify her thesis topic, and graduate. She was especially proud of her research skills in document retrieval. Yanni Yanni was born in Lanzhou, the capital city of the Gansu province in northwest China. She grew up in a well-off family and felt lucky that her high school was not a big stress for her 65 because of Gao Kao pressure like other competitive high schools were. The downside to this was students in her school did not get high Gao Kao scores for top universities. However, encouraged by her parents to step out of her comfort zone and explore the world, she chose a school in HP city for college and enrolled in a study abroad program in the US. At the time of our interview, Yanni was a first-year graduate student at her alma mater, the CEUTCM. Yanni expressed a deep desire to be a person who positively affected others and felt a sense of responsibility as a nurse that gave her confidence in her path to becoming a nursing professional. Gina Gina grew up in HP city and was in her first year as a nurse in a hospital in HP city at the time of our interview. Working at the hospital caused her to refigure her hobbies because she had less time to devote to them. She mainly spent her after-work time exercising or playing games to decompress. At the hospital, Gina was engaged in standard residence training and took the National Nurse Exam. During the residence year, she spent three months each in internal medicine, emergency, and intensive care unit, respectively. She had become skillful in nursing techniques and documentation, skills that were not taught in class, particularly in medicines (drugs). At the time of our interview, Gina had just transferred to the pediatric dental department, which varied significantly from her previous experiences in other departments. Her new job posed challenges for Gina and she hoped to settle down in a more familiar department but also realized that, as a new employee, she did not have many choices and would have to wait for her leaders to decide. This uncertainty caused Gina concern over her future, such that she planned to potentially quit nursing or pursue graduate study if she could not sufficiently settle in at the pediatric dental department. 66 Lia Lia came from a village in the Gansu province. She loved her middle school physics teacher who became an inspiration for her to study education. She did not have a positive experience during high school and had to retake the College Entrance Exam (复读), as a result. Through effort and perseverance, she eventually succeeded and came to HP city for her college education. However, Lia’s career choice of education became a source of tension in her family, as her parents preferred she attend medical college instead of studying education. Of the six college choices on her application form, she put down two normal universities and four medical universities. Unfortunately, her Gao Kao score did not meet the normal universities’ admission benchmark, so she ended up at CEUTCM. After graduation, Lia chose to work for the HP Mental Health Hospital, despite the bias and stigma many Chinese citizens hold against mental health patients. At the time of our interview, she had worked there for one-and-a-half years and felt her experience helped her better understand mental health as a normal, treatable phenomenon. Lynn Lynn was raised in HP city and was a senior nursing student at the time of our interview. She was graduating in a few months and had been admitted to the graduate nursing program at CEUTCM. Her graduate study was focused on emergency and critical care, and nursing management. Lynn described having a productive research experience in her college years. She published an innovative study in a Chinese medical education journal in her sophomore year and participated in a faculty research project. She wanted to learn more about data analysis, modeling, and to continue working as a clinical nurse. 67 Anna Anna grew up in a small town in Zhong County of Chongqing city in southwest China. As her parents were migrant workers stationed in another city in China, she was raised by her grandparents and moved in with her paternal uncle’s family when she reached school age. Anna felt lucky that her uncle and his wife treated her like their own child even though they had their own daughter. Although Anna had an open, happy personality, she said she was not a high- achieving student and had low self-esteem before attending college. She wanted to study medicine, but knew her academic performance was not up to medical schools’ admission standards. She was the only student in the study who chose to study nursing. Learning nursing in college helped Anna feel deeply satisfied with her study and internship experiences. She received numerous awards for academic excellence and student leadership. She further understood nurses do not have high social status in China and that many nursing students are not happy. This motivated her to promote positive change in the profession. At the time of our interview, she was preparing for graduation and looking for a job. Her goal was to find a hospital that would give her opportunities for professional development in geriatric nursing. As these introductions indicate, the eight students at the center of this study came from varying backgrounds and had varying hopes, dreams, and goals. What they shared, however, was having to navigate a national exam system that limited their ability to choose their career paths and incited challenges with themselves, their families, and their culture. First Steps in Nursing My interviews show that, of the eight participants, Anna was the only one who voluntarily began a nursing career in college. The other seven were instead assigned to study 68 nursing based on their Gao Kao results. This phenomenon is consistent with research findings (Eddins, et al., 2011; Smith & Yang, 2017; Wong & Zhao, 2012) discussed in Chapter 2. As a result, many graduates with bachelor’s degrees in nursing change career after graduation. In this study, six of the original 14 interviewees were no longer working or studying nursing at the time of data collection. In what follows, I present participants’ early experiences in their nursing programs to illustrate the struggles and emotional stress when students are assigned to study what they don’t intend. Such experiences and challenges are important for me to understand the barriers for Chinese nursing students to develop their professional identity and self-concept. This early twist of college choice against personally willingness poses a major barrier to professional identity development for Chinese nursing students. How Did Participants Enter Nursing? What schools and majors students can access is typically determined by the Chinese Gao Kao testing system. Under this system, students aim for optimal performance on the Gao Kao exams so they can obtain admission to their top choices in college and major. However, the results of this test are as contingent on luck and socioeconomic background as they are on students’ skills, as tens of thousands of students compete for limited seats. To avoid losing college admission completely, most comply with the adjustment (服从调剂) to other choices of colleges and majors if they are not admitted by their first choices. In rare cases, students do not agree to the adjustment and instead opt to the study for another year and retake the exams (复读). Through data collection and analysis, I found most of my participants originally wanted to study clinical Chinese medicine, meaning nursing was not their first choice. For many Chinese students, what to study is not based on personal preference alone. In many cases, parents and relatives play important roles in this decision-making process. My interviews revealed a diversity 69 of experiences and situations among participants after receiving their Gao Kao scores, some of which were more complicated than others. For instance, Hong left the Yunnan province and went to HP city to enroll at CEUTCM. She described that, although she did not know anything about nursing, she chose to comply with the admission adjustment: My high school study was a little bit above the average, so when I took the college entrance examination, I chose to comply with adjustment like most of my classmates. I was transferred to the nursing major even though I had not chosen it at the time [of college applications]. I wasn’t courageous enough to go back to high school and study for another year to retake the exams, so I went to CEUTM. I knew the university was located in HP city, but I did not have a clear understanding of the future development of my major [nursing]. I only knew that it (the school) was in HP city, which is far away from Yunnan, but a very developed city. (Hong) 我高中学习中等偏上一点点，然后高考的时候可能和大多数同学一样，是选择了服 从调剂，所以就调剂到了我们当时根本就没有选择的这个护理专业，是调剂过来 的. 当时没有那个复读的勇气，就到了大学。我当时只注意到上海，但是没有去很 清晰的认识到我专业的未来的前景发展，我对我的专业也没有很具体的了解. 只知 道是在上海, 是一个离云南很远的，但是很发达的城市。 (Hong) Retaking the Gao Kao exam is an arduous journey, and few students want to do so. For Hong, even though nursing was not her choice of major, HP city was attractive, which represented hope and opportunity. Other participants, like Gina, considered retaking Gao Kao when they received their admission to nursing. Gina shared: My parents and I thought about whether I should retake the exam. I didn’t want to study nursing. At the freshman parents’ meeting, we learned the job market was good for nursing and it didn’t sound as bad as we imagined. So, I continued [with it]. Not long after the semester began, several students left school and decided to retake the Gao Kao exam. But for me, I felt if I decided to do something, I should stick to it. I thought maybe I would like nursing after a while. (Gina) 然后当时也想过进护理的专业的时候，我包括我父母，还有我自己也想过要不要再 重新考一遍，不是很想学护理，但是最后还是放弃了。进入学校之后感觉在第一次 70 听新生的家长会的时候，觉得说这个职业也还算是可能比较好找工作，然后前景也 没有那么想象中的那么差，然后学下去了。然后可能刚开学没多久的时候，就听到 有几个同学他们还是选择放弃，就重新去考试了，再换个专业这样子。但是可能像 我这样的性格，我一件事情的话坚持决定要坚持下去的那种性格，然后学着学着我 想我可能就会喜欢上的。(Gina) Gina’s case indicates that education and knowledge can change people’s hearts and minds about nursing. Imagine, if such an education program were established among secondary education system, nursing could become popular among healthcare related majors. In addition to complying with exam adjustments to ensure college attendance, some participants were persuaded by their parents to study nursing. For some parents, like Angie’s, the move to push their children to study nursing was justified due to the difficulty of the college entrance exams: I wanted to study clinical traditional Chinese medicine (TCM). That year, the TCM admission scores were particularly high. In 2015, the previous year, the clinical TCM admission scores were 560-570; but in 2016, the cut-off scores were at 600. Then I was transferred to nursing. I was very reluctant to study nursing. In western China, like Sichuan, I think most of the nurses are graduates from health schools or technical secondary schools. I don’t have [a] high regard for this profession. At that time (admission), I felt very bad about this major. I discussed it with my family and I said I would go back and retake the exam (复读). Then my dad said that it was not easy for me to perform well in Gao Kao that year, so he said I shouldn’t repeat the exam. He thought it was good to study nursing because it’s related to medicine. He said, “You have wanted to study medicine since you were a child.” And he said nurses and doctors are the same. I listened to my dad and went on studying nursing. (Angie) 结果那一年就是大家都大家那一年好像有一个中医热潮的感觉，那一年中医录取分 数特别高。我们当时 2015 年的时候，可能中医就说 560-570 的那个样子，然后我们 那一年 (2016)就收了 600 分，然后我们就被调剂到护理了.调剂到护理的时候，当时 我就有一点不情愿嘛，因为在四川这种西部地区，我想护理大部分都是卫校啊中专 啊出来，包括我自己对这个专业的认同感也不是很多，就包括去医院的时候，也就 是觉得一些小护士姐姐啊怎么样，我当时就觉得我自己读这个专业就很亏。然后我 就跟家里商量过，我说我要回去复读。然后我爸爸就说今年难得发挥超常,考的挺 好的，所以他说你干脆就别复读了。他说我觉得读这个专业挺好的，反正跟医学相 关，你从小也就想学医学的，他说护理医生不是一样的嘛。然后我就听我爸的话我 就去读了. (Angie) 71 For Angie, she knew nursing, but in a negative way. However, she listened to her father’s advice and balanced her decision. She entered nursing with doubt, regret, and a feeling of dissatisfaction. Other parents encouraged their children to pursue nursing because it seemed more practical and likely to lead to a job. For example, Yanni wanted to go to HP city and put CEUTCM as her first choice of college. However, CEUTCM only offered six majors to students in the Gansu province. Of these six majors, Yanni put nursing as number five on her list. She said she didn’t even remotely think that she would be admitted by nursing. Although nursing was far from her first choice of clinical Chinese medicine, her parents advised studying it if she wanted to experience life in a metropolis: But my mother was more worried, because she felt that this profession (nursing) was not good, and she believed I should study a profession like Chinese medicine. However, my dad didn’t think so. My dad did some research and he told me that the nursing employment rate is very high. He said if you wanted to stay in a big city in the future, it is definitely the most important thing to find a job. Then he told me I should study hard. He thought that, if I could find a job in the future, it may not be that important what major to study. If there is no way to earn a living in HP city with a TCM doctor degree, there is nothing wrong with studying nursing. (Yanni) 但是我妈妈是比较比较忧愁的，因为他觉得这个专业不好，他就觉得应该去学一个 中医这种专业，她就觉得学医总感觉比护理好，但是我爸不是这么想的，我爸他就 觉得查了一下，他跟我讲说专业就业率很高的，他就说在大城市的话，如果以后想 要留下来，肯定还是最重要的，还是要找个工作。然后他就跟我说你去好好读，反 正他觉得如果以后能找上工作的话，其实学什么专业可能就不是那么重要了，他觉 得你与其你学过中医，然后读到博士还是就说是没有办法在上海谋生的话，其实读 个护理这么看也没有什么不好的. (Yanni) It seems Yanni had no idea about nursing when she got her admission letter. Her parents’ involvement was typical among many Chinese parents, study for a job. Again, studying nursing in HP city almost guarantees a job in the future. Participants’ parents also influenced their decisions to study nursing because they disapproved of their children’s desired careers. Lia’s childhood dream, for example, was to be a 72 teacher. However, her parents counseled her away from this profession and toward nursing as an alternative: When I was filling up the college application form, my family, including my relatives, wanted me to work in healthcare. I argued that I didn’t want to. They called many relatives to persuade me, saying that they felt the medical profession was short of people and the prospects for employment would be better, and the job is stable. Unfortunately, I was not admitted Shaanxi Normal University because I was four points behind the cut-off score. I missed all my chances to be a teacher. I wanted to be a teacher since I was a child, until I graduated from college. Even now, I still wish I was a teacher. (Lia) 在当时报志愿的时候，我家人包括我亲戚，他们都想让我从事医学这个行业。然后 我当时也是跟我父母就是在那边争，就是自己不想报那个医学专业的，他们就找了 很多亲戚打电话劝我，说觉得医学这个专业现在缺人，就业的前景会比较好一点， 然后工作也稳定。但是我第一个也填了陕西师范，但是没录上。差 4 分。就这样与 教师的这个专业就全部就错过了。我就是从小学开始其实一直想当老师，就是一直 想当老师直到现在的大学出来，包括到现在，就一直很想当老师的这个职业。(Lia) As the above indicates, Lia’s parents pushed her to apply to medical colleges because they felt medical fields had more job opportunities and were more stable. Studying healthcare-related majors was thus her family’s wish, not hers, and continues to impact her to this day. Parents and relatives, however, were not the only ones who chose nursing for its practicality. In some cases, it was the participant themselves who chose nursing for this reason. For instance, Lynn was one of the top students in her class. At the time of our interview, she was doing her senior year internship at one of the CEUTCM hospitals and had just gotten the news that she had been admitted to graduate study in nursing at her university. Although nursing was not her first choice, she took a practical approach to starting her college nursing career: My aspiration was to study English or to be a teacher. I did put nursing on the application form, but it was the last of my choices, which started with Traditional Chinese Medicine, rehabilitation, food and nutrition, and nursing. I did not select clinical medicine because the cut-off score was too high. At the time I thought perhaps [nursing] was my destination. I always felt this was my destination and I should study hard. I never thought about transferring to other majors. My mother also told me that nursing is a welcome major for immigration to other countries. It’s not like business management, where some people may not find a job with it. I also originally wanted to go abroad, but the pandemic makes everything complicated, plus there had been an anti-Chinese movement in Australia, which 73 made me give up the idea. I have been lucky to be recommended to graduate study at CEUTCM. So, I just want to study hard and well. I’m very interested in ICU nursing, and in the future, I want to work in this area. It should be very nice.” (Lynn) 我的志向，要么是想学语言或者是想做老师。护理也报了，护理当时，就是一个个 顺次填下来，就是把上中医基本上，上中医我基本上填了, 医生没有填，医生分数 线太高了，从康复开始填，然后是食品营养，一直要填到护理。当时觉得就是，可 能就是上天最好的安排，既然就让你学护理，你就好好学吧。我是一直抱着上天让 你学，你就好好学这样的一个心态。反正我就一直这么学，然后我也没想过要转别 的。那个时候因为我妈妈都跟我说了，就她说你这个职业你在国外是个什么移民专 业，你不会像其他什么工商管理那种，有的可能找不到工作。我是觉得本来是真的 想出国的，但是后来因为疫情，澳洲现在有点反华什么的，然后我想想就算了。然 后再加上这次属于是运气很好，就是被保研了，就可以直接保了上中医的研，然后 就想那就好好学。我对急危重症还真的是蛮感兴趣，就是 ICU 那方面 ，我真的还 蛮感兴趣。然后，然后我就想既然就这样子的话，以后可能会从事急危重症这方面， 以后在 ICU 组也蛮好。 (Lynn) Lynn’s decision to stay in nursing was both from herself and her parent. She believed in one’s destination, and nursing was her calling at the time of college enrollment. Yet, it seems her mother had knowledge of global nurse shortage and held a different plan for Lynn. The pandemic might only suspended Lynn from pursuing an international nursing career temporarily. However, Lynn’s story illuminated an area that many others were not aware of international nursing. As I mentioned in chapter 1, nurses’ global mobility can exacerbate nursing shortage in China (Eddins et al., 2011). At times, the pragmatism that drove parents to encourage their children to study nursing was not just about job stability but was also about leveraging opportunities when their scores did not gain them access to their ideal schools. Lily, for example, missed all the cut-off scores for her selected colleges and thus slipped (滑档) out of the admission scheme. Normally, she would have had to retake the Gao Kao the following year but in Yunnan province, she had the opportunity to make the second round of college and major selections. Her father therefore suggested she study medicine, even though nursing was not her first consideration: I wanted to study finance or accounting. But my dad said it is good to study medicine, and he said that the older doctors get, the more popular they are. It is about the experience. I 74 didn’t reject the idea. I thought it was good. Then I applied for clinical medicine. However, the admission score for that year was more than a dozen points higher than the previous year, so I didn't make it and I slipped [out of the admission process] ( 滑档). During that time, the teacher in our school notified me to reselect my majors. So, I went and made my choices. There were five choices and the fifth one was CEUTCM. I selected nursing and was admitted. (Lily) 我自己是有一点想学金融会计那些之类的，然后我爸就说学医挺好的，他说越老越 吃香。对，就是经验，然后我就说我也不排斥，我觉得也蛮好的，然后我一开始报 的不是护理，是临床医学。但是后面那一年的取分就很有问题，它高出了前一年十 几分，所以我就没有录上，就滑档了。在滑档期间，我们学校的老师还通知我去进 行一个第二次的补报志愿。我还是去填了，填了之后还就正好填到第五，总共有 5 个，填到第五就是上中医，上中医就填了一个护理, 所以就被录取了。(Lily) Like the parents of Lynn, Yanni, Lia, and Angie, Lily’s father was the one who advised her to be in medicine or healthcare. However, this phenomenon shows how little did students and their parents know or understand nursing. There was no discussion about nurses’ mission of care and healing. All decisions were made based on pragmatism. Anna was the only participant who wanted to be a nurse from the start. However, even she was not immune to parental influence. When her uncle asked her to apply for normal universities, she put one down as her first choice. Overall, Anna wanted to do something that gave her a sense of achievement. She knew she was not a top student and she did not get a high score on the Gao Kao. Anna thus selected nursing for all medical college applications: My goal was very clear: to go to a medical college because I want to do something that gives me a sense of achievement. Studying nursing was the closest I could get to my goal with the score I had. I don’t think I was very surprised [when I received admission]. In fact, you know your ranking and other students’ rankings in previous years. I actually feel it’s okay and I feel like now I have a college to go to. (Anna) 其实我一开始上医科类的大学，就是感觉自己的目标很明确，因为我想我以后想做 做一份我觉得能够给我带来成就感的工作。所以在那个时候我就觉得学护理是我能 够以我当时的分数以及和我的想法最接近的一个选择。我当时没有很意外，其实你 你知道你自己的排名，你能看到前几年同学排名什么样子，知道自己被录取其实都 没有很意外，因为其实就觉得还好，就感觉自己有学上了。(Anna) 75 Anna was the only student who wanted to pursue a career with a sense of mission. In her mind learning healthcare, helping people heal was the field for her to dedicate her life. She was very proud of the choice she made. Anna’s early belief of healthcare and nursing helped her develop a solid sense of self-concept early on. To better understand the landscape of nursing students’ intention of studying the major in CEUTCM, we can obtain a picture from Angie’s description of her first class in nursing program. Our class has 160 people. The first class we had was a lecture. Our teacher asked us how many of us chose to study nursing voluntarily. Only one person in our class raised hand. The teacher was surprised that all of us were adjusted (调剂) to nursing. And then the teacher said to us that if we are all adjusted, they (the nursing faculty) are very worried that we have a low sense of identity with the nursing profession or our passion for learning is not high. (Angie) 我们专业 160 个人，首先我们开学第一个就是讲座。我们老师当时就问，他说你们 有谁是自愿来读这个专业的，我们全班就只有一个人举手了。我们老师说你们全都 是调剂的呀...然后我们老师就跟我们说，如果调剂的话，我们就担心你们对这个专 业的认同感或者是学习激情不高。(Angie) The stories shared here indicate that participants’ experiences of Gao Kao and college admissions varied but also overlapped. Chinese Gao Kao is a competitive enterprise wherein tests scores determine students’ educational and job opportunities. Zhu (2015) described Gao Kao as “life- determining” and “only-score-based”. Every year, millions of Chinese high school graduates participate in Gao Kao, and many of them are assigned to study majors they have no interests or intention to study. However, like the nursing students in my study, most of the students have to stick to the majors and make a living after graduation. Participants’ experiences reflected how this admission process directed parents, families, and at times the students themselves to make decisions about higher education that disregarded students’ personal aspirations. Neither the students in this study nor the parents seemed to understand the field of nursing and what it entails, as their rationale for studying nursing appeared to be economic and pragmatic. 76 Efforts to Transfer Out of Nursing Of the eight participants, some (e.g., Lynn and Gina) resigned themselves to study nursing even though it was not their first choice. Others were thought about or determined to take advantage of their universities’ option to change majors after the first year. However, changing majors is not an open system and is governed by strict regulations. The biggest obstacle in this regard is the transfer quota limit. For instance, Angie wanted to transfer her major to traditional Chinese medicine. However, the major only accepted two transfers among all the candidates in the university. Angie was not permitted to change majors because she was ranked third: I made some preparations for transferring to Chinese medicine in my freshman year. I still wanted to be a doctor. I feel Chinese medicine has developed well in the past few years, and it is also our country’s tradition. During the first semester of freshman year, my thought was that I must make the transfer successfully; otherwise, I would go back and retake the exam. I participated in the transfer interview. There was a student who wanted to transfer from integrated Chinese and Western medicine to Chinese medicine. He was admitted for transfer, but not me. I then felt I had to continue studying nursing. After all, it wasn’t too bad. My mind started to change during the second semester of sophomore year. (Angie) 其实我为转中医学做了一些准备，大一刚进校，我总归还是想做医生，而且又觉得 中医药在这几年发展也不错，然后本来也是咱们中国的传统医学。我觉得是在大一 上学期的时候，我当时的念头就是我非转不可，不转我就要去复读。去转专业面试 的时候，跟我一块面试的，他是一个中西医结合的临床学生，他要去转纯中医的学 生，然后当时是录了他，然后没有录取我. 我觉得那就读护理吧, 读护理也挺好的， 所以是我觉得是在二年级下学期开始转变的吧. (Angie) As Angie’s story shows, the transfer quota limit prevented her from switching her major to the one she really wanted to study. After two years of studying, Angie accepted she would not be able to transfer majors and described this acceptance as a combination of “surrender to her destiny and fate, and a greater understanding of the nursing profession and its possibilities.” Some participants, like Yanni and even Anna, thought about transferring but did not act on the idea. Although Yanni and Anna did not try to transfer majors, they still internalized the 77 nursing profession’s lack of prestige in Chinese society. Anna, for instance, loved working with people and she did not think studying anesthesia imaging (a choice she could make) would satisfy her. In describing the amount of nursing students who considered transferring, she said, “There are about 600 students in my class. I think at least 80% or perhaps 90% [thought about transferring], and I’m not exaggerating.” Anna’s comments indicate tensions and suppressed feelings of dissatisfaction among many nursing students. Such feelings can be detrimental for college nursing students developing self-concept and professional identity let alone a sense of belonging to the nursing profession. Indeed, Chinese universities do not usually give students the freedom to transfer majors. Although students pay a portion of higher education costs, public university tuition fees are heavily subsidized by public funding (Wang, 2003; Yu & Jin, 2014). As such, public universities must comply with strict admission and enrollment quotas determined by the government’s education administration agency. As a result, students enrolled through admission adjustments (调剂) do not usually have the option of changing majors during their college years. Participants of the current study confirmed this as some tried to change majors but were ultimately prohibited from doing so. Summary In this chapter, I introduced the eight participants of my study and presented the stories they told me of how they embarked on their nursing journeys and the obstacles they tried to overcome during the first year of study. Most of the participants stumbled into nursing without any interest in or knowledge of the profession. They felt the nursing profession did not have high social status. For them, to be a nurse means eating bitterness (要吃苦), in that many students 78 tried to change their majors, but most were forced to stay due to few transfer opportunities at their universities. Unfortunately, this scenario reflects many other Chinese undergraduate nursing programs. Students are assigned to study nursing and many want to transfer out. The uncertain start for nursing students paves a bumpy road for many of them. In the next two chapters, I will build on the themes presented in previous chapters and further explore nursing students’ professional socialization experience in the context of Chinese nursing education system. Using participants stories, I will show how the hospital experiences in the American and Chinese hospitals affect the students in pursuing their nursing education and develop their professional identity, and why the current system and culture pose significant challenges in cultivating students’ professional identity and the nursing profession. 79 Chapter 5: Findings at the US Hospital: Seeing Is Believing In this chapter, I present and analyze my nursing student participants’ professional experiences at Great Lakes Hospital during their summer programs in 2018 and 2019 in the US. Their stories centered on three major areas of their experience: nursing methods for mental health, humanizing patient care, and respect for nurses and the nursing profession. The retelling of their experiences revealed some stark differences between the American and Chinese hospitals, what kind of learning happened during the time, and implications to nursing students’ professional identity. In nursing education, professional socialization (i.e., observing nurses, doctors, and their behaviors and interaction with each other, patients, and others in hospitals) is a critical component of students’ professional identity development in the interaction sphere (Arreciado Marañón & Isla Pera, 2015; Cohen, 1981; Ewertsson, Bagga-Gupta, & Blomberg, 2017; Price, 2009; Strong, 1989; Zarshena et al., 2014). At the time of this study, participants’ nursing curriculum implemented early professional activities and hospital observations starting in the first year of the program. All of the participants opted to take financial support from their universities to study abroad in the US for eight weeks. The three weeks they spent doing observations at Great Lakes Hospital was a key part of the trip, as it gave the students new perspectives on nursing in taking care of patients’ mental health, humanity in patient care, and how nurses and nursing profession are respected. These three aspects are closely related to nursing students’ professional socialization and help shaping their sense of nursing identity through knowledge learning, nursing practices, nurse behavior, and behavior of other medical staff. 80 Although the nursing curriculum in higher education in China was developed from that of western nursing (Wong & Zhao, 2012; Yan et al., 2014), the students noticed many key facets of the US healthcare system that differed from what they were familiar with. Encountering these differences caused them to reflect in ways that generated new knowledge on what nursing and care looked like and what it meant for them in the future. Consequently, the Chinese nursing students would find nursing professional identity contains multiple facets of characteristic, norms, and values than they knew before. Great Lakes Hospital is a tertiary hospital with 310 acute care beds. It is home to cardiac programs, state-of-the-art clinical centers for oncology, women’s and children’s health, medical/surgical units, and a full-service pharmacy. The Chinese nursing students were divided into pairs and rotated among the following departments: Same Day Surgery, PACU/Recovery, Surgery, Cath Lab, Emergency, Labor & Delivery, Oncology, Step Down, Critical Care, Cardiac, Med/Surgery, Pediatrics, and Stroke. While the students all cycled through the same units, their experiences differed in accordance with the shifting, fast-paced nature of the work environment in terms of which doctors, nurses, and patients they met with and their observations of how healthcare activities were carried out at Great Lakes Hospital. Why This Program? Participants’ reasons for participating in the program were generally similar. Some, like Hong, wanted to gain a better understanding of US nursing. In 2018, she remarked, “It is really about curiosity. I came because I’m curious about nursing in the US.” Others who went in 2018, like Angie, also desired professional development in America: I want to see what America is like, just like I left Sichuan for HP city. I haven’t seen the outside world. I have heard other people say things but seeing is believing. By seeing it, I can learn how others develop and what I can do when I go back. My thought was at least 81 I would improve my English language skills if I didn’t obtain any professional development [in nursing]. (Angie) 就还是想看看美国是怎么样的，就是跟我当时出四川去上海是一样的，就是没看过 外面是怎么样的，我觉得听别人说,我还是眼见为实吧。还是看了之后才会知道别 人是怎么发展的，别人在做什么，我回去之后对我能做什么。起码就是我当时的思 想就是如果我那个专业就是不能提升，我英语总能提升一点吧。(Angie) Here, Angie describes the importance of seeing nursing processes up close as an effective means of learning and adds practicing English as another benefit of the program. Other participants shared this sentiment as well. In addition to hands-on experience at a hospital and the experience of traveling and working abroad, participants also indicated an interest in studying the differences between American and Chinese medical environments. For example, Lily, who participated in the program in 2019, said, “I want to see the outside world, the American education environment, how nurses and nurse educators work, and the differences from those in China.” Lia was similarly motivated: I want to find out what is the difference between us and the outside world. Everyone says the outside world has freedom. Why is it better? We don’t have freedom in our country, so I want to go and see. The other thing is nurses do not have high social status in China, but American nurses have high social status. I think going abroad is a rare opportunity for me. There won’t be such a chance going abroad to see the difference and learn after graduation. Also, my English is poor, and I want to improve it in a native environment. (Lia) 就是想去看一下国外跟我们国内到底有什么不一样,因为大家都说国外很自由，为 什么很好？国内是不自由的，就想去看一看。其次还有就是说什么我们国内护士地 位不是很低嘛，国外护士地位高。然后自己就觉得出国也是一个很难得的机会,可 能工作了很少会有机会出去看看不一样的东西，然后学习不一样的东西。也还有另 一个方面就是自己英语很差，然后也想着去国外环境熏陶一下。(Lia) Here, she explained that, in addition to wanting to experience America and improve her English, she also wanted to see what a healthcare system looked like wherein the nursing profession was culturally valued. Even though she hadn’t visited the US before, she had the impression of 82 American nurses’ higher social status than that of China and wanted to see how it looked like. For Lia and other Chinese nursing students, American hospitals present a very different model representing advanced technology and better healthcare system. Study abroad was keen for them to find out the nursing differences between China and the US. However, they did not have concrete knowledge about American nurses and the nursing profession although the Chinese nursing students showed a strong mindfulness of social status of nurses. Nursing Methods for Mental Health During our interviews, some participants relayed being impressed with nursing techniques and methods they do not have in China, particularly those centered on mental health, like therapy programs in drawing, meditation, and music. For instance, one nursing professor taught the students about meditation in nursing as a method for helping patients relax. She showed students how to apply essential oils to each other’s hands and forearms, and how to massage in and take deep breaths of the soothing aromas. As this type of therapy can calm people mentally and physically, it can aid in disease treatment and recovery. Gina recalled drawing during the class and said, “the most impressive [thing about the] class was we sat together and drew on stones as part of the meditation process. I then did some research and felt this method was fascinating.” These simple techniques opened Chinese students’ eyes while their initial focus on American nursing was high technology and advanced equipment. In addition, students witnessed how music can be used to improve mood and mental health. For instance, in her observation reflection, Lia described: In the afternoon, they have music therapy sessions for in-patients. There were violin and cello players. I was very impressed that a patient was very excited and emotional that afternoon at the ward. Once the music started, I saw the patient change from talking excitedly to being quiet and peaceful and finally smiling. It was a dramatic transition. I thought their nursing was indeed more comprehensive. Unfortunately, we don’t have enough personnel in China. Our nursing could be better if we had the same. (Lia) 83 每天下午有音乐治疗，有风琴啊，大提琴，小提琴。我记得印象很深刻的就是有一 个病人，当天下午情绪很激动风琴啊，大提琴，小提琴。我记得印象很深刻的就是 有一个病人，当天下午情绪很激动，然后当天正好有音乐治疗，我们就进去看了。 看的时候，发现在演奏的过程中，这个病人的情绪，就是从刚开始的激动，慢慢他 不说话了，到后来他就变得很平和，并且脸上还露出了笑容。就是整个的一个情绪 转变会很大。国外就是很全面。我们这边就是人手，国内人数就是不够，没办法做 到这些，我觉得如果做到这些的话，可能护理就会更好。(Lia) As Lia’s story shows, observing this part of nursing practice in the US caused her to reflect on elements that may be missing from Chinese nursing. Music therapy has had a wide application in various clinical settings in the US, including pediatric care (Bradt, 2013; Loewy, Stewart, Dassler, Telsey, & Homel, 2013), for people with dementia in long-term care facilities (Amano, Hooley, Strong, & Inoue, 2022), and in hospice and palliative care for pain management (Groen, 2007). Research has shown it has a positive intervention effect in treating depressive symptoms among elder adults (Werner, Wosch, & Gold, 2017). Thus, through this opportunity to study abroad, the Chinese nursing students in this study engaged techniques for more effectively attending to patients’ mental health that they would not have learned otherwise. This reflection presented new areas of nursing professional identity expanding the Chinese students’ perceptions of care and pointing to more professional and career trajectories in nursing. Humanitarian Care in Nursing In mapping and comparing the curriculum and pedagogies between China and the US, Li, Zhang, and Ma (2005) have highlighted how the lack of humanization in Chinese undergraduate nursing curricula was limiting and had hampered students’ development in terms of personality and abilities. However, there was a lack of discussion of what training or courses entailed to improve humanities in Chinese nursing education. Another study on the effect of humanizing medicine for Chinese medical students in a short-term study abroad program confirmed the program strengthened students’ uptake of patient-centered concepts, improved students’ 84 communication skills with patients, and deepened their understandings of medical science, medical ethics, and healthcare laws and regulations (Du, Zhang, & Sun, 2019). Yet, the question remains: How can nursing be humanized as a practice? As the following participant stories demonstrate, some Chinese students witnessed cases in the Great Lakes Hospital that exemplified intentional humanization of care in the delivery room, the hospital’s general services, and palliative care settings. The student participants were surprised to find they were permitted to be in the delivery room. There, they not only witnessed birth, but also nursing practices they felt were more human centered than those they were used to. For example, after being present for a stillbirth, Lily said: I was more impressed by the obstetrics and gynecology department, where they prepared clothes for those little babies who were stillborn. There were also some bamboo baskets (for the stillborn babies). I really think it is particularly humane. I don’t think they have paid attention to this in China. Right, I never expected to have such things in this area. I think it is really a special, thoughtful, humane thing they have considered. (Lily) 我印象比较深的还有在妇产科，他们有专门给刚出生就夭折的那些小婴儿会准备一 些寿衣。就是小婴儿的寿衣。还有一些竹篮什么的，我就觉得特别的人性化，现在 在国内我觉得是没有关注到这个点的。对,觉得我都没想到还能有这个方面的这样 一些东西，我就觉得真的是他们考虑的特别的全面，特别的人性化。(Lily) In students’ mind, hospitals only pay attention to save people’s life. In busy Chinese hospitals, there is no energy and resource for the dead. However, taking care the dead shows respect to life and to relevant patients. It also comforts those who are still alive and gives them hope. If more nursing students experience and learn about this, they may bring more kindness practice in their work. In addition to the delivery room, end-of-life care was also a revelation for participants in terms of human centered care. The following story affected Hong so deeply, she shared that she was still processing it with her peers in China: 85 A patient was living on a ventilator. After the patient’s family decided to euthanize him, they removed his ventilator and injected him with a large amount of morphine. We were all there, watching the nurse unplug the patient’s ventilator, leaving only the infusion tube (IV) and urinary catheter. Then, for about half an hour, his heart rate slowly dropped to near zero. While nurses and family members touching and stroking the patient, the family members shared what the patient liked during his lifetime and the memorable experiences they had together. When the medical process was over, our medical staff moved out of the room, giving the family and the patient space. After a period of time, the family came out with tears in their eyes. We went in for cadaver care. That was my first time giving care to a body, the only time. I was deeply touched. That patient, his body was warmer than my hand. (Hong) 当时有个患者是靠呼吸机生活的，经过患者家属和医生护士的决策之后,决定给他 安乐死,就把他的呼吸机给拔了，然后给他注射大量吗啡。那个场景我们都在, 看 着护士把他的呼吸机拔了，只保留输液管以及导尿管，就给他注射大量吗啡。然后 差不多半小时左右，他的心率就慢慢的降到接近死亡。那个时候我们大家我能看 到, 护士以及家属们在不停的抚摸那个患者，是让他慢慢的安稳的走，在抚摸当 中,家属很自然的去分享这个患者生前喜欢的东西, 以及他们美好的经历。当这个 过程结束之后，我们所有的医务人员都退出来, 退出来之后，让家属以及那个患者 待了一段时间，当家属含着点眼泪出来的时候，我们就进去做尸体护理，那个是我 第一次去做尸体护理。唯一的一次，印象很深刻，当时那个病人，那个已经逝去的 患者，他的身体比我的手还热呢。(Hong) It was a peaceful and touching process for Chinese students to observe and share. It carries profound meanings and challenges traditional Chinese attitude toward death, choice for living, and quality of life. For nurses, their job includes helping patients and families taking care the ultimate inevitable result of diseases, death. This is perhaps a new area for nursing students to socialize themselves when they develop their professional identity. Hong further reflected on the cultural differences between the US and China in the field of nursing: Even though this is a normal procedure, I can tell the difference of humanity between Chinese and American culture, between China and the West. In China, euthanasia and its feasibility are still being debated. But when I was a trainee in the US, I experienced it. I have a warm feeling of this incident. I really feel good about it. Also, there was a special institution called “hospice” at the hospital, I have not seen it before in China. It makes me think the US handles death more humanely than in China. China is working hard to explore and develop [the possibilities of palliative care], but in practice, I think they still have a long way to go. (Hong) 86 这只是一个小过程，但是从中我还是能感觉到中西方，中国和美国人文精神的不一 样。像中国到现在都还在争论安乐死，以及可行性。但是当我在那里见习的时候， 已经经历了这样的一个场景，而且是一个让人觉得很温馨的场景，我觉得是很不错 的，包括我在那个医院见习的时候，看到有专门一个机构 hospice。在中国我好像 没见过，让我觉得美国在这方面，就是死亡上面的人文关怀做的可能比中国要到 位，中国现在也是在很努力的去探索发展，但是在实践上面我觉得还是要去多做努 力的。(Hong) Chinese hospitals are supposed to commit to save lives only if the patients can afford the cost. Sometimes, the motivation of saving loved ones drives families bankrupt and causes greater harm. Palliative care is a new concept to Chinese society. As Hong mentioned, it takes time for the society to accept and establish a system providing the much-needed care as Chinese population is aging rapidly (Zhang, 2017). Finally, the participants of this study also shared stories of their experiences with social work, particularly in terms of its role in patients’ post-hospital care. This, too, helped expand their conceptions of how to conduct out-patient, human centered care. Angie explained: There is also a teacher (staff) doing social work. The teacher who does this job specializes in helping patients with poor family conditions. After the patients return home, for example, some may need oxygen therapy machines or wheelchairs. This teacher finds these things for them in other institutions and organizations. He/she would also contact those patients who have suicidal tendencies and are unwilling to come to the hospital. Because of this, I think this job is very important and meaningful. (Angie) 还有一个叫 social work 的老师，做这个工作的老师就是专门帮助一些家庭条件不 是很好的病人，他们回去之后，比如说需要氧疗机的，需要轮椅的。这个老师就在 社会的一些机构和组织中去给他们寻找这些需要的东西。然后那些有自杀倾向不愿 意来住院的病人，他就会跟他们联系，反正就是从事一些社会性的工作。我觉得这 个工作是很有意义的。(Angie) Social work is not a new concept in China. It has a nature of volunteerism. Medical social work imbedded in hospitals was introduced to Chinese hospitals in 2016. However, a national research (Chen et al., 2019) found that the work is irregular, staff are not professionally trained, 87 and service is limited among various hospitals in China. It seems Angie was not aware of medical social work indicating her hospital may not offer this service to patients. Respect for Nurses and the Nursing Profession A key experience for the Chinese student participants was how doctors and nurses treated them with respect. Some felt it differed greatly from their experiences in China. For instance, Gina explained: “I think what makes me happiest is the teachers (doctors and nurses). They basically come to talk to us whenever they have time. If you don’t understand, you can ask them, and they will answer your questions at any time. They are also excited to have us here.” For Gina, this was especially notable because, in China, hospitals are usually very busy, especially in big cities. Nursing students thus do not often get to talk to doctors or even other nurses. Notably, several participants of this study mentioned they had not had the opportunity to speak with any doctors during their observation experiences in China. Moreover, as Angie pointed out, hospital staff in China are reluctant to allow nursing students in operating rooms or require the students to stand far away from the operation table. At Great Lakes Hospital, however, not only was Angie permitted to enter the operation room, but a doctor directly invited her to come closer to the operating table so she could get a better view. Overall, Angie was impressed by the working relationships and atmosphere in the operating room. She described this setting in detail: I observed four operations that day. In the operating room, I feel they had a clear division of responsibilities. There was an anesthesiologist and a nursing anesthesiologist, both monitored the patient’s vital signs. There were also two nursing assistants; one helps the doctor use the equipment and the other sits on the opposite side of the operating table to observe the operation process and then adjusts the room to the appropriate temperature, humidity, and light. The chief surgeon usually left after the operation and the remaining two assistant surgeons helped with sutures. I think their working relationships are very harmonious. I feel that they are colleagues, not superiors and subordinates, because they don’t do things like calling the nurse to do things. Although 88 they didn’t speak much, there was a very harmonious atmosphere in the room. They all worked together to help the patient transfer and wiped the entire room together. (Angie) 我那天就看到 4 台手术，我觉得在手术室呢就是感觉他们分工很明确，就是一个麻 醉师和一个护理专业的麻醉治疗师，他们两个人在病人头部给他们监测生命体征这 些东西。然后两个护理助手，一个是就是帮助医生用器械, 然后对面还有一个就是 坐在那个医生手术台对面是整体观测整个手术流程，然后调整适宜的温度, 湿度和 光亮啊。然后就是有一个主刀医生，然后可能有两个副主刀。那主刀医生一般做完 手术就走了，然后剩下两个副主刀医生就帮他们缝线. 我觉得整个相处是很和谐 的，我感觉他们是同事的关系，不是上下级，不是说那个医生说叫那个护士,唉你 把这个给我, 他们给我的感觉就是他们虽然没怎么说话，但是就是有一种很和谐的 氛围在里面，他们都在一块帮忙病人转运,帮忙擦拭整个用过的房间。(Angie) Here, Angie pointed two major differences from a nursing student’s perspective: American doctors care about a nursing student’s learning experience and American medical staff work as a team. Yanni echoed this by framing it in terms of mutual respect among hospital staff: I think most of us are very busy at work in China and the nurse teachers are kind of just completing tasks [by taking us through the different departments]. But nurse teachers in the United States are very serious. They introduce us to every patient and tell them we are interns. Even if we come for a half-day observation, they still introduced us to everyone. However, they (nurse teachers) do not do this in China. The teachers just tell you what you are going to do. When you first come to a department, there will be no introductions. She (the nurse teacher) won’t introduce you to her colleagues, doctors, or patients. You just go there, and after a few days, you become familiar with people and they get to know your name. (Yanni) 我觉得大多数我们在国内可能还是工作比较忙，然后老师也是有点完成任务的那 种，然后也不是说特别的像美国那边的老师会很认真，他们会把我们介绍给每一个 病人，或者我们是实习生什么的，我们即使是中午过来见习，他们也要跟大家介绍 一下，但是在国内不会的，老师就会说你去干个什么，就是一进来也不会有这种介 绍，不会把你介绍给他的同事，也不会把你介绍给他的医生，也不会介绍给病人， 反正就是来了，然后过两天你自己就混了脸熟了。老师大概也知道你叫什么名字 了。(Yanni) In Yanni’s case, she was treated like an outsider, as if she was not a member of the hospital staff. What kind of learning environment could this provide to nursing students? Unprofessional is on the surface, deep down the students were left with feelings of isolation, marginalization, and 89 helplessness. The disrespect was not only toward the student interns, but also toward peer nurses and patients. According to the stories participants shared during our interviews, there appears to be a stark comparison in how nursing students were treated in the American hospital and the Chinese hospitals. At Great Lakes Hospital in America, the Chinese students were treated as professionals by nurses and doctors, who seemed to want the students to learn, even though they were aware the students were only visiting for a short time. However, in Chinese hospitals, the students’ stories suggested that, besides students’ nurse educators, doctors and other nurses do not pay much attention to student interns. In this way, participant stories highlighted how American nursing education seemed more human centered and a respected profession than it did in their home country. The Chinese nursing students felt happiness in a respectful working environment which is positive in nursing identity development. Reflections on American Hospital Experiences In reflecting on their time at Great Lakes Hospital, the Chinese nursing students of this study specifically underscored the experiences they had that were meaningful to their understanding of identity in the field of nursing. Some were so affected that they were inspired to pursue advanced nursing studies. Below, I share how, through their reflections, participants identified notable features of both countries’ medical systems that both enabled and hindered certain practices in nursing education and hospital practices. Their experiences added nuanced layers to their socialization as they develop self-concept and identity in nursing. Why Nursing is Respected in American Hospitals? As demonstrated in this chapter, the participants felt nurses had low social status in China. This has been confirmed by a study on Chinese patients’ perceptions of physicians’ and 90 nurses’ social statuses that found most patients believed nurses had a lower social status than doctors in terms of economic treatment, professional authority, and knowledge (Feng et al., 2017). Although nursing in America still suffers from inadequate recognition and public misperceptions of healthcare (Baer, 2009), American nurses have been found to enjoy a higher social status with more compatible incomes, distinctive training requirements, and professional development trajectories than Chinese nurses (Jisiden, 2021). Lily, for instance, discussed how nurses in American hospitals had special responsibilities and could work independently: I think that, in foreign hospitals (American hospitals), the nurses are very independent. They do some related operations for the patients and don’t need to go through the doctor all the time. So, I think they are more independent and can use the knowledge and skills they have learned to provide care to patients. They take initiative. Of course, also because of the nurse-patient ratio. There are fewer patients (in American hospitals), so you have more energy to focus on patients. Also, everyone has a mobile computer. I think these mobile devices greatly reduces nurses’ time in taking notes, which allows them to better take care of their patients. Although hospitals in China use computers, like in HP city, we have PDAs but only in some departments in certain hospitals, and not every nurse has one. (Lily) 我是觉得国外的医院的话，那种各司其职，护士自己也是很独立的，会去给病人做 一些相关的操作什么的，是不需要经过有医嘱什么之类的那些。所以我觉得他们更 加的独立，更加的能用到自己学到的一些知识，去给病人提供护理这样子。主动性 会更强一些。当然也是因为就是护患比嘛。人比较少的原因，你有更多的精力去放 在那个病人的身上。还有是因为他们医院普遍都是在用，每个人都是一个小电脑， 电脑推着走，我就觉得很大程度上减少了你的一个文书书写的工作，就是解放了护 士，那么他才能更好的去关心这个病人，有更多的精力去关心病人这样子。在国内 虽然有医院已经...像在上海，比如说我们有了 PDA 还有一些个别的医院，他们这 些也是有些科室是会有电脑，但不是人手一个。(Lily) Like Lily shares here, scholarship suggests the patient-nurse ratio is a key factor of nurses’ burnout and drives them to leave their profession (Chen et al., 2019; Yang & Hao, 2018). I mention this here because this topic appeared in every participant’s narrative when they discussed the disadvantages of working in a Chinese hospital. Although burnout on nursing 91 students’ professional identity development is unclear and remains under-researched (Wang, et al., 2019), it surely isn’t an appealing characteristic of the nursing profession. Specialized Job Responsibilities Some participants in this dissertation study assessed the social value of the nursing professions in China and America in terms of specialized education and job responsibilities. For instance, Angie felt the American nurses she encountered had a higher level of education (i.e., a bachelor’s degree or higher) than nurses in China and many are nurse specialists. For example, Angie explained: I feel American nursing training is more specialized and systematic. Nurses who take care of patients practice their specializations. If the patient needs oxygen, there is a dedicated oxygen therapist. If the patient needs to recover, a rehabilitation therapist helps teach them how to walk and go to the toilet. If you need ultrasound technology, there is a nurse/staff specialist who helps you perform ultrasounds. In China, a nurse takes care of many things for a patient. I do oxygen inhalation, the injections, and helps the patient get up and walk. I don’t think there are clear nursing responsibilities [like in America]. It is not specific; one nurse does everything and the workload is very heavy. When workers share the workload through different specializations, everyone can perform their duties and the workload will not be that big, right? Now, though, nurses in China feel tired and the wages are low. (Angie) 就是我感觉美国的护士是更专科的和更系统的，就那些管病人的护士，他就是做他 自己的事情，如果这个病人需要吸氧啊，会有专门的氧疗治疗师过来. 如果这个病 人需要康复, 又会专门康复治疗师过来，就是帮助他怎么走路, 怎么去上厕所。如 果你又需要一些什么超声技术，又会有专门的超声技术的治疗师过来，就提个超声 仪器来帮助你在超声下进行穿刺。就是我感觉分工是很明确的，而且真的就是很专 科的。那么在中国的话，你病人的所有需要是你在做，他的吸氧也是我去做，打针 也是我去做，他要起床行走了也是我去做。我觉得还是专科分类不全,还是什么都 在做，然后就是工作量也很大。如果你真的建立了起这种不同的岗位的话，我就觉 得那么首先你的专业能力就体现出来了,工作量就不会那么大了，对吧？现在大家 会觉得又累，工资又那么低。(Angie) Here, Angie considers the specializations within the field of nursing in America and connects it to economic status. Angie’s impression is correct. According to Buerhaus et al. (2017), in 2015, 38% of registered nurses in US nurse workforce had a bachelor’s degree and 15% had graduate 92 degrees, while in China, only 15% of registered nurses had undergraduate or post graduate education (Jiang & Han, 2019). Indeed, economic status is a crucial indicator of subjective social status (Singh-Manoux et al., 2003). Yang and Hao (2018) found that a nurse’s average monthly income was $315 at an affiliated hospital of Suzhou University in the Jiangsu province. Consequently, the hospital lost most of its nurses with bachelor’s degrees. This is somewhat surprising given Jiangsu province is one of the most developed provinces in China with the second highest GDP (Jiangsu Government, 2019). However, in China, this phenomenon is not unique to Jiangsu. This has been evidenced by the Chinese government’s 2016-2020 nursing development plan (National Health Commission of the People’s Republic of China, 2016) which stipulated one of its goals was to improve nurses’ benefits and salaries. Summary In this chapter, I presented the Chinese nursing student participants’ narratives about their experiences at Great Lakes Hospital. Their experiences of an American hospital at times led them to compare them with their experiences in Chinese hospitals. Through these comparisons, they were able to make sense of their experiences in both the US and in China. In particular, their observations of the American Great Lakes Hospital were enlightening and gave them new perspectives on nursing and what human centered care can look like. They specifically spoke on three major areas of their experience: nursing methods for mental health, humanizing patient care, and respect for nurses and the nursing profession. The experiences in American Great Lakes Hospital socialized the Chinese nursing students beyond advanced nursing technology as they expected before coming to the US. Rather, this professional socialization taught them new nursing identity: holistic care, humanity, teamwork, and respect to 93 all. In the next chapter, I will bring participants’ narratives of their experiences in the Chinese hospitals and shed lights on nuanced and mixed pictures of their professional socialization processes and implications to their professional identity development. 94 Chapter 6: Findings: Experience in Chinese Hospitals and Beyond In Chapter 5, I presented the findings of the Chinese nursing student participants’ experiences in Great Lakes Hospital in the US during the summers of 2018 and 2019. In this chapter, I present participants’ stories about their experiences in Chinese hospitals. Critical to students’ professional socialization, immersive hospital observations and clinical experiences sallow students to learn professional behavior and nursing techniques in real healthcare settings (Cohen, 1981; Ewertsson, Bagga-Gupta, & Blomberg, 2017; Price, 2009; Strong, 1989; Zarshenas, Sharif, Molazem, Khayyer, Zare, & Ebadi, 2014). Hospital experience is a crucial part of nursing education, professional socialization, and identity develop in the interactional sphere of Cohen’s (1981) nursing education model. However, scholarship of global nursing education and research have indicated a mixed picture of this process, which is not always smooth, positive, and ideal for nursing students and negative hospital experiences undermine nursing students’ professional identity development (Browne, et al., 2018; Cantey, 2012; Condon & Sharts-Hopko, 2010; Coram, 2016; Lee & Yang, 2019; Howkins & Ewens, 1998; Price, 2008; Thomas, et al., 2015; Zarshenas, et al., 2014). Many elements affect nursing students’ professional socialization outcomes and their professional self-concepts as nurses. The Chinese bachelor’s degree requires students to begin visiting hospitals during their first year of study to gain exposure to nursing. For the participants of this study, the length of their hospital experience began with a two-week observation period in the first year, followed by a four-week period in the second year, and then an eight-week period during the third year. Students’ focus at the hospitals is mainly to observe healthcare practices. In their senior year, students do a nine to ten months clinical internship at various tertiary hospitals. 95 Overall, the findings in this chapter show students’ hospital experiences varied significantly across hospitals. They indicate that the nurse educators, doctors, patients, and the overall working environments affected students’ experiences, thought processes, behaviors, and sense of identity as nurses (Cohen, 1981; Ewertsson, et al., 2017; Price, 2009; Strong, 1989; Zarshenas et al., 2014). In the following sections, I analyze their stories according to five overarching themes in the data: 1) interns’ daily routines, physical challenges, and irregular learning in hospitals, 2) hospital learning environments, 3) interactions with nurses and patients, 4) forming professional identity and self-concept, and 5) leadership’s understanding, trust, and treatment of nurses. I conclude by revisiting these themes to exemplify how they contributed to an uncertain sense of professional identity among the nursing students. Daily Routines, Physical Challenges, and Irregular Learning in Hospitals Although student interns usually follow routine schedules during their internships, protocols can differ among hospitals in terms of what practices and procedures nurse interns can participate in. This resulted in varying experiences across study participants. They said, in general, the nurse interns usually cycled through four to five departments in inpatient and outpatient sectors, including general surgery, gastroenterology, emergency, mental health, cardiology, OBGYN, Pediatrics, ICU, Chinese medicine, stomatology, community medicine, and others. Student interns usually followed regular routines. They typically worked together with a nurse educator supervisor. For morning shifts, they often arrived at the hospital at 8am and began their shifts by observing morning rounds with doctors and nurses. Afterward, they prepared IVs, checked patients’ vitals, and replaced patients’ saline bottles. They then took a short lunch break. Upon returning, they went through IV replacement and other care procedures, such as mouth care, catheterization, etc. The final part of their daily routines was attending to patients on rounds 96 before the next shift arrived. It is worth noting here that, in China, nurses work in eight-hour shifts and they usually take care of about 12 patients. According to Chinese nursing education regulations, student interns are prohibited from performing any invasive procedures independently, such as intramuscular and intravenous injections. Nurse interns can, however, perform these procedures with a nurse educator’s supervision. One thing participants’ stories revealed about their daily routines was that they were usually asked to do more than just the “routine” work described above. For example, they were often asked to fetch prescription medications for patients, and some were asked to do bedding replacement (changing sheets) daily, a job normally assigned to nurse assistants. The work of changing sheets became so tedious in addition to their other duties that some student interns struggled with significant fatigue. One nursing student who quitted nursing specifically talked about how the daily duty of changing sheets made her determined to leave the profession. Hong, for instance, said: A day’s work may seem insignificant, but there are many other factors in it. Mainly I’m tired, really tired, because you may not be able to sit at all during the day. After all, we are nursing students. When the teachers are sitting, and if there are chairs, we might squeeze [in] and share. But you know the hospital environment in China, sometimes it’s more a matter of space that we don’t have a place to sit. We all stand. This is a pressure for me, because I am tired and need some time to relax, but there is none. On the one hand, it is due to the space limit and on the other hand, it is due to our identity. Sometimes, even if there was a chair, I didn’t dare to sit when the teacher was there. (Hong) 一天的工作内容好像就是这这么点儿，但是那其中又掺杂着很多因素，主要是累， 真的累，因为就是一天下来可能坐不到凳子的, 而且毕竟我们是护生，当老师们在 坐的时候，我们是，如果有凳子，也许我们会挤一挤去坐一下，但是医院环境老师 您可能也比较知道，就是有时候是比较狭小的一个空间，可能我们都没有地方坐， 都是站着的, 这个对于我来说是一个压力，因为本来就挺累的，需要给我们一定的 放松时间，但是没有。我要的放松时间，只是坐下来稍微坐一下，我都觉得很可 以，但是这个在很多的科室里面是很难做到的，一方面是碍于空间，一方面是碍于 我们的身份。也许有时候就算有座位了，老师在那我也不敢坐。(Hong) 97 Here, Hong describes how her daily work as an intern became physically exhausting. To her, there was no way to relieve this exhaustion by sitting down and taking a break due to a lack of space in the hospitals to do so as well as social hierarchy. Angie’s intern experience only lasted six months due to the COVID-19 outbreak. Yet, her experiences were not short of tasks, especially in the gastroenterological surgery and pediatric bone marrow transplant units. She felt the resources in these areas were not sufficient to provide treatment to many patients. In her hospital, four to five patients shared one room and patients usually had to be settled in the hallways. At times, she was the only nurse intern in the ward. She said “Sometimes, when I [had] to work alone, I had to walk more than 20,000 steps a day. One day, I just couldn’t bend down and I had to visit the emergency room at night and get acupuncture, and then I got better.” Angie’s story illustrates that the lack of resources at her hospital not only negatively impacted patients, but also nurses’ mental and physical well-being. Angie’s and Hong’s experiences indicate that the hospitals were full of patients, did not always accommodate nurses’ physical well-being and used the student nurses for labor beyond the scope of their internships. Burnout is a common problem for nursing students and staff in hospitals. Research has shown academic burnout takes a toll on students’ emotional and physical health in ways that align with Hong and Angie’s stories. Burnout is a major factor affecting Chinese nurses’ job satisfaction, occupational stress, and departure from the nursing profession (Chen et al., 2019; Chen & Fang, 2016; Liu et al., 2018; Sun et al., 2019; Wu et al., 2007; Zhang et al., 2021). In addition to burnout, participants had to navigate a challenging evaluation process for their internships. On one hand, to pass, they were required to complete particular training activities. On the other hand, their stories revealed that some hospitals did not always follow the 98 training curriculum. Regardless, the hospitals still signed off on students’ evaluations, which poses serious questions regarding the quality of hospital training and how college nursing programs track students’ internship outcomes. Moreover, some interns had to grapple with significant limitations and regulations on what they could do at the hospitals that limited their learning and professionalization. During Lia’s internship in 2019, for example, a serious incident had occurred among the previous student interns, so the hospital only permitted the interns in Lia’s cohort to do less-skilled work, help draw blood, and replace saline bottles in their technique training. Lily similarly struggled with these curtailed duties. She described her hospital as different from other public ones because it was designated to provide health care services to elite government employees, many of whom were retirees. As such, she and her teacher only cared fewer patients than in other hospitals. She described feeling like “I really couldn’t learn anything. I was wasting time there every day, and I had to get up early and commute for an hour on the road.” She felt her nurse teacher did not give her and the other students opportunities to practice technical skills either like IV injections, as she was only allowed to practice it once and other students didn’t even get one chance to do so. Although she had a helpful nurse teacher in General Surgery, her overall summary of the internship was: “I felt that it didn’t stir any feelings in my heart. I felt numb. I didn’t [get to] think much.” Her internship was then cut short by the COVID-19 outbreak and she wasn’t able to gain experience in other departments. One participant’s story who differed from the rest was Lynn’s, who was a student intern at the time of my study and moving on to graduate studies the following year. Like the others, Lynn described having to navigate a lack of resources at her hospital, but notably, she reflected on these experiences by using them to inform her plan for her future nursing career: 99 As far as the clinic is concerned, I firmly told myself I must never be a nurse in the general ward in the future. Many departments have general wards, such as surgery, gastrointestinal surgery, and endocrinology; I call these general wards. I found out that working in general wards is really tiring. For example, I found out that you have to deal with different people in these wards (patients and their families). Some are very difficult and every day, your work is already very busy and then you have to deal with interpersonal communications. You will feel really tired and be very busy. (Lynn) 以临床上面来讲，我是坚定的告诉自己，以后千万不要做病房里的护士，很多科室 都会有普通病房，比如说什么外科，什么胃肠外科啊，什么内分泌，就这种我都称 为普通的病房。在普通病房里面，我发现了，你要跟不同的人打交道，然后不同的 人，就是你会发现有一些很刁钻的病人，每天你的工作已经很忙了,你还要去对付 一些人际的交道，你会觉得真的很疲惫，然后而且很忙。（Lynn） Here, Lynn describes the difficulty of working in what she calls “general wards” and having to engage interpersonally with patients and their families in addition to working in a crowded, under-resourced medical environment. She further explained that in general wards, a nurse usually takes care of 12 patients. She later expanded on this by identifying a particular unit that she planned to strive to work in: I worked in the ICU for three weeks. ICU only takes care of patients; it does not deal with family members. This work really makes me feel great in my heart. There is no doctor-patient communication (医患关系) in the ICU because usually patients are in a coma or other serious conditions. From the perspective of actual workload, you only need to be responsible for three patients. (Lynn) 我中间有去 ICU 三个礼拜。ICU 它不会和家属打交道，这件事情就真的让我心里 非常有好感度。不用和家属打交道，医患沟通就没有了，ICU 里面都是昏迷和比较 serious 的一些病人在里面。而且从实际工作量角度上面来讲，你只需要负责三个 病人。(Lynn) Although Lynn did not specifically talk about the violence against healthcare workers in China, we both understood what she meant by not having direct contact with difficult patients and their family members. There has been a high rate of workplace violence (WPV) toward doctors, nurses, and other healthcare workers in hospitals in China at various levels (Lu et al., 2019; Tian et al., 2020; Wang et al., 2021). In some cases, doctors even lost their lives to angry family 100 members of patients. Lynn’s choice of pursuing a career as an ICU nurse is thus partially a strategy for avoiding these risks of violence. While Lynn’s reflection became the basis for where and how she wanted to work in a hospital after school, some participants became demoralized by the tedium of the tasks and how they were treated or exploited by staff and nurse teachers. Anna, for instance, noted: It felt as if the whole hospital couldn’t operate without the nurse interns. For example, because nursing care is a lot of work, it can be very boring and tedious. You arrive at a certain time every day [and] you have to take blood pressure and temperature, and ask about patients’ bowel movements and urine, which is usually standard procedure. Especially if you have been doing it daily for many years, you feel even more bored, so the nurse teachers would ask the intern students to do it all. Student interns can basically cover 80% of a nurse’s work at the later period of internship. If teachers/nurses want to treat students harshly, they could assign 80% of the work to students, while they only do some paperwork. (Anna) 就会觉得好像整个医院离开了护理的实习生就转不动了一样。比如说因为其实护理 很多工作，不管听上去还是做起来都是很枯燥的.你每天到了一定的时间，你就要 去测血压测体温，询问大小便这一类的情况，非常的枯燥。尤其是你如果干了很多 年之后，其实更觉得枯燥，可能老师会将这个事情全部都给实习的同学去做。尤其 是我们到了实习后期，我们所学到的和掌握的东西是可以基本上涵盖老师工作的 80%。如果说老师对你稍微狠一点，他就可以把他 80%的工作都给你做，他来做一 些文书工作。(Anna) In this story, even though Anna didn’t say she or her cohort were treated harshly, she did point out what was going on in her hospital. She went on to explain that this kind of work environment caused her to feel negatively about herself and her development of a professional identity: The university may arrange for you to intern in a hospital of poor quality. These hospitals usually hire nurses with low education degrees, like technical degrees. Those nurse educators won’t be able to teach you much. You won’t learn. What you do is tedious work every day during the internship. Working in such an environment, you feel hit, a blow to your concept of self and your professional identity. (Anna) 如果说学校给你安排的实习的医院，它很差，同时医院差的同时，它进来的一些护 士他们的水平也会比较低，都是一些专科或者是怎么样的。那种老师的话他其实并 不会教你很多，你在这个当中其实学不到什么，你每天都是干着非常枯燥的工作， 干着这种实习的工作，其实这会很打击你，很打击你的职业认同感。(Anna) 101 What Ann described here, a lack of teaching and mentoring also occurred to other participants. During the interviews many participants confirmed their professors didn’t have regular communication with them regarding their hospital experiences during the clinical internship. Hospital nurse educators usually assigned them to nurse teachers and there were no daily reviews or debrief meetings with the students. The nursing students did not have learning groups among themselves either. It seems there was not a formal assessment process at the end of internship. Here raises serious questions about the pedagogy of Chinese nursing education. On the surface, professional socialization has a significant place in curriculum starting from freshman year. However, it does not follow a pedagogy guiding the process for intended outcomes as Cohen (1981) defined in nursing students’ socialization and professional identity development involving faculty, nurse educator, and regular learning reflective activities. Interaction with Nurse Educators, Nurses, and Patients The socialization process (Cohen, 1981) of the internships took place via interactions between the novice nurses and the professionals at the hospital (i.e., nursing teachers, nurse educators, and doctors). As role models, the nursing students looked upon these professionals for support and guidance. Price (2008) has specifically pointed out that the nursing socialization process is heavily influenced by other nurses. Yet, my research data shows the participants of this study did not have many meaningful interactions with nurses and doctors in Chinese hospitals. The nurses at the hospitals instead gave nurse interns conflicting impressions. Some participants’ accounts of their experiences show discontent among the nurses and they negatively influenced the nursing students. Two particular types of interactions with nurses emerged in the students’ narratives: exemplary role models and those who were discouraging and negative. 102 Nurse Educators as Exemplary Masters of Techniques During their internships, the nursing students invested themselves in improving their nursing skills and techniques. The nurses at the hospitals who showed mastery of patient treatment techniques became the students’ role models. Some of the nurse teachers showed care toward the students’ development and growth. For example, Anna shared: In the first department of my internship, I met a teacher who was outstanding and kind. Her department is urology. She taught me some puncture techniques when she had free time [and] she taught me all about the urinary system, starting with the adrenal glands. She also pointed out to me which aspects I should pay attention to. The talks were almost like mini classes to me. She was outstanding in the department. (Anna) 在我实习的第一个科室，我遇到那个老师她很厉害，她也很好。她的科室是泌尿外 科，我进了科室之后，她除了会教我一些穿刺的技术，只要一有空的时间，她就将 泌尿系统，从肾上腺开始，全部给我讲一遍。同时还跟我讲你应该注意哪些方面， 就相当于是小课一样，在整个科室当中是非常突出的。(Anna) Anna talked about this teacher with admiration. She said she wanted to be a nurse like this nurse teacher, a good role model for her, excellent in knowledge and skills and caring for students. But she also pointed out there aren’t many teachers like this one. Nurse teachers with graduate degrees had a particular influence on the students. For example, during her two months in the General Surgery Department, Lily described her impression of a such a nurse: “The feeling was very different with this teacher than with others. You can tell her level is higher than others. She is also very strict to us. Sometimes you feel she is fierce. But in the end, she is a really nice teacher.” Lily’s story demonstrates that nursing students are keen to learn from nurse teachers and meet high expectations. Importantly, Lily also said that it was this nurse teacher who made her feel better about the nursing profession, a profession has a healing power delivered by individual with knowledge and skills. Lily also paid specific attention to nursing techniques and ability to manage multiple medical situations in a 103 general surgery ward. In Lily’s mind, a professional nurse should have both management and technique skills. For my research participants, learning and improving their nursing technique is the primary goal during hospital observation and internship. Angie also expressed her admiration of those nurses who had special skills, especially those in the surgery department. She recognized them as nurse specialists, and they motivated her to be a specialist herself in the future. Many nurse teachers in surgery are specialists. They specialize in units such as intestinal care, nutrition management, puncture and PICC, and radiography. They can take the certificate examination in HP city because HP city is more developed (in nurse education). Then, they can carry on procedures independently. In the future, they may also open specialty clinics in intestinal care, wound care for outpatients, etc. It’s all possible. Yes, I think the surgery department had a big impact on my career goals and what I want to do in the future. For example, now I want to be a specialist nurse [like them and] have a specialized technique, such as special care for wounds or peritoneal dialysis. This is called APN in the United States, advanced practice nurse. (Angie) 外科有很多是专业的老师，专门做肠道护理的老师，专门做营养管理的老师，专门 穿刺做 PICC 的老师，还有专门和医生一起做造影的老师，他们都是自己这方面的 专家，因为 HP City 发展的比较好，他们可以出去考证，考了证之后可以单独做这 个操作，然后甚至以后发展的好，他们还可以单独开肠道， 伤口护理的门诊，都 是可以的。对，我就觉得他们这个科室对我职业生涯影响和我以后想做什么还是挺 大的，比如说我现在就想做一个专科护士，就像他们那样有一个专门的技术，比如 说专门护理伤口，或者专门做腹膜透析，这在美国就是叫 APN，高级实践护士。 (Angie) Independent nursing clinic is a new idea to Chinese nursing students. Angie was aspired to become an advanced nurse practitioner (APRN). In the US, an APRN need to earn a graduate- level nursing degree either a Master of Science or a PhD (Doctor of Nursing Practice) degree with a focus on Nurse Practitioner. However, the current Chinese nursing system only has RN, registered nurse. It will be a long way for Angie to achieve her dream. Positive professional identity development and self-concept also occurred when interns observed nurses’ special abilities and responsibilities. For instance, Lia shared that, although 104 many believe nurses only follow doctors’ orders, they actually have a key role in doublechecking doctors’ prescriptions because in many cases, doctors’ orders were incorrect. If nurses don’t check, wrong medicines get sent to patients. Gina similarly was impressed by the nurse teachers in the emergency department working at the triage station. “Those teachers can basically diagnose the problems with a few questions and triage patients to different departments,” she said. It was a skill and level of professionalism she wanted to achieve for herself. Here Lia and Gina noticed two roles that most participants missed. Nurses’ professional knowledge and skills may not directly work on patients’ care and healing in wards. There are other roles, such as helping check on prescriptions and sending patients to the right doctors having impact to patients’ safety and saving lives. Both these roles demonstrate that the nursing profession’s medical knowledge and skills are deep and comprehensive and far beyond many people’s idea that nurses can only implement doctors’ orders. As a result of these observation, Lia and Gina recognized nurses are indispensable and valuable team members of hospital successes. Discouragement from the Nurses While the nursing students looked up to their nurse educators and other nurses as role models and mentors, some encounters with nurses were not encouraging. For instance, my interviews with Lynn, Hong, and Gina revealed that some of these nurses tried to persuade them to give up nursing. Lynn shared, “All of the teachers (nurses) told me this: change your profession as early as possible. Every time we talked, they would say this to me. They would say to make the change when you are young because nursing is really exhausting. But the teachers in ICU wouldn’t say these kinds of words to me.” Gina conceptualized this phenomenon in terms of conflicting influence, explaining that there were always “two voices” from the nurses around her. 105 One voice told her nursing is a profession with a great future and much potential, that she should advance her study to the graduate level and become a specialized nurse. The other voice encouraged her to give up nursing as soon as possible and find other ways of making a living. In addition to these conflicting accounts of the profession, some nurses exhibited negative behaviors that contributed to unhealthy working environments for the students that inhibited their learning (Cantey, 2012). Of this, Yanni shared that the nurses in the East Hospital’s Orthopedic Department had negative attitudes toward interning students. These nurses only acknowledged the nursing students to ask the students to do work for them. The department nurse leader was not friendly either, such that the students often avoided encountering her if they could. After two weeks of this, the students decided they didn’t want to stay anymore and requested to transfer to another department. Yanni’s story was particularly surprising as a whole department was boycotted by the students. This is a nightmare for nursing professional socialization at multiple levels. The negative impacts are palpable both in short term and for the future. Students wasted their precious hospital time; they lost confidence to the hospital staff, and they had to endure mental and psychological stress and pressure. In the long run, this experience became a stressful memory, undermined their confidence of nursing, and made them question whether they should stay in the nursing profession. Another notable way the negative encounters between nurses and interns manifested when staff nurses discouraged interns’ study. For example, Yanni also told me that her classmate talked to the nurses at the Orthopedic Department about applying for graduate studies and received demoralizing responses: They (the nurses) were a little disdainful to you and think it makes no sense to come here to be a nurse after you get a postgraduate degree. They believe your academic qualifications don’t make a difference from senior nurses who graduated from junior colleges or technical schools. They are older and look down on you for studying or make 106 you feel that your major is already like this anyway and your hard work is useless. (Yanni) 他们都会觉得有点不屑，觉得你考了研究生出来还是来这里当护士, 没有意义。觉 得你学历提高了，你研究生跟我们这些可能是大专中专毕业的老师 （没有区 别），他们那边年龄比较大，有点瞧不上你去求学，或者觉得反正你专业都已经这 样了，你的努力也没什么用的这种感觉。(Yanni) Here, the responses from staff nurses indicate the prevalent belief and practice of social hierarchy in Chinese hospitals’ nursing ranking system. The lack of a clear professional development and promotion trajectory for nurses make nurses less motivated to continuing education and improvement, particularly those with lower education levels. Although Anna was the only student determined to study nursing initially and who expressed her love of this profession throughout this study, she too shared a story that echoed the others’ experiences of nurses’ conflicting messages to the students. She explained: In my studies and internships, I feel I have not changed my identity and love for the profession of nursing. Nothing has particularly affected me. But in the words of my clinical intern teacher, I’m still too young (to understand the hardships of nursing). Yesterday, the clinical teacher asked all the other nurses if they still loved this profession. None of them spoke and I was the only one who said yes. Then she said, child, to be honest, you are still too young. [It made me feel] that they have been in the clinic for a long time and fixed their idea of this profession as such. (Anna) 不管是在我的学习和实习当中，我觉得我好像都没有变过对护理这一职业的认同以 及热爱，没有什么特别多的事情在影响我，可能是按照我们临床实习老师，就是代 教老师的话来讲，孩子你还太年轻，她就说你就是太年轻，昨天老师还在问其他所 有老师，你们有谁是热爱这份职业的，他们都没有说话，就只有我在旁边说：不 是，我！他说,说实话，孩子,你还是太年轻，你感觉他们这种已经在临床很久的老 师把这份职业有点固定化了。(Anna) The above illustrates how discouraging the nurse teacher could be to the students. Sometimes, they were not only not helpful but further damaging the nursing profession. It seems such behavior is widespread among hospitals in China because Anna is from a different medical university in southwest of China. Anna furthermore shared Yanni’s experience regarding 107 interning at low-level hospitals, noting such hospitals tended to have more nurses with technical school training and that students wouldn’t learn much beyond going through tedious tasks every day. She said such experience would severely diminish students’ sense of belonging and professional identity. Patients’ Attitudes toward Nurses My conversations with the students indicated that they all cared deeply about what patients thought about nursing and nurses. While they were happy to hear patients’ compliments and encouraging words, all participants in the current study agreed that patients generally did not think highly of nurses or the profession. Patients believed doctors determined their well-being and saved their lives and that nurses were merely service members for doctors and that their primary functions were giving injections and medicine. Lynn commented on how deep these feelings about nurses are: Although they (patients) rely on you so much, their sense of recognition of you is not high. They think you should do everything for them. But doctors are different. The doctors are saviors to them. I think, in fact, there is the National Nurses’ Day now and in all aspects, the situation for medical/healthcare staff has been improving, including national policies. However, you will find people haven’t changed their minds about the nursing profession. It feels like no matter what you do, you can’t change it, and it feels like it’s already deeply ingrained in people’s mind. Yes, the salary of nurses is not low; everything is better than we thought. But if you go outside and ask others whether they would be willing to let their child enter the nursing profession, they still don’t want them to. It seems that it has changed a little bit in the nursing industry, but the essence has not changed. They still look down on this profession. (Lynn) 他们虽然这么依赖你，但是他们对你的认同感就是不高，就是觉得你应该为我做 的。然后但是医生就不一样，医生就是我的救命恩人。我觉得其实现在你看护士节 也有，然后各方面其实包括国家的政策，对医护人员其实也在一直在提高，但确实 你会发现，无论是现在人还是过去，人们对于护理这个行业的改变，好像从来没有 改变过，感觉好像是无论做什么就是改变不了，感觉好像已经是根深蒂固了。对， 你说现在去外面了解一圈，其实护士的工资也不低，就是什么都比我们想象中的要 好，但是你如果去问人家，愿意让你的孩子去从事护理行业吗？还是不愿意，所以 这个问题其实还挺挺奇妙的，好像看上去是对护理这个行业有点改变了，但是其实 本质还是没有变，还是看不起这个职业。(Lynn) 108 Lynn’s comment indicated that there have been improvements in the nursing profession, from nurses’ benefits to nurses’ public images. However, culture change is a different story. At the time of our interview, Lia was having similar experiences at a mental health hospital. She remarked on her experience with patients’ differing attitudes toward doctors and nurses in terms of trust: When a patient has a problem, you (the nurses) are the first to [try to] comfort them, but patients are more willing to trust the doctor and less willing to trust nurses. I feel it’s the same in every ward. Patients have a lot of thoughts they may share with the doctor as soon as the doctor asks. Many of them are reluctant to talk about their ideas with us nurses because they think we are not very useful. (Lia) 病人发生问题，你第一时间给他们做安抚，但是他们更愿意相信医生，而更不愿意 去相信你护士。这种观念到现在都很强。每个病区我其实都感觉是一样的，他们会 有很多心里的话，这些可能医生一问就问出了，我们护士好多他们都不愿意讲，因 为他们觉得你的作用不大。(Lia) Lia’s story further illustrates the mis-cultural perceptions about doctors and nurses among Chinese patients. For some, a key result of these kinds of experiences resulted in participants’ internalization of patients’ treatment and attitudes toward them and the nursing profession. After noticing the differences in how patients treated doctors and nurses on her rounds, Hong reflected: During rounds, nurses’ discussions were usually about operational matters, such as checking pressure sores and whether the pipes are open and the connections are tight, etc. I think these are relatively basic operations. But when it comes to the doctor’s rounds, I can see they are thinking more from the pathological level and what causes such diseases from the patient’s personal living habits, etc. (Hong) 护士查房他们做的更多的是操作上的东西，看会不会导致压疮，然后管道是否是 通，连接是否紧密等，让我认为是相对基础的一些操作，但是到了医生的查房，就 能看到他们更多是从病理层面上去考虑，从病人个人生活习惯看如何导致这样的疾 病等。(Hong) The differences in case discussions between doctors and nurses Hong describes above made her believe being a doctor is more valuable than being a nurse. Hong particularly pointed out that 109 many people think nurses are not highly educated and that they can only do hard labor work. What’s more, as women are more prevalent in the nursing workforce, the profession is often negatively feminized. For instance, Hong also shared a story about an episode with a patient’s family member in the emergency room that profoundly impacted her: I was in the emergency room last month and the patient could not talk anymore, so I was communicating with one family member. The family member was a man. He asked me if I was there for an internship. I said yes, and then he asked about my education qualifications. I said I am now a graduate student, and he said, “Nurses have graduate students?” He was shocked and then said it was a pity for me to go to graduate school. He said his daughter did not have a good Gao Kao score and went to a nursing undergraduate program. He said that he is so regretful and that he has been persuading his daughter to get out of the profession. He then warned me that if I wanted to have a better career, I shouldn’t carry the name of nursing. This incident was a blow to me. (Hong) 当时在实习的时候也是在抢救室，也就是上个月发生的事儿，那个时候我在实习。 在抢救室病人都不能说话了，我都是在跟家属交流。那位家属是位叔叔，就问到 我，“你们也是来实习的？”我说是的，然后他问到了我的学历，我说我现在是研 究生在读，他说“护士竟然还有研究生？”，就是特别惊讶，然后说太可惜了，怎 么会去读研究生，然后他就顺便说到了自己的女儿，她说她的女儿当时成绩没考 好，去读了一个护理的本科，他说现在黄肠子都悔青了，一直在劝，一直在想办法 让自己女儿走出这个行业，然后也告诫我，如果你要成大事，就不要背上护理的名 头，这件事对于我来说打击还挺大的。(Hong) As I mentioned earlier, my study’s participants cared about patients’ confirmation to their work, any encouragement and comment meant a lot to them. Also, nursing students’ parents’ encouragement played an important role for them to continue their study. The discouragement from a relevant parent could easily shook the ground of one’s belief. It further indicates that the nursing students’ belief of the profession and their professional self-concept are very fragile, especially in the context of Chinese nursing students’ recruitment and admission. The confidence to be a nursing professional has to solidify constantly in many circumstances. 110 Forming Professional Identity and Self-concept Scholars have shown that many factors contribute to the development of professional identities and self-concepts, including professional knowledge, training, and socialization (Anderson & Taylor, 2004; Beijaard et al., 2004; Maginnis, 2018). For nursing students, the hospital is a major site wherein students continue their professional socialization. Patient care and outcomes are essential to nurses’ job and their professional and personal growth (Benner, 2000; Benner et al., 2009; Purnell, 2009; Stowe, 2006). As quality care heals patients, nurses feel professional satisfaction in providing it. However, the Chinese nursing students at the center of this study also expressed a desire for their work to be recognized by patients and respected. For Angie, self-concept in the context of developing a professional identity as a nurse was rooted in her own values of wanting to do work that benefited society regardless of money and status. Nursing was thus meaningful to her because it allows her to help people. Angie noted that a crucial factor for her professional identity was patients’ and their family members’ recognition of nurses as valued professionals. She said, “For me, what I need is recognition of my value (from the patients). This is a very, very important factor to me.” Angie defined this recognition in terms of not being treated as a “servant” (服务员). She elaborated that she felt valued when patients asked what she studied while she was visiting hospitals in her undergraduate studies. When she told them she studied nursing with a bachelor’s degree, they would say, “that’s great, is that advanced nursing?” Affirming comments like these helped Angie build a positive professional identity as a nurse. Some participants shared this desire for positive recognition but framed it as a matter of credibility. For instance, Gina discussed how learning nursing and nursing knowledge helped her develop her professional identity as a nurse: 111 It might be true that most Chinese people’s impression about nurses is that they just give injections and are not significant compared to doctors. However, through my studies I now know I need to learn many things, like a lot of fundamental scientific knowledge. The learning process is not easier for nurses than for doctors. For the clinical part, nursing is professional and not everyone can do the work immediately. Such professionalism makes me feel my professional identity. (Gina) 可能在中国大家印象中，包括老一辈他们现在的印象都是护士你就是打针，跟医生 比起来没什么了不起的。但是学习过程中就是，我知道我们要学很多东西，要了解 很多基础的知识，然后学的过程也不比医生要简单。然后一个就是临床工作，它是 有专业性在的，然后并不是说每个人都能过来，你就直接能上手的。这种比较专业 性的领域，让我有这样子的职业的认同感。(Gina) Gina’s reflection pointed out that internalizing nursing knowledge through practice and observation helped the students develop self-confidence and professional identity. Similarly, Yanni’s sense of identity came from putting knowledge in practice. Of this, she said, “Maybe working in a hospital is a little different than what you learned in school. But if you have experience, it feels good to work in a hospital. The internship is still very important for us. You can accumulate a lot of such clinical experience, not just learn textbook knowledge, and to be more humane.” Yanni applied her school knowledge to practice in a way that humanized the nurse-patient relationship during her internship in the Cardiac Surgery unit. She was asked to help a new patient with hospital registration, and, after the paperwork, she took time to tell the patient about things he needed to pay attention to with his condition. When that patient saw Yanni later, he called her “teacher.” This made Yanni feel a sense of achievement and thereby a stronger sense of identity as a professional. Lia too felt a sense of confidence in having opportunities to transfer book knowledge into practice and care for patients in a professional setting. For Lia, this was especially true regarding communication with patients as a mediator between their knowledge and medical knowledge. She said the textbooks teach how to communicate with patients; however, when facing patients, 112 situations can be more complex, especially when patients are suffering from illness. She learned through experience that nurses need to be flexible and improvise to deliver effective care: When you face a patient, there are many conditions [to consider]. They may not follow your books. I found that the more contact you have with patients in a clinic, the more flexible you have to be because they may not have our professional knowledge or know as much as we do, so they will use common language to communicate with us. Sometimes, they ask questions, and you think they might not understand the professional language in the book, so you have to switch your [communication strategy] to a different way. During the internship process, the nursing profession became less distant to me. (Lia) 但当你面对一个病人的时候，你会发现状况会很多。他不会按照你书本去做，所以 我发现在临床你越多接触病人，你就要更灵活的去对待这些病人。他们可能没有我 们的专业知识，没有我们懂得那么多，所以他们会用通俗化的一些语言去跟我们讲 。他们有时候提出问题，你就想书本上的专业性语言他们可能听不懂，那你就得转 换一种方式。我觉得在实习的这个过程中就是让护理这个专业变得没有那么多的距 离感了。(Lia) Yanni and Lia’s stories told us several important learning and socialization processes happened during their hospital experiences. First, transferring knowledge from books to practice. It is an elevation of learning from pure application to synthesizing and creating a new way to communicate the knowledge to others. Second, during the process, the nursing students felt compassion and empathy toward patients as they hoped that their knowledge would help patients’ recovery and care. Third, good patient communication is a fundamental part in healthcare. It not only establishes trust between the medical staff but improves patient care outcome (Boynton, 2016; Raphael-Grimm, 2015). The stories indicated when nursing students are engaged in these activities their sense of professional identity grows. Furthermore, Anna, Yanni and Lia’ reflections demonstrated that nursing students can develop a sense of self-agency (self-authorship) (Renn & Reason, 2013) when they take initiatives. Anna’s positive relationship to her development of a professional nursing identity came from exploration and continued learning. She particularly emphasized the importance of being proactive in discovering one’s interests to successfully build a professional self-concept: 113 I think the main factor is your own proactiveness. At the beginning, you must actively explore and discover. You can’t just accept the environment and the things the teachers give you. You must also explore by yourself to see what you are interested in in this field. Constantly discover what you are interested in and, at the same time, this interest is based on your profession. For example, there are many scientific research projects in nursing. You can conduct interviews or you can do questionnaires. You can explore some of the problems in your field that need solutions. The process of inquiring strengthens the connection between myself and the profession, which can help establish a sense of professional identity. If you just accept what others bring you, you will be worn away gradually, especially if your environment is not good. (Anna) 我觉得主要的因素还是要你自己的积极主动吧。你一定要积极地主动去探索和发 现，你不能只去接受老师给你的环境和给你的东西，你一定要自己去探索你在这个 领域当中你所感兴趣的东西，你要不断的发掘自己所感兴趣的东西，同时这个感兴 趣的东西是基于你的专业的。比如说我们护理也会有很多科研项目，你可以去做访 谈，你也可以去做问卷，你可以去探索你的领域当中有哪些需要急需解决或者说待 解决的一些问题，你在探索的过程当中，我觉得会不断地增强自己与专业的联系， 是可以很好地帮助你去建立职业认同感的。因为我觉得如果你真的只是去接受别人 给你带来的东西的话，你会慢慢地被消磨掉，尤其是在你的环境不是那么好的情况 下。(Anna) Here, Anna articulated that her professional identity built up when she embraced and grounded herself in the nursing profession. With this, she was motivated to explore and learn more, which further strengthening her sense of identity. Anna told me a story to illuminate what she meant by being proactive. Nurse training doesn’t include reading electrocardiogram (ECG). It’s a doctor’s responsibility. However, Anna thought it was a crucial skill for her if doctors are not available when a patient encounters cardiac problems. She learned ECG by herself and later she corrected a doctor’s diagnosis that awed the doctor and gained herself a lot of respect. Overall, participants’ stories about the positive experiences they had at the hospitals indicated their professional identities were closely connected to confidence and self-value. Their nursing identity began to form through affirmative interactions with patients, technical improvement, applying textbook knowledge to practice, and seeking new knowledge for themselves. 114 Leadership’s Understanding, Trust, and Treatment of Nurses It is important to note that recognition from hospital leadership and medical staff also played a role in the nursing students’ sense of self-concept and emotional well-being (Cantey, 2012). Participants conceptualized this recognition as encompassing understanding, trust, and fair treatment. As students, the interns were sensitive to their environments. They listened to and observed their leaders, administrators, and doctors, and in the process, many internalized negative encounters. The Lack of Leadership Understanding and Support Having a relationship of trust with administration was difficult in some situations because of how nurses can be treated unfairly by leadership. For Lily, hospital leadership was crucial to helping or hindering nurses’ professional identity and self-concept development. She felt the hospital leaders did not usually care about losing nurses, as if they were disposable. However, if a doctor were to quit, the hospital president would try hard to keep the doctor but not value nurses the same way. Indeed, it isn’t difficult for hospitals to hire new nurses. Lily further felt there was discrimination toward nursing research, as she often heard her faculty complain about a lack of research funding. As a graduate student, Lily was concerned about her future career if she wanted to concentrate on research in nursing. The reality has presented future obstacles for her and other nursing graduate students and may hold back their nursing identity development. Lily’s experiences and impressions of leadership’s lack of understanding and valuing of nurses and nursing may stem from a wider cultural lack of understanding and valuing of nurses and nursing. For instance, at nursing conferences, high-level leaders have been surprised to see nurses with doctoral degrees. Such a phenomenon illuminates an overarching lack of understanding of the nursing profession from leadership in China that can and does negatively 115 impact nurses’ professional identity development. Yanni remarked on this via a new hospital president’s question about nurses at a meeting. The president asked, “Why do we have so many nurses? Don’t we have enough nurse assistants (护工)?” Yanni commented, “It seems there is much misunderstanding about nursing. Not only do the masses not understand nursing, but the professionally trained medical people also hold misunderstandings.” For Lia, who worked in a mental health hospital, this low esteem of nurses by leadership sometimes meant nurses were not supported by leadership when they were attacked by patients. Where she worked, it was not uncommon to hear insulting language and physical harm toward nurses from male patients. She said, “even within our nursing department, the leaders’ attitude toward nurses is distrustful.” She gave an example of an incident between a male patient and a nurse, where the patient hit a nurse badly on her head with his fists for no reason. The hospital blamed the nurse and held her responsible: The leaders didn’t believe that the incident just happened. They believed the nurse was responsible. Every time, I feel helpless and chilling. Several levels of leadership came and did all the investigations, asking other patients and nurses as witnesses. They just didn’t believe what the nurse told them. It is their belief that the nurse must have done something to make the patient become violent. At such a moment, you really feel that being a nurse is indeed bitter. (Lia) 上层的都不相信这个事件，觉得一定是你护士的责任造成了这一起事故。每次面 对这些的时候就很无奈, 我觉得很心寒。后来他们分好几批下来查这个事件，找病 人问，找其他的护士问。但是他们就是会不相信，他们总觉得这些病人暴力一定是 有你护士这方面的原因的。就这时候就会觉得护士这个行业确实也很苦。(Lia) Lia said this incident had a chilling effect on her. She also shared a story about her hospital regarding video surveillance. The hospital had recently installed cameras in all wards, including in the nurses’ office. It seems a safety measure for all staff and patients because the hospital was short-staffed, and there was only one nurse on duty during the night shift for a big ward with seventy patients. However, Lia felt the camera was unnecessary for the office and worried the 116 purpose was to warn the nurses that they were being watched, because nurses were not allowed to take a nap during night shifts, be on their cell phones, or read non-medical materials. Lia felt the hospital’s intention was not about caring for nurses’ safety but rather about keeping watch over them. Although Lia loved her job, she also felt disillusioned because of this. In terms of there being a cultural imperative for the devaluation of nurses and the nursing profession, Lee and Yang (2019) have pointed out that Confucianism has significantly influenced nursing education and students’ learning, particularly in hospital settings. One of the key teachings of Confucianism is social hierarchy based on seniority in age, job title, and work experiences. As participants’ experiences verify, this orientation in hospitals presents in the work and interpersonal relationships as early in a nurse’s career as interning, as nursing student interns are considered to be at the bottom of ladder (Lee & Yang, 2019). The Lack of Interprofessional Understanding from Doctors Doctors enjoy high respect from hospital administrators, staff, and society, and they are part of the leadership team in hospitals. However, nurses face many more challenges from hospital leadership at various levels and patients and their families. For patient care, doctors and nurses work as teams. While nurses are respectful to doctors, they may not receive reciprocal behavior from some doctors. This feeling of being looked down upon by doctors undermines nurses' confidence and is detrimental to nurses' emotional well-being and interprofessional communication between doctors and nurses. Such damage may affect the quality of patient care and outcome. Angie said: We can conduct many advanced operations, and we feel our professional identities. But many doctors don't understand nursing. For those doctors, they don't see your professional identity. They don't think you can handle advanced procedures. They think you are not much different from those young nurses with technique or associate degrees. So you can only give patients injections and medicine. This attitude makes me doubtful about my profession. (Angie) 117 其实我们现在是能做很多高级的东西的。认同感还是挺多的，但是他们医生其实对 这个专业也不了解，对这个专业不怎么了解的医生，他们对你也不是很认同，他们 不觉得你们护士能做很多高级的东西，你跟中专和大专出来的那些小护士一样，什 么都不会，只能打针吃药，那我觉得那我就会觉得我对这份职业会有一些怀疑。 This is the reason why Angie was so impressed by watching how doctors and nurses worked harmoniously in the operation room at the Great Lakes Hospital. What she experienced was a teamwork and interprofessional collaboration with respect. There is also a sense of pressure for nurses to prove themselves, such as Anna learned to read electrical cardiograph (ECG) by herself. A Wavering Professional Identity While the nursing students in this dissertation study came to settle into the nursing profession during their internships, some expressed concerns about their futures. Angie rated her sense of professional self-concept or identity at about 70-80% and the worries she shared during our interview revealed deeper societal problems: You have to face some realities. I have a professional identity. I love what I do. Being a nurse is not like working in finance because the purpose is not to make money. Instead, being a nurse expresses my value. The other 20-30% are real problems. After graduating with a master’s degree, I don’t know if I can practice advanced nursing because there is no established system to certify my qualifications. I may face a long path, at least two to three years, to do the basic nursing job like nurses with associate and bachelor’s degrees. I may not be able to utilize my advanced knowledge and training in graduate and undergraduate studies beyond writing articles. This is something discounting to my professional identity. Another aspect is the broader environment. I said earlier that the overall nurse quality is not high. You are always looked down upon by others. There is a widespread saying in Chinese social media. Men say they will not marry three kinds of women: nurses, daycare teachers, and bank clerks. They have strong discrimination against these professions. So, when I tell people I’m studying nursing, or I’m a nurse, I feel people may suddenly give me a look of dislike or discrimination. I think in society, you need to feel accepted. So, this also reduces my professional self-concept. (Angie) 你毕竟面临一些很现实的问题。我对这个职业认同感是有的，这个职业是我喜欢 的，不是说像我做金融或者做什么，感觉我就是为了赚钱而生的。因为我会有一种 118 价值观在里面.那就剩下那百分之 20-30 的话就还是一些很现实的问题吧，因为我 毕竟读了研究生，我也知道我不可能一出去就能做什么高级护理，因为毕竟要做这 个也没有一个系统性的,就是要考个证什么的。就是可能出去我还会面临很长，比 如说起码得 2~3 年基础的工作，就是跟专科跟本科出来都是一样的，然后可能除了 写文章就发挥不了研究生或者本科的一些高级的知识，我觉得这是可能是稍微没有 那么认同的一点地方。还有一个就是护理的大环境，就是像刚刚说的大部分护理人 员的素质还是不高的，你出去肯定总会被人歧视的。中国网上也就很流传的话，就 是他们男生的话说，女生中的三个就是不娶，不娶护士，不娶幼师，不娶银行职 员，就是对这三个职业他们的歧视是真的很大的。我觉得不管是我现在在说我读护 理或者是我以后说我做护士，肯定会有人突然对你有一种那种不喜欢，或者是说对 你有一种歧视的那种眼神，我觉得那么你在社会上的话，你肯定还是需要一些认同 感的，所以我会觉得这方面也是对我的认同感减分的一个地方。(Angie) Angie’s comments here illuminate serious problematic social aspects in Chinese society, particularly regarding gender discrimination, sexism, job inequality, and misogyny. The experience of social contempt based on gender and occupation can have profound emotional and psychological impacts on female nurses and others like them (Feng et al., 2017). Scholars thus continue to ask: who can defend the nursing profession and protect nurses on social media when negative social perceptions of nurses and the profession are so deeply ingrained (Hoeve, et al., 2013; Holroyd et al., 2002)? The participants’ stories also show how this kind of social stigma gets perpetuated through online social media platforms and causes young nurses to doubt their futures. Hong was particularly distressed by what she found on the internet when using the Chinese search engine Baidu to find images of nurses for a presentation. To her surprise and dismay, all the nurse images were sexual (黄色图片).It shocked Hong and caused her to feel more unconfident in becoming a clinic nurse. Hong feared making clinical mistakes and was so fearful that she even considered becoming a volunteer first after graduation. Lily’s uncertainty about her future career was not only informed by the negative experiences shared in earlier sections of this chapter, but also by how widespread this uncertainty 119 and doubt was among the students in her class. Not long before our conversation, her program launched an effort to collect questions the students had about working in hospitals and being nurses. Of the 90 students in her class, Lily was dismayed to find that nobody asked questions about clinical nursing or how to prepare for hospital interviews. Instead, people asked questions about how to find advising or teaching positions in colleges and how to take civil service exams. This was especially disheartening for Lily because her program is one of the leading nursing programs in China, yet it seemed to her many students who entered the program were not engaged. For Lily, this increased her sense of uncertainty in self-concept and her future in the nursing profession. What the stories in this chapter suggest is that Chinese nursing students’ sense of professional self-concept and identity development is impacted by wider societal factors, from the general working conditions in hospitals to negative incidents, such as workplace violence against doctors and nurses, poor leadership, and negative social media representations of nurses. These factors cause them to feel doubtful, demoralized, and uncertain about their careers. The participants demonstrated that nursing interns learn about their profession—and thereby develop their professional identities and self-concepts—from peer students, teachers, nurses, and patients. They have their aspirations in the field of nursing but are also aware they might have to expect less. It thus seems many nursing students are not quite settled in the nursing profession and struggle with having second thoughts about their futures. Anna’s words expressed the most critical factor for working as a nursing professional. She said: “one must be very clear about what you want. Why do you want to study healthcare? Is it only for a stable job or do you study healthcare because you feel the calling?” 120 Summary In this chapter, I shared participants’ stories about their experiences in Chinese hospitals during their internships and the concerns that arose from these experiences that negatively impacted their professional self-concept and identity. In analyzing these stories, I found participants showed significant nuances and complex feelings as nursing students and nurses. They had positive experiences but the negative experiences they had were prevalent and prominent. These experiences all fall under six main themes: daily routines; physical challenges; irregular learning environments in hospitals; interactions with nurse educators, nurses and patients; what makes nursing students connect to their professional identity and self-concept; hospital leadership’s lack of understanding, trust, and poor treatment of nurses; and a wavering professional identity among the nursing students. The participants told and re-lived their lives during our conversations. At times, I became emotional and troubled by their unfair situations and worried about their well-being. My respect for the students grew as I learned about the obstacles they had to overcome, academically, physically, and emotionally as they forged a path to their professional aspirations with hope. 121 Chapter 7: Discussion, Recommendations, and Conclusion Overall, this study examined Chinese undergraduate nursing students’ professional socialization experiences in hospitals and the implications of those experiences to their development of a professional nursing identity. Chapters 5 and 6 present the Chinese nursing student participants’ personal experiences, perceptions, impressions, and reflections of their internships in the US and Chinese hospitals, respectively. The students shared stories about their interactions with hospital nurses, nurse educators, patients, and clinicians, explaining how they felt about these interactions and why. Together, their narratives represented a spectrum of nuanced experiences that had notable implications for the students’ professional identity development and self-concept. Overall, positive hospital experiences yielded stronger senses of professional identity and self-concept, while negative experiences were detrimental and undermined their development processes both emotionally and psychologically. These results align with existing scholarship on nursing students’ professional identity development under positive and negative circumstances (Cantey, 2012; Cohen, 1981; Condon & Sharts-Hopko, 2010; Coram, 2016; Ewertsson et al., 2017; Howkins & Ewens, 1998; Thomas et al., 2015; Lee & Yang, 2019; Price, 2008). Furthermore, this study productively extends existing literature on nursing students’ professional socialization and identity development in the context of Chinese nursing education via a comparative analysis of Chinese nursing students’ experiences interning in both Chinese and US hospitals. In this chapter, I first discuss this study’s theoretical implications for nursing students’ socialization and professional identity development and argue for a sociocultural lens in examining Chinese nursing students’ professional socialization and professional identity development. I then elaborate on participants’ reflections on their training experiences and 122 impact to their professional identity development. I proceed with a meditation on other factors that hindered participants’ professional identity development, such as toxic hospital leadership behaviors. Finally, I offer recommendations for nursing education in China and research in nursing education based on my findings and conclude with future directions for study. Theoretical Implications As discussed in Chapter 3, this dissertation study employs an analytic framework based on Cohen’s (1981) three-sphere model of nursing students’ professional socialization and identity development. The three spheres (i.e., cognitive, interactional, and personality) do not exist independently but rather fluidly interact and interfere with each other. Nursing students build and construct their professional identities and self-concepts through their experiences in the three spheres. This study specifically concentrates on the interactional sphere in hospitals, the most crucial location for students’ professional socialization and identity development. In such settings, nursing students’ experiences in the interactional sphere affect elements in the other two spheres. For example, in the interactional sphere, students encountered nursing norms, cultural norms, and responses from peer nurses and other hospital staff that affected their progress in establishing a professional self-concept and identity in the cognitive and personality spheres. In the following section, I discuss my study’s implications for Cohen’s (1981) framework based on participants’ positive and negative experiences in the interactional sphere and how those experiences impacted their cognitive and personality spheres. Given the unique context of Chinese nursing students’ experiences, I also advocate for a sociocultural lens for examining Chinese nursing students’ professional socialization and identity development. The sociocultural lens touches all three spheres for Chinese nursing students pursuing their careers. 123 Experiences in Relation to Cognitive Sphere The Chinese students’ experiences at the American Great Lakes Hospital were overwhelmingly positive. And these experiences demonstrated a positive association with students’ cognitive sphere. For example, when Lia observed how music therapy comforted a patient with a mental distress, she searched for evidence in research and found established literature in this area. It inspired her to think about learning more when she returned to China. Humanitarian care is another subject that some students experienced and will certainly explore in their work in China. In addition, music therapy and humanitarian care are two areas Chinese healthcare lagged. Cohen’s (1981) framework holds that negative experiences in the interactional sphere may negatively impact nursing students’ cognitive development. This aligns with the findings of the present study, as participants indicated negative experiences at the hospitals undermined their confidence and self-concept and thereby their professional identity development. Although the students remained in the nursing profession, their negative experiences and the promise of future difficulties gave them pause and prompted them to consider leaving nursing or finding ways to avoid certain functions of the job. In other words, participants indicated staying in the profession would mean having to find ways around its inequities. Angie, for instance, said she felt she had a 70-80% sense of her professional identity as a nurse but that the other 20-30%, characterized by a persistent lack of respect and burnout, prevented her from feeling wholly confident in this identity. Hong’s negative experiences in and out of hospitals had seriously undermined her confidence to be a clinic nurse. She considered seeking a job as a volunteer after completing her nursing graduate studies. Lia considered changing her job or applying for a graduate program if 124 her hospital’s problematic working conditions, poor leadership, and disrespectful treatment of nurses did not improve. However, the overwhelmingly negative experiences in the Chinese hospitals did not necessarily impact participants’ cognitive spheres in terms of their academic capacity. For instance, five of the eight participants entered or were about to enter graduate programs in nursing. It may be that they felt higher degrees and advanced training would earn them respect as nurses in the Chinese context. Based on our conversations, such activities seemed to strengthen participants’ sense of professional identity and self-concept. For example, Angie pursued graduate study because her dream was to become an advanced nursing specialist in surgery care. Lily wanted to combine her clinical work with research and conduct evidence-based nursing. Lynn planned to concentrate her graduate studies in ICU care and management and Lia and Gina, who were nurses at the time, also considered applying to graduate programs in nursing in the future. It is thus possible the negative interactions the students had during their undergraduate studies motivated them to pursue advanced degrees in order to achieve higher levels of expertise as professionals. Experiences in the Personality Sphere In terms of the personality sphere (Cohen, 1981), the Chinese nursing students demonstrated self-agency, perseverance, and resilience in the face of their negative experiences with college admission and interning at hospitals. Although many of the study’s participants did not originally want to major in nursing, they showed a strong sense of self-agency and perseverance by making consistent efforts to settle into their new routines, make goals for themselves, and pursue or make plans to pursue advanced nursing degrees. Lily, Yanni, Angie, and Hong were all in graduate programs at the time of our interviews. They expressed hope that, 125 with advanced training and research capacity development, they would be able to bring high- quality nursing practices to the profession, work independently, and change people’s perceptions of nurses. Similarly, even though nursing was not their first career choice, Gina, Lia, and Lynn not only accepted nursing, but also expressed determination in carrying out their duties with passion and care. Yet, despite this, my findings suggest participants’ development of self-agency was hindered by the education system, the healthcare system, and the invisible sociocultural tradition of hierarchy in Chinese society (Jun, 2005; Lee & Yang, 2019; Sun, 2017). Importantly, the challenges participants faced yielded a necessary resilience in their personalities that in turn strengthened their professional identities as nurses. These challenges included struggles with college admissions, difficulty transferring out of nursing, burnout, and multiple forms of marginalization during their internships. Angie’s days of body-breaking work, Hong’s descriptions of restlessness at work (i.e., no place to sit down), and Lia’s long and tedious night shifts all reflected the burnout prevalent in busy Chinese hospitals. The participants, however, did not quit. In fact, when speaking on these experiences, they did not even complain. Lia, who chose to work in a mental health hospital, where working conditions were difficult and demanding, noted she felt it was her calling to help those suffering from mental diseases. She thus made this choice in defiance of the societal stigmas on mental illness in Chinese culture. Meanwhile, Lynn identified what she believed was the most crucial attribute of a nurse in China: “pressure-resistant.” All study participants expressed similar sentiments in this regard, indicating their understanding and development of a resilient professional identity may be a key aspect of retaining students in the profession. It seems counter intuitive or paradoxical that, on the one hand, the nursing students showed self-agency and sought practical changes but, on the other hand endure consistently 126 unfair treatment in hospital work environments. Angie, Lynn, Lily, and Gina explained this in terms of a feeling of “fate” or “destiny,” which may reflect the influence of Confucianism and Buddhism on Chinese society (Jun, 2005). Confucius teaching promotes hierarchical relationships, loyalty, and obedience, while Buddhism promotes the transcendence of self to “emphasize compassion for others and conduct ourselves with restraint out of a responsibility” (Jun, 2005, p. 94). The nursing students’ narratives indicated that some of the younger generations growing up with industrialization and influence of western-style individualism are still deeply rooted in the cultural traditions of Confucianism and Buddhism. A Sociocultural Lens for Chinese Nursing Students’ Professional Identity Development To better understand Chinese nursing students’ learning and working conditions, their professional socialization must be understood as an ongoing process across multiple sociocultural contexts, particularly school, community, and family environments. School environments, or students’ college years, are when most students cognitively develop nursing knowledge and nurses’ roles in healthcare settings (Cohen, 1981). In China, school is crucial to establishing nursing students’ acceptance of and persistence in the profession, as evidenced by the fact that six of the original 14 participants of this study left the nursing profession immediately after graduation. Given the challenge of retaining nursing graduates, how can the education system help students thrive in nursing and stay in the workforce? Cohen (1981) also found that, in regard to nursing students’ professional socialization and identity development, the cognitive, interactional, and personality spheres were all equally important. While this framework has seemingly universal value for nursing education, it does not account for the impact of sociocultural dynamics at play in the development of professional nursing identities in different societies (Chen, 2001; Condon & Sharts-Hopko, 2010; Hoeve et 127 al., 2013; Holroyd et al., 2002; Lee & Yang, 2019). For Chinese nursing students, the interactional sphere is a complex mix of multiple factors (i.e., the hospital, a primary location for professional socialization and identity development, and nursing students’ social groups, including peers, nurse friends, and families) that fluidly affect their personality spheres as well as cognitive sphere. The hospitals simultaneously barraged nursing students with opportunities, challenges, advocates, and adversary forces. While the need for employment brings students to the profession, the harsh—and at times inhumane—working environments drive them away, as illustrated by participants’ experiences in this study. Persisting in nursing therefore requires tremendous determination and passion. Without strong minds and unwavering determination, nursing students and new nurses may not survive the systemic challenges they are sure to face and may leave the profession early. Another factor in the interactional sphere is the circle of peer nursing students and nurse friends. In these groups, the students were able to process with each other, share experiences and information, and seek emotional support. For example, Angie shared a story about a nurse friend who sought help from her regarding a particularly miserable hospital experience. Lia said her professional knowledge from working at the mental hospital became handy when other nurse friends needed emotional support. Yanni and Lily explained how their friends avoided applying for jobs at hospitals their peers told them were hostile. In other words, nursing students develop strategies to live and survive in systems that lack accountability. Still, these strategies are not always effective—they can provide temporary relief but not the deep institutional change necessary to render the need for them null. The final important factor of the interactional sphere is family. Chinese families tend to be more actively involved in their adult children’s lives, especially parents. Of this, Wong (2017) 128 has noted Chinese people understand there is a critical connection between parents and education, such that parents exert a “purposeful impact” (p. 27) on their children’s educational outcomes by giving advice, providing economic support, and choosing where their kids will live. According to Yang (2004), the social-orientated self is a distinct characteristic of the Chinese self, particularly the family/group-oriented self. In this way, an individual “expects to play an appropriate role and be accepted by the family (group) to meet his or her identity-related needs” (Sun, 2017, p. 3). In the context of Chinese nursing students’ professional development, professional identity is thus not separate from their general self-identities or the identities their families recognize and accept. As such, listening to their parents and receiving their families’ acceptance of their nursing identities are crucial for many Chinese nursing students, as family acceptance and encouragement can help students overcome the challenges of pursuing a career in nursing. In my study, family support may also help propel the students pursuing advanced studies, which is the key development in the cognitive sphere. This study further found parents played a vital role in helping the students ground themselves in the nursing profession. Parents’ affirmative attitudes toward the nursing profession were powerful in shaping their children’s thoughts and actions. Lynn’s mother, for example, guided her in viewing nursing as very important in healthcare and made her feel like she had a bright future in the profession. Lia’s and Yanni’s families encouraged them to take advantage of studying nursing as a way to change their lives by moving to the metropolitan HP city they felt would open doors to new opportunities. Hong’s father, a doctor of Chinese medicine, also encouraged her to take up nursing. These instances show that, in Anna’s words, you won’t be able to continue nursing “if your family always reminds you that you have to work three shifts and your life is upside down, with nights as days and days as nights. You don’t have a fixed 129 working schedule. You can’t rest during the Spring Festival and other holidays.” Such complaints from family have the potential to compound with the already prevalent challenges of nursing and can eventually cause one to give up. On the contrary, however, the participants of this study showed families’ and parents’ positive attitudes toward nursing can positively influence students’ perceptions of and confidence in the profession. How Students’ Experiences Impact Their Professional Identity Development Participants’ narratives reflected that, even though the majority of their interactions in Chinese hospitals were negative, they forged on their studies and worked diligently as nursing students and nurses. A key factor of their ability to do so seemed to be due to their personal relationships, particularly those with helpful nurse teachers. In the following section, I explain students’ personal relationships with their nursing teachers and the disconnections they experienced between hospitals and nursing colleges. I also discuss participants’ understandings of the concept of the core value of nursing (i.e., “caring”) and detail the types of learning that took place in the American hospital. Nurse Teachers’ Personal Connection with Students In Cohen’s (1981) three-sphere framework, nurse educators play an indispensable role in every stage of students’ socialization and professional identity development. Except for two cases, however, the Chinese nursing students’ narratives did not always reflect this. Researchers have found establishing relationships with others to be an essential factor in meaningful and transformative learning (Taylor, 2007). This was true for two of the Chinese nursing students, such that the nurses who cared about the students’ learning and who actively forged personal relationships with them seemed to have a more positive impact on participants and their development. Angie’s and Anna’s stories in Chapter 6 especially demonstrate how nursing 130 teachers who took time to foster personal relationships with the students were regarded as more than just role models in the students’ professional identity development. Angie said her experience with a particularly kind nurse teacher helped her see and feel the value of nursing and inspired her to be a specialized nurse. Anna had a similar experience, as her nurse teacher was an excellent role model and mentor and made her want to continue learning. These nurse teachers’ personal connections with the students humanized the idea of professional identity, narrowed the gap between nurses, students, and the profession, and gave the students a sense of belonging necessary to the formation of a strong professional identity. Disconnections between Hospitals and Nursing Colleges Nursing faculty play a significant role in the interactional sphere, particularly when students intern in hospitals (Cohen, 1981). However, there was a marked absence of nursing faculty in participants’ stories. Specifically, students could not recall interactions with their college faculty during their clinical internships. This disconnection between hospitals and nursing colleges presents an even greater challenge to Chinese nursing education. As nursing colleges bring students to the profession and educate them, hospitals should be an extension of students’ education, wherein they are similarly nurtured by exemplary role models, mentors, team support, and a collaborative working environment that welcomes students into the fold. Instead, many hospitals seemed to actively contribute to driving the students out of the profession before they could even begin. Lynn, Hong, Gina, and Anna, for example, all shared stories about how hospital nurses told them to stay away from the nursing profession. Lynn explained, “All of the teachers (nurses) told me this: change your profession as early as possible. Every time we talked, they would say this to me.” Similarly, whenever she told her nurse 131 teachers she loved nursing, Anna received comments like, “child, you are still too young,” which led Anna to conclude that the nurses felt nursing was a bad profession. According to Cohen (1981), effective learning in hospitals requires the implementation of effective structures with clear roles and relationships between nursing teachers, students, student learning groups, and mentors. However, participants’ narratives suggest they, at best, received minimum structure in their hospital training and, at worst, were exposed to actively harmful educational structures. One outrageous example is Lily’s comment to her second half of hospital internship as “In my heart, I feel numb. I feel I don’t learn anything. It was a waste of time every day.” The lack of clear communication and learning structure between the hospitals and the nursing college were evidence of this, indicating a serious gap in curriculum and pedagogy that resulted in a lack of leadership and ineffective mechanisms for identifying and addressing problems. “Caring” as Expressed among Chinese Nursing Students “Caring” has been identified as a fundamental value of the nursing profession (American Association of Colleges of Nursing, 2008; National League of Nursing, 2007). Scholars have defined it as a mix of knowledge, competence, and compassion (Falk-Rafael, 1996; Price, 2008). Stowe (2006) has asserted nursing education should be centered in nurturing “a more consciously caring individual for our society” (pp. 127-128). The participants of this study, however, showed a wavering sense of professional identity. This does not mean they did not work hard and exhibit care in their work. For instance, Lia said, “you must have love to be a nurse” and noted she felt very happy when she saw a patient’s mental health improve after treatment or when they checked out of the hospital. Similarly, Gina felt the most important quality of a nurse was compassion and empathy (同理心). Anna said caring for patients made 132 her feel like nursing was a calling. Angie expressed her passion for healthcare as: “I love working in hospitals. I have always wanted to be a doctor, but being a nurse is nice too. I feel my value here, saving lives.” It is important to highlight that not every student reflected on professional identity in terms of caring and love. Yanni felt the most important quality for a nurse was clinical experience: Working in hospitals, one must have rich clinical experience, nursing knowledge, and the capability to deal with emergencies. It means one must know what to do if a patient encounters an emergency. Then all other characters are not important. (Yanni) 我觉得如果在医院的话，首先得有丰富的临床经验，有基本的知识，还得有一些处 理突发事件的能力。他得知道，比如说一个人突然出现了意外，该怎么办？然后他 的性格什么的不是很重要了。(Yanni) Here, Yanni asserted her belief that competence and knowledge are the most important aspects of a nurse’s professional identity, a belief also evidenced by students’ pursuit of advanced nursing degrees. Nursing education programs can thus benefit from and better serve students by designing and implementing curricular components that balance cognitive and practical elements with “consciously caring” which entails empathy, nurturing, knowledge, and competence. As illustrated by participants’ stories, nursing students experience many struggles in their journeys to becoming professionals. Educators can help students reflect and derive meaning from their struggles, discoveries, hopes, and spirituality (Purnell, 2009) in regard to caring, knowledge, and skills. Falk-Rafael (1996) has defined this as “empowering caring,” which is enabled by both knowledge and experience. What Kind of Learning Happened at the Great Lakes Hospital? Some of the Chinese students’ narratives indicated that their learning experiences have a transformative learning feature, particularly those in which they observed how American medical 133 staff delivered care for mental health, hospice, and surgery. Transformative learning theory was first introduced by Jack Mezirow in 1978. He defined it as “a learning that transforms problematic frames of references — sets of fixed assumptions and expectations (habits of mind, meaning, perspective, mindsets) to make them more inclusive, discriminating, open, reflective, and emotionally able to change” (2003, p. 58). I posit this because the Chinese nursing students’ learning contexts went from a less advanced (not necessarily technical), less socially respected Chinese hospital system to a managerial and technologically advanced, respected hospital system in the US, which allowed them to transform their frames of reference for nursing. Importantly, what was transformative for the students was not the American hospital’s advanced technology, but rather the methods of delivering humane care, something they had not previously experienced in the resource-strained Chinese healthcare system. For example, Hong observed the last moment of a dying patient and the care his family and nurses provided him. She and another student then cared for the body afterward. Hong was not scared. Instead, she said, “I was deeply touched during the process. This is the first time for me to care for a body. I even have a warm feeling.” She further reflected: The nurse is not just an executor here, he/she can also be a companion and a healer. This healing is spiritual. The patients are not only those who lie in beds, they can be their families. I think as nurses and other healthcare workers, our job is not only saving a patient. Sometimes, helping him end the life journey peacefully is also our responsibility. This makes me realize a new area we can engage. (Hong) 护士在里面它不仅是一个执行者，他也可以是陪伴，就是治愈。那个治愈是精神上 的治愈。我们的病人不只是躺在床上的病人，也包括他的家属，让我感觉护士包括 整个医疗行业，就是我们不一定是非得把这个病人给救起来, 有时候帮助他去安然 的走向死亡，这也是一个我们的职责吧。让我意识到一个新的护士或者是医务工作 者可以做的事情。(Hong) As Hong’s testimony reflects, this new learning environment made it possible for the students to look at things from different perspectives and identify problems they had never considered. 134 Meanwhile, Lily observed the hospital’s delivery room provided baskets and clothing for stillborn babies. This struck her as humane and thoughtful and prompted her to reflect on how no Chinese hospital she knew of offered this kind of service. In addition, Angie witnessed collaborations between American doctors and nurses in an operating room that helped her reframe the subordinate status of nurses to doctors she had internalized during her socialization at a Chinese hospital. She had never thought doctors and nurses could be equal as professionals nor support each other as a team. These experiences all challenged the Chinese students’ “fixed presumptions and expectations” (Mezirow, 2003) of a nurse’s job and gave them a more empowering model of what nursing can be. Other Contributors to Chinese Nursing Students’ Professional Identity Development The students’ narratives in Chapters 5 and 6 clearly demonstrate that negative interactions with nurses, patients, and hospital leaders undermine students’ professional identity development. A lack of accountable curricular and pedagogical internship structures will only continue to hinder nursing students’ professional identity formation, which will in turn sustain high nurse attrition and low-quality healthcare for patients. The student participants of this study used a comparative lens to reflect on their internship experiences in the American and Chinese hospitals. This was reflected in their use of two different kinds of words to describe their experiences in the Great Lakes Hospital and the Chinese hospitals. Namely, they used words like “happy” (Yanni), “amazing” and “harmonious” (Angie), “deeply touched” (Hong), “miraculous” (Lynn), and “friendly” (Lily) to describe their experiences in the American hospital. In the Chinese hospitals, however, all of the students used two words to describe nurses’ work: “busy” and “burnout,” and others described nursing as a profession of “eating bitterness” (吃苦).Remarking on the strikingly different experiences in 135 her US and Chinese hospital internships, Yanni explained that, in the Great Lakes Hospital in America, she felt the nursing profession was a mission and a calling, and she felt happy everyday going to hospital; while at the Chinese hospital, she was exhausted and noted every day felt like “just getting by.” These strikingly different feelings and emotions are a reminder to nursing educators that ignoring students’ stress will likely result in delayed and weakened self-concept and professional identity development. The Lack of Leadership in Hospitals Cantey (2012) has found violence and incivility to be detrimental to nursing students’ professional identity development in the US. She thus recommended intentional transformations in leadership to facilitate nurturing and supportive environments, wherein nursing students can form positive associations with their future careers. While violence and incivility were not prominent themes in my study, Cantey’s (2012) call for transformational leadership resonates nonetheless, as participants shared accounts of harmful behaviors they directly experienced or that were relayed to them by friends and colleagues. For example, Lia, Angie, Yanni, and Lily shared experiences with distrust, coercion, pressure, and ignorance from other nurses, nurse educators, and leaders at various levels in the Chinese hospitals. Unfortunately, the participants’ stories are not unique in this regard. Researchers around the globe have documented similar phenomena in nursing education (Cantey, 2012; Howkins & Ewens, 1998; Lee & Yang, 2019; Price, 2008; Thomas et al., 2015). Together, these studies show poor leadership in nursing education can cause feelings of agony, distress, anxiety, and hopelessness that can severely damage nursing students’ impressions of the profession and cause them to significantly doubt their professional prospects. 136 In the Chinese context, poor leadership compounded with other factors, such as involuntary college admissions and burnout, has resulted in high nurse attrition rates across the country (Yang & Hao, 2018; Zhang et al., 2021). The participants of the current study were well aware of this problem. Angie described the high attrition phenomenon as follows: Many people change their job in the first five years. Job hopping is specifically high among nurses with undergraduate degrees. I haven’t checked the data, but I feel all the nurse friends in my circle have changed their jobs. Some are now in designing, some are in sales, and some went back to their hometowns. (Angie) 就很多人就在这 5 年就已经跳槽了。包括本科生，本科生第一年的跳槽率是很高很 高的, 就我没有去看过专门的数据，但是我感觉我朋友圈的以前的学姐现在都跳槽 了，有自己去做设计的，有自己去卖东西的，有自己回老家的，就跳槽的真的很多 很多。 (Angie) Angie’s personal account here confirms existing findings that the nurses with bachelor’s degrees had highest drop-out rate in Chinese hospitals (Han, 2017; Mai et al., 2016; Tian, 2011; Yang & Nan, 2015). Lily further shared that some hospital leaders do not believe there is a shortage of nurses in the labor market, that they can always hire new graduates to fill vacated positions, a supposition that has been verified by scholarship documenting how abusive hospital leadership drives nurses to leave their positions (Lin, 2019; Xu et al., 2018). Such attitudes and behaviors perpetuate the problem of attrition, further damaging the nursing profession and ultimately compromising patient care and healthcare quality. These issues have become so prevalent that top Chinese leadership in health administration have explicitly pushed for better nursing education, professional development, improved benefits, and protections for nurses’ rights (Bureau of Medical Policy and Administration of PRC, 2020). However, the top-down policies designed to address these issues usually lack specificity, benchmarks, and accountability (National Health Commission of the PRC, Chinese Nursing Development Plan, 2016). These issues may thus be more effectively 137 addressed by local decision-makers. Regardless, many hospital leaders must update and improve their knowledge of nursing, nurses’ roles in patient care and in the delivery of quality healthcare, and advanced nursing education to effectively reform their perceptions of professional nursing and enact meaningful changes in the current system. One of the most fundamental challenges to such reform may stem from the privatization of Chinese healthcare in the early 2000s, as this has driven public hospitals to prioritize profit over all else (Blumenthal & Hsiao, 2005; Yip & Hsiao, 2014). Since privatization, the Chinese healthcare system has been dealing with a host of consequences (Yip & Hsiao, 2014), including failure to provide patients quality healthcare (Tam, 2010) and an abundance of social conflicts. It may thus take an exceptionally long time for many hospitals to improve working conditions for their nursing staff than the Chinese government original expected. Other Factors Keeping Nursing Students in the Profession In addition to increased senses of professional identity and self-concept, participants also decided to stick with nursing for other reasons. Some cited stability as an advantage. Hong explained, “nursing is relatively stable because of high demands. We shouldn’t lose our job if we don’t do anything wrong.” Lia and Anna expressed similar sentiments. Another advantage is better access to healthcare. Of this, Gina said, “The first advantage I can think of is that my family, including myself can have better treatment compared to people without hospital relationships (关系).” Lily affirmed, “it is easier for my family to seek healthcare because you know doctors and your teachers there, it’s more convenient.” Angie and Hong felt the same. This indicates quality healthcare is not equally accessible to Chinese citizens, which has been a national problem for decades (Dong et al., 2021; Gong et al., 2021; Yuan et al., 2019). It is also important to note here that the students identified their families’ needs as an important point of 138 consideration in their career choices. Lynn, Gina, and Hong further believed nurses’ benefits are better than those of other jobs. Moreover, some highlighted the focus of hospital working environments on patient care as desirable compared to other professions. Lynn particularly felt good about the departments she’d recently interned in, noting, “I feel my work environment is nice. People support and help each other. I feel I’m happy to be here every day.” Together, these external factors appeared to help keep the students in the nursing profession and may potentially serve to further positive development of their professional identities as nurses. The education abroad experience provides a unique lens to expose and examine the problems in Chinese nursing education, particularly in two different hospital settings in the US and China. The different experiences provoked the Chinese students to look into their past experiences and realized what they have gone through in Chinese hospitals was not normal and rather harmful. Furthermore, through Cohen’s (1981) framework of the three spheres in nursing students’ professional socialization and identity development, my study identified a few crucial factors in Chinese nursing education that directly and indirectly influence nursing students’ self- concept and growth in the nursing profession. There is a great hope that what students learned from the study abroad program will continue inspire and encourage them to learn and advance. On the other hand, the negative influences and current status quo demand changes and reform. COVID-19 and Nurses’ Image The COVID-19 pandemic had positively affected nurses' image in China. During the early outbreak in Wuhan, isolation was the only way to cut transmissions. Group isolation was a method used in the city. Nurses cared for the patients and fought the deadly disease at the frontlines with doctors risking their lives while the disease was not fully understood by medical science. Nurses spent more time and cared for patients with all kinds of symptoms to reduce pain 139 and save lives in ICUs and temporary isolation hospitals. It seems that Chinese society suddenly realized nurses were indispensable in treating patients for their recovery. Nurses carried their knowledge, skills, and compassion to work with the public and patients when many people were unsettled and scared about their livelihood. Nurses also became heroes in social media and public media; the Chinese government and leadership took this opportunity to praise the heroism of the healthcare professionals. They bestowed honors and even financial rewards to those who made extraordinary sacrifices and contributions to save people's lives. Doctors and nurses were called anti-pandemic heroes. For this, the nursing students felt the pandemic might be a turning point for the good of the nursing profession. Hong said, "Chinese nursing played a vital role during the pandemic. Their images have improved, and I can feel it". Lily said that before the pandemic, patients always gave credit to doctors for their recovery; however, this time, "they specifically thanked nurses for their care and help in interviews with media." Lynn said: In a sense, I have to thank this pandemic. The overwhelming coverage and praises of medical staff (doctors and nurses) have indeed changed many stereotypes about them. They helped change people's traditional concepts about healthcare and nursing. 某种意义上面来讲，要感谢这次疫情. 铺天盖地报道的就是医护人员，然后弘扬医 护人员，确实也是改变了很多对医护人员的刻板的印象，改变大家对于医护工作者 的传统观念。 Gina observed the same phenomenon and commented that maybe she shouldn't thank the pandemic, but it was an opportunity to improve nurses' status significantly in people's hearts. Indeed, the students had hoped and believed that the nursing profession in China would be better in the coming decade, even though the changes may happen slowly and gradually. Implications for Practice and Research As previously discussed, nursing student recruitment and retention are significant problems in Chinese healthcare systems. Although reforming these systems takes time and 140 resources, this does not mean nothing can be done at the local level. Small drops in water can have a ripple effect. Based on participants’ stories and insights, I recommend the following activities as initial steps toward improving student recruitment, retention, and effectively cultivating nursing students’ professional identity development. Provide Early Education on the Nursing Profession The findings of this study show that, prior to entering college, the participating nursing students had little to no knowledge of nursing, nursing science, or its roles in healthcare. Early nursing science education programs might thus proactively aid universities and nursing programs in reaching out to students in secondary education to spread knowledge and information about nursing, healthcare, and careers in nursing. In recent years, more Chinese universities have opened their campuses to high schoolers and their parents during summer. However, it is not clear how organized and informative these visits are. Workshops centered on careers in nursing and nursing knowledge, visits to labs, and nursing simulation classes can be effective tools for sparking curiosity and interest in the profession. In the US, high school students often have opportunities to volunteer at and visit hospitals to explore possible careers in healthcare. Universities with teaching hospitals in China can play a vital role in pioneering these kinds of collaborative, early nursing education programs, especially during summer breaks. Improved Communication between Hospitals and College Nursing Programs The nursing students in my study repeatedly shared that their program only required the Chinese hospital to complete their evaluation book during their internship. However, neither the hospital nor the nursing department conducted regular review meetings or had discussions about the students’ learning. It was thus up to the individual nurse educators to decide how to interact 141 with the students. Without a clear quality management protocol, the students’ experiences were extremely varied and largely negative. Overall, the results of this dissertation study indicate improving hospital internship curriculum and pedagogy is an area in need of urgent attention. A possible pedagogical innovation would be to intentionally build mentorship between nursing students and nurse educators. Such relationships were especially effective for participants in advancing the students’ professional identity development and a sense of belonging to the nursing profession. Notably, there did not seem to be a channel for the students to report back to their universities about their hospital experiences. Instead, students were left to deal with the situations by themselves without any resources or guidance. This lack of communication points to the marked absence of engagement and care between the hospitals and the nursing colleges. Furthermore, it seems once students reach their senior year in college, they are handed off to hospitals for their final clinical internship. These hospitals have minimum structure in place for assessing learning and counseling students or meeting their needs. Counseling is particularly crucial to helping students deal with difficult situations and care for their emotional well-being. Without these structures, nursing students are left to swallow whatever happens to them and try to make sense out of it by themselves. As universities have counseling programs and resources, I advise they invest in providing nursing students access to such services during clinical internship period, as they are essential to students’ success in and beyond their careers. Support Education Abroad In Chapter 2, I explored extant research that has shown Chinese healthcare students can benefit from short-term study abroad programs. Most international students visit the US to improve their English and learn about American culture. While these programs are meaningful, 142 in-depth professional experiences is more critical to learning because they are high-impact and potentially transformational (Anderson Sathe & Geisler, 2017; Blake-Campbell, 2014; Carter, et al., 2019; Dirkx, et al., 2010; Foronda & Belknap, 2012a; 2012b; McDowell et al., 2012). It is therefore vital to support high-impact study abroad programs, such as the nursing program referenced in this study. Recall that some of the nursing students described encountering ideas and practices they had not experienced in Chinese hospitals, especially in terms of the humanitarian aspects of care and innovative ways of healing described in Chapter 5. These transformative learning experiences indicate studying abroad can be of unique value to nursing education. However, studying abroad in the US is expensive. It requires visionary leaders and a strong commitment to financially support these programs. Without universities’ financial support, few Chinese nursing students would be able to afford this once-in-a-lifetime experience. Future Research Too few researchers have examined Chinese nursing students’ lived experiences and these experiences’ relationship to the students’ professional identities formation. In focusing on nursing students’ experiences in bachelor’s degree programs, the current study only reveals the tip of the iceberg. There are many more nursing students in technical schools and associate degree programs in China. What are their experiences, and how do they develop their professional identities? More qualitative research is needed to gain a comprehensive understanding of nursing education curriculum and students’ professional identity development in different school contexts. Research like this can help policymakers, hospital leaders, and nursing education practitioners improve students’ educational experiences and strengthen their professional socialization and professional identity development. 143 During my interviews with the nursing students, it seemed their emotional well-being was a defining factor in establishing their self-concept and professional identity. Scholars have found many factors affect nursing students’ emotional well-being and how they create and employ coping strategies like music therapy and emotional freedom techniques (İnangil et al., 2020; Martin et al., 2022; Qiao et al., 2011; Smith & Yang, 2017; Vuolo, 2018). However, emotional well-being may be a factor of Chinese nursing students’ decisions to leave or stay in the nursing profession, regardless of whether their strategies of coping with stress affect them physically in the short term. Deeper dives into this can reveal the extend of the problem and identify the most concerned stressors and help nursing educators and practitioners develop intervention strategies. Future researchers might also look beyond nursing students who stay in nursing, as the profession loses tens of thousands of young nurses every year. This study provides an example of such a loss, as six of the 14 nursing students I originally interviewed left nursing right after graduation. What factors make young nurses leave and risk seeking a new career? The answer may offer valuable insights and lessons for improving nursing education and the profession in China. Future studies might also focus on ways to effectively connect to and communicate nursing knowledge and research findings to practitioners in the Chinese healthcare system that can begin transforming the status quo. Researchers could, for instance, work with hospital leadership to collaboratively determine the content of staff training programs and best practices for improving nursing education quality and retaining future nurses. Leadership buy-in and support are crucial to a program’s success because Chinese organizations usually work from the top-down rather than the bottom-up. 144 Finally, my study scratches the surface of transformative learning for Chinese nursing students, particularly in terms of their short-term professional experiences in the US. In the context of study abroad and healthcare, transformative learning is one of the most significantly sought-after learning outcomes, especially regarding students’ international experiences in holistic transformations of self (Anderson Sathe & Geisler, 2017), social and global awareness, multicultural sensitivity (McDowell et al., 2012), and critical social and cultural consciousness in healthcare in developing countries (Armistead & Carter, 2019). Blake-Campbell (2014) and Armistead and Carter (2019) have stressed transformative learning in short-term study abroad program is key to understanding learning significances. Despite this, nursing research has more space to apply a transformative learning lens to analyzing nursing students’ international experiences (Foronda & Belknap, 2012a). Some research findings indicate transformative learning in multicultural awareness and sensitivity, cultural competencies, self-efficacy, healthcare discrepancies in developing countries, professional development, and global health (Edmonds, 2012; Green et al., 2008; Kako & Klingbeil, 2019; Kelleher, 2013; Kulbok et al., 2012; Maltby et al., 2016; Pavlic et al., 2019; Philips et al., 2017). It is noticeable that most of the scholarship in the transformative learning literature in the settings of healthcare education abroad is situated in developing or low-income countries. Employing a transformative lens to international nursing program research will therefore further enrich the literature and guide the effective design of future international, experiential learning programs. Conclusion This dissertation study examined the complicated and nuanced lived experiences with professional socialization of eight Chinese nursing students in Chinese and American hospitals, as well as the implications of those experiences for the students’ professional identity 145 development. The results indicate the association between students’ negative hospital experiences and a wavering sense of professional identity caused participants to exhibit complex, ambivalent feelings for the nursing profession. The students’ positive experiences at the American hospital starkly contrasted with their primarily negative experiences in the Chinese hospitals. Yet, although they felt a sense of pride in being nurses after their time in the American hospital, their perceptions are limited in that they do not comprehensively reflect the complexity of the American healthcare system. Nevertheless, the students expressed their belief in positive changes and their hope for a better future for nursing in China. The current status quo accords low levels of professional identity for nursing students and nurses, which has resulted in a high nurse attrition rate that poses a significant danger to healthcare, public health, and Chinese society broadly. Only when nursing education programs, university leadership, hospital leadership, nurses, and researchers work together to address these issues will it be possible to effectively promote policies that engender positive, sustainable changes and reforms at all levels of nursing education and hospitals. 146 APPENDICES 147 Appendix A: Participant Invitation Letter Dear Student, How are you? I hope all is going well with you. I am currently conducting my dissertation research, and I would like to invite you to participate in this study. My research topic is Understanding Chinese Nursing Students’ Professional Socialization and Identity Development. Your participation will include two interviews. The interviews will be in Chinese lasting between 45 and 60 minutes. The second interview is a follow-up and will take 20 to 30 minutes. All interviews will be recorded and transcribed. You will receive a copy of the interview transcript. Your participation will contribute to a better understanding of Chinese nursing students’ professional identity formation, and the role of education abroad plays in the process. A copy of the consent statement is attached. You agree to participate in the study by receiving this email and signing up for the interview. The interview schedule is attached. I hope you will consider being a part of this study. If you have any questions or concerns, please don’t hesitate to contact me by email or WeChat. I am grateful for your participation and contribution. Thank you so much. Qing Xia 148 Appendix B: Participant Consent Statement 1. Explanation of the research and what you will do: You are invited to participate in an interview-based research study to understand how education abroad program influences nursing professional socialization and identity development among Chinese nursing students. If you agree to participate, I will conduct two interviews with you. The interview questions will include how you chose to study nursing, your learning experience in college and hospital in China, and your learning experience during the education abroad program in the US. The interviews will be conducted in Chinese. The interviews will be recorded and later transcribed. You will be assigned a pseudonym, and all details relevant to your identity will be masked. You will receive a copy of your transcript after the interview. In addition, you will be invited to make corrections or clarifications to the transcript. 研究说明以及您将要做的事情： 您被要求参加基于访谈的研究，以了解海外教育如何影响中国护理专业学生的护理专业社 会化和身份发展。如果您同意参加，我将对您进行两次采访。面试问题将包括您如何选择 学习护理，您在中国的大学和医院的学习经历以及在美国的海外教育项目中的学习经历。 采访将以中文进行。采访将被录音并做文字转录,将为您分配一个您的笔名，所有与您的 身份有关的详细信息都将被屏蔽。面谈后，您将收到文字转录副本。您将被邀请对转录进 行更正或澄清。 2. Your rights to participate, say no, or withdraw: Participation in this research project is completely voluntary. You have the right to say no or change your mind during the research and withdraw. You may choose not to answer specific questions or request not to be recorded. 您的参与，拒绝或退出的权利： 参与此研究项目完全是自愿的。在研究和退出过程中，您有权拒绝或改变主意。您可以选 择不回答特定问题或要求不进行录音。 3. Costs and compensation for being in the study: There is no cost for participating in this study. 参加研究的费用和补偿： 参加这项研究没有任何费用。 4. Contact Information for Questions and Concerns If you have any questions or concerns about this study, such as how to participate, how information gathered will be used, please contact the researcher: 有关问题和疑虑的联系信息 如果您对此研究有任何疑问或疑虑，例如如何参与，如何使用收集到的信息，请联系研究 人员： 149 Qing Xia Doctoral Candidate of Higher, Adult, and Life-long Education (HALE) College of Education Michigan State University Email: xiaqing@msu.edu If you have any questions or concerns about your role or rights as a participant, would like to obtain information or would like to register a complaint about this study, you may contact: 如果您对自己作为参与者的角色或权利有任何疑问或疑虑，想获取信息或希望就本研究进 行投诉，则可以联系： Michigan State University Human Research Protection Program 4000 Collins Road Suite 136 Lansing, Michigan 48910 Phone: 517-355-2180 Fax: 517-432-4503 Email: irb@msu.edu 5. Documentation of informed consent: You indicate your voluntary agreement to participate by receiving this form and sign up for the interview. 知情同意的文件： 您可以通过收到此表格并开始本次面谈来表明您自愿参加。 150 Appendix C: Interview Protocol Background • Tell me about yourself, your hometown, your high school education experience, your Gao Kao, and college admission experiences o How did you feel about studying nursing when you received the admission? Experiences related to nursing education in China ● Tell me about your studies in college. o Can you describe your studies in college? o How do you think your studies has prepared you to be a nurse? o What do you want to achieve to be nurse? o How do you describe public perception of nursing profession in China? ● Tell me a little about your professional experience as a nursing student or a nurse. o Can you describe your experiences in Chinese hospital as a student intern or a nurse? Can you describe a typical day of your job? o What have you learned? o What are the differences between a student intern and a nurse? o Do you have any stories or people who affected your feelings or understanding about nursing in college and in Chinese hospitals? o Do you have any stories of an event, people (patients, teacher, supervisor, peers, people in your life) affected your feelings or understanding about nursing? o Can you describe the advantages and disadvantages for being a nurse in China? Experience related to education abroad in the US o What motivated you to participate in the study abroad program? o Can you describe your experience during the program in the US? o During the program, what experience did you like? Why? o How would you describe your experience at the Great Lakes Hospital? o Can you share with me any event, occasion or American healthcare personnel that stick out in your mind? o How did the experience in the US make you feel about nursing? Comparing the experiences in China and the US • Did you observe differences between the Chinese and American healthcare system and nursing? • What have you learned from the differences? Nursing Professional Identity • How do you describe your school’s effort to establish nursing professional identity? • What do you understand about nursing professional identity? • How would you obtain your nursing professional identity? • Can you tell me about any experiences that affected your understanding of your nursing identity in past a few years? • As a nurse, how do you think about COVID-19 pandemic? Future plan • How do you feel about your future as a nurse? • Do you have anything you want to share with me, or any questions for me? 151 Appendix D: Reflection on Data Collection via Zoom Meetings Zoom technology is powerful. It enabled my international research when the in-person meeting was impossible. Without Zoom, I wouldn’t have completed my study. Instead, Zoom makes it easy to overcome the barriers of space and time differences. However, for my research, Zoom meetings also exposed some limitations. For example, although people can meet online from different time zones, their biological clocks maintain energy levels according to their local time. The natural and physical differences may keep people from performing at the same level of effectiveness. For some people, the brain may be less agile and composed due to the difference in time when conducting the meeting. China and the US have a 13-hour difference. The interviewees and I had opposite energy levels during our meetings. Sometimes, I felt my mind didn’t work as quickly, or the interviewees couldn’t comprehend my questions satisfactorily. In addition, not every person handled the virtual meetings and conversations well. Some were more easily fatigued than others. The feeling of meeting each other in person is different from staring at the camera in Zoom. It was tiring to keep the body in a stiff position with eyes fixed on one spot for a long time. Compared to Zoom meetings, in-person meetings can happen in more relaxed spaces and environments. For example, a meeting at a teahouse or a coffee shop will naturally bring people closer to each other. Conversations can be less intensive, nervous, and more reflexive and responsive. In addition, it is difficult to observe body language in Zoom meetings. Sometimes, body language reveals feelings that are otherwise unexpressed, which are essential for a researcher to understand and interpret verbal cues and expressions. Finally, a teahouse or a coffee shop meeting can easily keep going for two hours, which gives enough time to talk through more thoughts and ideas emerging as the conversation goes on. However, a Zoom meeting always has a fixed period. 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