PROFESSIONAL IDENTITY DEVELOPMENT IN NURSES RETURNING FOR A BSN: A NATURALISTIC INQUIRY

Transcription

1 PROFESSIONAL IDENTITY DEVELOPMENT IN NURSES RETURNING FOR A BSN: A NATURALISTIC INQUIRY A dissertation submitted to the Kent State University College of Education, Health, and Human Services in partial fulfillment of the requirements for the degree of Doctor of Philosophy By Marcy S. Caplin December 2016

2 Copyright, 2016 by Marcy S. Caplin All Rights Reserved ii

3 A dissertation written by Marcy S. Caplin B.A., State University of New York at Binghamton, 1980 M.S.N., Yale University, 1983 Ph.D., Kent State University, 2016 Approved by, Director, Doctoral Dissertation Committee Alicia R. Crowe, Member, Doctoral Dissertation Committee Joanne Dowdy, Member, Doctoral Dissertation Committee Tricia Niesz Accepted by, Director, School of Teaching, Learning, and Alexa L. Sandmann Curriculum Studies, Interim Dean, College of Education, Health and Mark A. Kretovics Human Services iii

4 CAPLIN, MARCY, Ph.D., December 2016 TEACHING, LEARNING AND CURRICULUM SERVICES PROFESSIONAL IDENTITY DEVELOPMENT IN NURSES RETURNING FOR A BSN: A NATURALISTIC INQUIRY (204 pp.) Director of Dissertation: Alicia R. Crowe, Ph. D. The purpose of this study was to understand how nurses with associate degrees in nursing (ADNs) returning for bachelor of science (BSN) degrees experience professional identity development. Major nursing organizations are calling for the BSN to be the entry level for professional nursing practice. If BSN programs produce professional nurses, then it follows that when technical ADN nurses return for a BSN, they undergo a change in professional identity. This study utilized Mezirow s transformation theory to explain the change in professional identity occurring in nurses returning for a BSN. Utilizing a naturalistic design, data were collected from eight nurses in a BSN program through semi-structured interviews and student portfolios. The overarching finding was that nurses returning for a BSN experienced increased confidence that manifested itself in several ways: Nurses became aware of issues related to power and empowerment, such as reducing hierarchies, becoming valued team members, developing a voice, using power, and controlling their careers; nurses perceived an expansion of their roles that they had not previously considered; and nurses experienced an expanded worldview, including a changing image of nursing, seeing the bigger picture, experiencing new possibilities, and a thirst for learning. The findings deepen our understanding of professional identity development in nurses returning for a BSN. Implications for nursing education include developing a

5 curriculum educating nurses about the levels of nursing education, reducing fear and anxiety in returning nurses, and providing experiences that encourage transformation in thinking. Implications for nursing practice include supporting professional identity in the workplace and recognizing nurses who obtain further education.

6 ACKNOWLEDGMENTS Although this dissertation represents my work as a fledgling researcher, I would not have been able to complete this study without the support and guidance of my committee. Dr. Alicia Crowe was my advisor, faculty, and Director of my Doctoral Dissertation Committee. I also now count her as friend. Dr. Crowe, you have been a wonderful mentor, teacher, and advisor. You guided my studies and encouraged me through the dissertation process, even when times got rough. You had complete faith in me, as I did in you. I would also like to thank Dr. Joanne Dowdy, a member of my Doctoral Dissertation Committee. Thank you for encouraging and challenging me as well as for keeping me grounded (smile, peace, blessings). Thank you, Dr. Tricia Niesz, for teaching me qualitative research and being a member of my Doctoral Dissertation Committee. You provided guidance and excellent feedback in my qualitative research courses and helped me strengthen my research study. And, I would like to thank Dr. Theresa Walton-Fisette, my Graduate Faculty Representative. I appreciate the time you took to read my dissertation and the questions you asked during my defense to challenge my thinking. Thank you all for permitting my defense to be an enjoyable learning experience. I appreciate all your brilliant feedback and suggestions. I also want to thank my critical doctoral friend, Kathy Dwinnells. You supported and challenged me. You critiqued and ripped apart my papers to make them better. And, you were there when times got rough, giving me a shoulder to cry on and a meal at Ray s Place. iv

7 To my children, Sarahbeth and Greg, thank you for supporting and cheering me on. Your faith in me was endless. Dave, my husband of 34 years, while you encouraged and pushed me to pursue my doctoral studies, you were fighting your own battle and died before seeing me succeed. Bruce, although our relationship was young, you were proud of me and cheered me on to complete writing and defending my dissertation. Thank you all! It truly took a community to help me be successful! v

8 TABLE OF CONTENTS Page ACKNOWLEDGMENTS... iv LIST OF TABLES... ix CHAPTER I. INTRODUCTION... 1 Background of the Problem... 2 Rationale for This Study... 4 Purpose of the Study... 8 Research Question... 8 Definition of Terms... 8 Assumptions Assumption 1: Nursing is the First Level of Professional Practice Assumption 2: Nursing is a Profession Summary and Organization of the Document II. REVIEW OF THE LITERATURE Socialization Professional Socialization Professional Values Resocialization Formation/Reformation Perspective Transformation Mezirow s Theory Development Basic Tenets Professional Identity Transformation in Nurses Returning for a BSN Summary III. METHODOLOGY Naturalistic Inquiry Procedures Site Selection Sampling and Participants Sample Size Contact With Potential Participants Characteristics of the Sample Characteristics of the Researcher Potential Conflict of Interest vi

9 Data Collection and Analysis Semi-Structured Interviews Student Portfolio Reflections Researcher Notes The Process of Data Analysis Utilizing the data Emergent category designation Negative case analysis Bridging, extending, and surfacing the data Quality Criteria Credibility Peer debriefing Triangulation Member checks Transferability Purposive sampling Thick description Dependability Dependability audit Overlapping methods...76 Confirmability Confirmability audit Reflexivity Conclusion IV. FINDINGS Overarching and Major Findings Confidence: The Overarching Finding From Failure to Success: One Nurse s Story Confidence in Nursing Practice Empowerment Leveling the playing field Valued member of the team Voice Power Control over career Summary Role Development User of evidence-based practice Disseminator of knowledge Change agent Leader Advocate Educator vii

10 Summary Change in Worldview Changing image of nursing Seeing the bigger picture Summary Conclusion V. DISCUSSION AND IMPLICATIONS The Research Question Summary of Key Findings Discussion Relationship Between Confidence and Knowledge Power and Empowerment Leveling the Playing Field Nurse-Patient Hierarchy Tensions Professional Identity Transformation Limitations Implications Implications for Nursing Education Implications for Nursing Practice Future Research Conclusion APPENDICES APPENDIX A. INVITATION TO PARTICIPATE IN STUDY APPENDIX B. INFORMED CONSENT TO PARTICIPATE IN RESEARCH STUDY APPENDIX C. CONSENT TO AUDIOTAPE INTERVIEW APPENDIX D. INTERVIEW QUESTIONS REFERENCES viii

11 LIST OF TABLES Table Page 1. Participant Information Codes Following First Interview Codes Following Second Interview Final List of Codes ix

12 CHAPTER I INTRODUCTION Nurses with an associate degree in nursing (ADN) are returning to school for bachelor of science in nursing (BSN) degrees in record numbers in RN/BSN degree completion programs due to the increasing complexity of patient care, changing patient demographics, scientific advances, healthcare reform, and new technologies (American Association of Colleges of Nursing, 2008). Aiken, Clark, Cheung, Sloane, and Silber (2003), in their landmark study, found that the education level of nurses does make a difference in patient care outcomes. Specifically, they found that each 10% increase in the proportion of nurses with [bachelor s or master s] degrees decreased the risk of mortality and of failure to rescue... by 5% (p. 1620). The Institute of Medicine s (IOM) Future of Nursing (2010) report also recommends that nurses achieve higher levels of education to ensure safe, quality patient-centered care. Specifically, the report recommends that 80% of the nursing workforce hold a BSN degree by The American Association of Colleges of Nursing (AACN) recognizes the four-year BSN as the minimal level of education for professional nursing. The AACN document, the Essentials of Baccalaureate Education for Professional Nursing Practice (2008), delineates the outcomes for graduates of BSN programs. Each of the nine identified Essentials represents curricular elements that provide the framework for baccalaureate nursing education (p. 10). In particular, Essential VIII addresses professionalism and professional values. The use of the term professional implies the 1

13 2 formation of a professional identity and accountability for one s professional image (AACN, 2008, p. 9). If BSN programs produce professional nurses (AACN, 2008), then it follows that when ADN nurses return to school for a BSN, the nurses undergo a change in professional identity. Therefore, the purpose of this qualitative naturalistic inquiry study was to identify how nurses with associate degrees returning for a BSN degree experience professional identity development. Mezirow s transformational learning theory was used as the conceptual framework to understand how professional identity was transformed in these nurses returning for a BSN degree. This study will add to the growing body of knowledge that nurses returning to school for a BSN degree experience a transformation in professional identity. The results of this study have important curricular implications for nurse educators to understand how nurses in a BSN program experience professional identity transformation and to design nursing programs that enhance transformational experiences that lead to professional identity development. Background of the Problem Currently, there are three entry education levels into nursing practice. Diploma programs are typically two or three year hospital-based programs, based on the apprenticeship model of practice. The ADN program is also a two- or three-year program, typically offered through community colleges. The BSN program is a four-year degree offered at the college or university level. Although the graduates of each of these programs take the same licensing examination and receive the same title of registered nurse through the State Board of Nursing, diploma and ADN programs are often referred

14 3 to as technical programs (Megginson, 2008). The RN/BSN program, or degree completion program, provides the nurse with a diploma or ADN the opportunity to meet the additional course requirements needed to earn a BSN degree. The BSN education covers the basic nursing curriculum of diploma and ADN programs, but also includes the physical and social sciences, nursing research, public and community health, nursing management, and the humanities (AACN, 2014, para 4). According to the AACN (2014), this additional education, enhances the student s professional development, prepares the new nurse for a broader scope of practice, and provides the nurse with a better understanding of the cultural, political, economic, and social issues that affect patients and influence healthcare delivery (para 4). Mildred Montag developed the ADN concept of education in 1959, as part of her doctoral dissertation. This degree was originally intended to train technical nurses who would assist the professional BSN nurse (Megginson, 2008). In 1965, the American Nurses Association (ANA) issued a position paper recommending that the BSN be the minimum educational preparation for professional nursing practice. These events sparked the debate about minimal entry level into professional nursing practice that persists, and remains heated, to this day. While there has been much controversy about whether the BSN should be the entry level into nursing practice, it is generally accepted that the BSN degree represents the first level of professional nursing practice (AACN, 2014). Key organizations are calling for the BSN as the minimal level for professional practice. In 2000, the AACN recognized the BSN as the minimal level of education for

15 4 professional nursing practice. The IOM (2010) report, The future of nursing: Leading change, advancing health, recommended an increase in the number of BSN nurses to 80% by Benner, Sutphen, Leonard, and Day (2010) and the Carnegie Foundation for the Advancement of Teaching, in their study Educating nurses: A call for radical transformation, recommended that all nurses be prepared at the BSN level for entry into practice and that all nurses earn a master s degree within 10 years of licensure. The American Organization of Nurse Executives (AONE, 2005) also supports the BSN as the entry level into practice. Furthermore, research suggests that BSN nurses play a positive role in safe patient outcomes. In their landmark study, Aiken et al. (2003) found that mortality and failure to rescue rates are lower in surgical patients when there are higher percentages of nurses at the BSN level or higher on staff. In 2008, Aiken, Clarke, Sloane, Lake, and Cheney reaffirmed the results of their 2003 study, finding that for every 10% increase in the proportion of BSN nurses in a hospital, the risk of death decreased by 4%. Numerous other studies also show favorable outcomes associated with BSN-prepared nurses (Blegan, Goode, Park, Vaughn, & Spetz, 2013; Estabrooks, Midodzi, Cummings, Ricker, & Giovanetti, 2005; Friese, Lake, Aiken, Silber, & Sochalski, 2008; Kendall-Gallagher, Aiken, Sloane, & Cimiotti, 2011; McHugh et al., 2013; Tourangeau et al., 2007). Rationale for This Study Throughout my 15 years of teaching in an RN/BSN program, I have noted that many nurses in the courses that I teach did not know what a BSN would mean to them prior to starting the program. They were surprised at the changes within themselves as

16 5 they became a professional nurse. I have observed their professional identities transform as they move through the program. Students develop new professional goals as a result of their participation in BSN education and some expressed disbelief that they were continuing for a master s degree, something they previously never considered. Other nurses talked about how they now had the courage to try writing, presenting, and even running for office at the local or state level to affect greater changes in healthcare. In the RN/BSN courses that I teach, many nurses have commented that the BSN program opened their minds to possibilities that they did not know existed for them as a nurse beyond being at the patient s bedside. As an example, they became aware of areas of activism and advocacy in which they could make a difference. Some nurses described themselves as being able to look at the bigger picture, applying research in their nursing practice, and having increased confidence as part of an interprofessional team. I began to question why this change in thinking occurred, what this change in thinking represented, and how we, as nurse educators, could promote these changes in perspectives among nurses returning for a BSN. Many nurses in my courses found it eye-opening to see how nurses in different health settings across the country looked at issues from a variety of lenses and have learned different perspectives from these nurses. They realize that there is a world of nursing practice beyond Northeast Ohio that they did not know about. Mezirow (Merriam & Bierema, 2014) called this a transformational experience. Mezirow contended that returning to school and experiences in school can create disorienting dilemmas that lead to transformational experiences. For Mezirow, education helps adults

17 6 transform how they think of themselves and their world and includes life experience, critical reflection, and the connection between transformative learning and development. Based on my 15 years of experience teaching in an RN/BSN program, I felt that Mezirow s theory of transformational learning provided a lens through which to understand the changes in professional values, and thus, professional identity, that occurred in nurses with ADNs returning to school for a BSN degree. The traditional explanation has been that nursing students go through a socialization process in nursing school that leads to the acceptance of the attitudes and values of the nursing profession (Cragg & Andrusyszyn, 2005). After a student was socialized into the nursing profession, it was believed that nurses, such as the nurse returning for a BSN, became resocialized as they engaged in educational programs or assumed new positions (Hinshaw, 1977). A current understanding about the process experienced by nurses returning for a BSN is that nurses, who are already socialized, go through a process of perspective transformation of their professional values as they obtain their BSN education (Maltby & Andrusyszyn, 1997). Mezirow s theory of transformative learning is used to explain how nurses go through a transformation in their frames of reference when they encounter what he termed disorienting dilemmas that challenge their current frames of reference. Several studies suggest that perspective transformation occurs in nurses who return for further education (Cragg & Andrusyszyn, 2005; Cragg, Plotnikoff, Hugo, & Casey, 2001; Faulk, Parker, & Morris, 2010; Morris & Faulk, 2007). Transformational learning may result from an unexpected event that occurs as nurses in a BSN program are exposed to new ideas and ways of looking at the world. For

18 7 other nurses, returning to school itself may create a disorienting dilemma that changes a nurse s previously held assumptions and frames of references. When faced with such disorienting dilemmas, nurses must evaluate their behaviors, values, and beliefs with these new ideas and make decisions regarding incorporation of these new ideas into their professional identity. Professional values are a component of a nurse s professional identity (Benner et al., 2010). Many quantitative studies have shown that professional values scores increase in nurses who return for a BSN (Cragg et al., 2001; Koomey, Osteen, & Gray, 2015; Kubsch, Hansen, & Huyser-Eatwell, 2008; Wolf & Hoerst, 2007), suggesting that a change in professional identity occurs. However, Wolf and Hoerst (2007) also found that on entry into a BSN program nurses scores were lower than prelicensure BSN student scores. Additionally, Kubsch and colleagues (2008) noted that professional values scores fell after nurses graduated from their BSN and returned to the workplace. These studies by Wolf and Hoerst and Kubsch et al. suggest that the workplace is not supporting professional values, and by extension, professional identity. Qualitative studies (Delaney & Piscopo, 2007; Einhellig, 2012; Kalman, Wells, & Gavan, 2009; Lillibridge & Fox, 2005; Megginson, 2008; Rush, Waldrop, Mitchell, & Dyches, 2005; Zuzelo, 2001), looking at nurse s experiences in a BSN program, found that nurses changed, both personal and professionally, as a result of their BSN education. The current study will continue to add to this growing body of knowledge that nurses with ADNs experience a transformation in professional identity when they return for their BSN education.

19 8 Purpose of the Study The purpose of this qualitative naturalistic inquiry research study was to understand how associate degree nurses returning for a BSN education experienced professional identity development. Since nurse educators play an important role in the professional identity development of nurses returning for a BSN degree, the findings of this study will add to their understanding of how they can promote professional identity development in these returning nurses. The results of this study will also help nurse managers support professional identity in the workplace in nurses with a BSN. Research Question Based on this purpose, I sought to answer the following question: How do nurses returning to school for a BSN experience professional identity development as a result of participation in a BSN program? Definition of Terms The following definitions provide a common understanding of key terms used in this study. The defined terms are those that are at the core of the study, may not be understood by non-nurses, or have multiple meanings. Advanced degree in nursing: The nurse with an advanced degree has graduated from a graduate program in nursing and holds a Master of Science in Nursing (MSN). Associate degree in nursing (ADN): The degree conferred from a nursing program that requires at least two years of academic coursework (Finkelman & Kenner, 2016). Graduates of an ADN program are eligible to take the National Council Licensure Examination (NCLEX) to become a licensed registered nurse.

20 9 Bachelor of science in nursing (BSN): The degree conferred following a four-year course of study in a nursing program at the college or university level (Finkelman & Kenner, 2016). Graduates of a BSN program are eligible to take the NCLEX to become a licensed registered nurse. Diploma in nursing: A diploma, usually awarded by a hospital-based nursing program, following completion of a two-year program of study. It is a non-academic degree that allows graduates to take the NCLEX to become a licensed registered nurse. NCLEX: The National Council Licensure Examination (NCLEX) is a national examination required to obtain the license of registered nurse. There are two examinations, one for licensed practical nurses (NCLEX-LPN) and another for registered nurses (NCLEX-RN). When used by participants in this study, NCLEX refers to the examination for registered nurses. In the interviews, many of the participants simply refer to it as the exam. Nurse: This term refers to an individual who has graduated from a nursing program (diploma, ADN, or BSN), has passed the NCLEX, and holds a registered nurse license. Also referred to by nurses in this study as floor nurse or staff nurse. Nursing unit: An area in a healthcare facility with a specialized function serving a specific population of patients, such as a surgical, labor and delivery, or intensive care unit. Also referred to as a nursing floor. Prelicensure nursing program: A prelicensure nursing program is an entry level nursing program for those who do not hold a nursing license. Prelicensure programs include diploma, ADN, and BSN programs.

21 10 Professional identity: Professional identity is the sense of self as a professional nurse (Finkelman & Kenner, 2016) that evolves overtime. Professional values: Professional values are the standards for action that are accepted by the practitioner and/or professional group and provide a framework for evaluating beliefs and attitudes that influence behavior (Weis & Schank, 1997, p. 366). RN/BSN program: A program in which nurses with a diploma in nursing or ADN return to college for a BSN degree. Also called degree completion program. Staff nurse: A nurse hired to provide direct care to patients in a healthcare facility. May also be referred to as a floor or bedside nurse. Assumptions To better understand this study, two basic assumptions about professional identity development in nurses with associate degrees returning for a BSN degree need to be shared. These assumptions are the following: 1. The BSN degree is the first level of professional nursing practice. 2. Nursing is a profession. Assumption 1: Nursing is the First Level of Professional Practice The first assumption, that the BSN is the first level of professional nursing practice, has been defined and explored above in Background to the Problem. If a BSN is considered the first level of professional education, then the RN/BSN program is responsible for producing professional nurses.

22 11 Assumption 2: Nursing is a Profession The second assumption that is key to this study of professional identity development in nurses with an associate degree returning for a BSN is that nursing is a profession. To understand professional identity development in nurses, it must be presumed that nursing is, in fact, a profession. This is a concept that, like educational levels, has been the subject of much controversy in nursing. A profession has certain characteristics, which Finkelman and Kenner (2016) have summed up as: A systematic body of knowledge An education that occurs in institutions of higher learning A commitment to service A practice that demonstrates autonomy, responsibility, and accountability A practice that is controlled through standards and a code of ethics A commitment to the profession by all members While nursing meets most of these criteria for a profession, the biggest controversy lies in the multiple levels of education for entry into practice. As the first assumption demonstrates, there is a strong movement within the profession to move the entry level into professional practice to the baccalaureate level. Increasing the entry level to the BSN degree will also help address the need for a systematic body of knowledge. Nursing is developing a growing body of research and theory that is helping to define it as a profession. Moreover, through BSN education, nurses learn to use theory and research in their practice.

23 12 Nurses have a strong commitment of service to the public, making nurses accountable for staying updated on best practices and providing safe care. Nursing has established standards of care that identify the scope and limits of practice, such as the ANA Nursing: Scope and Standards of Practice (ANA, 2010). The ANA has also established A Code of Ethics for Nurses (2015a) to maintain standards of care and protect the public as well as the Nursing s Social Policy Statement (ANA, 2015b). Summary and Organization of the Document With record number of nurses returning for a BSN, it is important to understand the transformations that occur in professional identity as nurses move from a two-year technical associate degree towards a professional baccalaureate degree. In this chapter, I provided background and a rationale for the study, a statement of purpose, the research question, definition of terms, and fundamental assumptions key to understanding this study. In Chapter 2, I present the literature related to professional identity development in nurses. The literature review helps us to understand how socialization, resocialization, and professional socialization influence professional identity development. The recent trends towards formation and Mezirow s perspective transformation in influencing professional identity is also explored. Chapter 2 ends with a discussion of the development of professional values in nursing. In Chapter 3, I present how my conceptual framework led me to choose naturalistic inquiry as the epistemological stance for this study. In turn, I describe how naturalistic inquiry informed my selection of data collection methods, data analysis, and trustworthiness. In Chapter 4, I present the thick rich descriptions and the findings from the study. In the final chapter, Chapter 5, I

24 13 discuss the findings of this study, implications for nursing education and practice, and suggestions for future research.

25 CHAPTER II REVIEW OF THE LITERATURE In this chapter, I review the literature on key topics that inform my research on professional identity development in nurses with ADNs who return for a BSN degree. In order to understand professional identity development in nurses returning for a BSN degree, it is important to understand the concepts of socialization and resocialization in nursing practice since these processes teach nursing students the rules and behaviors of the nursing profession and help to shape their professional identity. These two concepts are key because, historically, they have been used to explain the changes experienced as students moved from student nurse to nurse (socialization) or as nurses changed their nursing roles or returned for further education (resocialization). Professional socialization, a specific type of socialization, occurs as students attain and incorporate the values and behaviors of the profession. Although the literature refers to both the terms socialization and resocialization to describe the process experienced by nurses returning for a BSN degree, I discuss studies that refer to nurses returning to school for a BSN under resocialization so that they can more easily be compared and contrasted to other studies looking at resocialization. More recently, some nurses have challenged the concepts of socialization and resocialization in favor of the processes of formation and reformation (Benner et al., 2010); therefore, I review more recent literature on the formation/reformation process. Mezirow s transformation theory is the conceptual framework used in this study to understand the process of perspective transformation that nurses undergo when they return for a BSN degree. So, at the end of the chapter, I 14

26 15 present Mezirow s theory along with studies that have used transformation theory as a framework to describe the change in values, attitudes, and behaviors that occur in nurses returning to school for a BSN. Socialization Historically, socialization is a key process in the professional identity development of a nurse. Students enter nursing school with a preformed notion of nursing and are transformed from a layperson to nurse. Socialization involves learning social behaviors in order to conform to and become a member of a group (Blais & Hayes, 2016). Socialization occurs through experience with socializing agents. In children, agents of socialization may include family, teachers, and friends. In adults, these agents may continue to include those from childhood in addition to coworkers and superiors in the workplace, peers, and members of social groups. In the adult, socialization is a process that prepares individuals for the roles they will assume as members of a group, career, or society (Hinshaw, 1977). It involves learning the knowledge and skills and undergoing an internalization process to prepare for these roles (Kramer, as cited in Hinshaw, 1977). For nurses, socializing agents include nursing instructors, peers, nurses, other healthcare professionals, preceptors, mentors, and, even, patients and families. Throwe and Fought (1987) defined socialization as the acquisition of new knowledge as well as attitudes, concepts, and roles (p. 15), with each change in practice requiring another period of socialization. They described socialization as ongoing as the nurse learns new roles; others call this process resocialization (Blais & Hayes, 2016;

27 16 Hinshaw, 1977; Hood, 2010; Lynn, McCain, & Boss, 1989). Throwe and Fought (1987) described socialization as a five-step process: (1) the development of identity and projection of self worth: (2) acquisition of new knowledge, attitudes, and skills; (3) interaction with others who emulate the role; (4) assessment of others reactions to the role; and (5) preparation for future role enactment. (p. 15) They noted that nurses returning for a BSN may find the ability to adapt to new attitudes and roles difficult, leading to anxiety and tension. Socialization has two phases: primary and secondary socialization (Morris & Faulk, 2012). Primary socialization occurs in childhood as the child learns from family, friends, school, and society. Secondary socialization occurs throughout adulthood through interactions in society and the workplace. It is during this secondary phase that students enter nursing programs and begin to learn the knowledge, attitude, and skills of the nursing profession, called professional socialization. Socialization of students in prelicensure nursing programs exposes them to key values, norms, and attitudes of the profession that help students develop a professional nursing identity (Blais & Hayes, 2016). Nursing students may be surrounded by a new set of values, attitudes, and behaviors with which they are not familiar. They need to reconcile their values, attitudes, and behaviors to those of their socializing agents, such as faculty and the nurses with whom they work during their clinical experiences. Mariet (2016) described that socialization can be both formal and informal. In a nursing program, formal socialization includes those activities that are planned in the

28 17 curriculum. Informal socialization is incidental to the planned curriculum, such as observing a nurse performing nursing care or interacting with a patient, and are contingent upon the student spending extended time with nurses in the healthcare setting. Several models explain the initial socialization process of prelicensure students in nursing, including the Simpson, Hinshaw, and Davis models (Blais & Hayes, 2016). The Simpson model has three stages: learning specific tasks, attaching to significant people in the profession, and internalizing professional values and adopting appropriate behaviors. The Hinshaw model also has three phases and is an adaptation of Simpson s model. Hinshaw s model differs in that it assumes that adults are actively involved in the process of socialization and have made a decision to learn new role behaviors and to be part of the socialization process. The Davis Doctrinal Conversion model has six stages that involve internalizing values, norms, and expectations of the profession: initial innocence work, labeled recognition of incongruity, psyching out and role simulation, increasing role simulation, provisional internalization, and stable internalization. Traditionally, it was thought that a nursing professional identity was developed through the process of socialization in nursing school (Blais & Hayes, 2016). Others suggest that it may begin before students enter a nursing education program as they begin to form beliefs about nurses and the nursing profession through experience with a nurse, the media, or their own beliefs of what it means to be a nurse (Hensel, Middleton, & Engs, 2014). Although a nursing program is a crucial time for professional identity development to occur, the process is ongoing throughout a nurse s career (Crigger & Godfrey, 2014; Johnson, Cowin, Wilson, & Young, 2012; MacIntosh, 2003). A nurse

29 18 already socialized into the profession may, for example, go through a period of change in professional identity when faced with dissonance between beliefs and actual experiences, when changing positions or responsibilities, or when returning to school. Professional identity continues to grow and deepen through nursing practice, the influence of peers, and participation on committees at work, professional organizations, and continuing education (Crigger & Godfrey, 2014). Professional Socialization A key element of BSN education is professional socialization, with the student internalizing values that are key to the nursing profession and developing a professional identity (Harrington, 1996). Whereas there are many definitions of professional socialization, they tend to have similar qualities, such as being an ongoing process; the acquisition of new knowledge, skills, and behaviors; and internalization of values. Du Toit s (1995) analysis of the definitions of professional socialization noted that values was a common theme as was norms, which she defined as the concretization of values (p. 165). Although a student enters school with a set of values, these values may change as the student is socialized to the values of the profession. Behavior was also a common theme in the definitions of professional socialization, since behaviors change as values change. A third common theme in these definitions of professional socialization was a change in the individual s concept of self to such an extent that a nursing identity develops (p. 166). Howkins and Ewens (1999) noted a shift in thinking in the professional socialization literature from the process of socialization being linear and passive to one of

30 19 it being a proactive process. In their study of how students made sense of the socialization process, they found that students past experiences were significant in shaping their professional socialization, making the professional socialization process complex and diverse (p. 41). Key to this process was the opportunity to reflect on practice. They concluded that professional socialisation should be seen from a new perspective (p. 48). Fagermoen (1997) pointed out that one difficulty in the study of professional identity in nursing is that the term is often used interchangeably with other concepts, such as professionalism, role perceptions, professional self, and self-concept. In her research on professional identity in nurses, Fagermoen used a definition of professional identity that linked it directly with daily nursing practice. For her, professional identity is the nurse s conception of what it means to be and act as a nurse; that is, it represents her/his philosophy of nursing... the values and beliefs held by the nurse that guide her/his thinking, actions, and interaction with the patient (p. 435). Further, she described professional identity as the values and beliefs held by the nurse that guide his/her thinking, actions, and interaction with the patient (p. 435). In these definitions, the nurse s values are closely linked to professional identity and these values are acquired through professional socialization. Like Fagermoen, Johnson et al. (2012) noted that a difficulty in the study of professional identity is that other terms are often used and confused with professional identity. Johnson and colleagues pointed out that the term self-concept is frequently seen in the literature when talking about professional identity and that the two constructs are

31 20 interwoven, making the study of each, as a separate entity, difficult. Johnson and colleagues, however, argued that professional identity and self-concept are different constructs. Self-concept is how people think and feel about themselves while professional identity is how individuals perceive their role in their work, an element of their total identity. They further noted that professional identity frequently is not defined in the nursing literature and studies. Professional Values Professional socialization occurs as students attain and incorporate the values and behaviors of the profession. Internalization of these values is a key process in professional identity development (Harrington, 1996). Professional values reflect the standards of the profession and guide the actions of the profession s members. In nursing, professional values are learned through prelicensure nursing education programs (Kubsch et al., 2008). These professional values and the accompanying behaviors are fundamental to professional nursing practice. Several nursing organizations have put forth documents that outline professional nursing values. According to the American Association of Colleges of Nursing (AACN) (2008) Essentials of Baccalaureate Nursing Education for Professional Nursing Practice, which guides curriculum for BSN programs, professional values include altruism, autonomy, human dignity, integrity, and social justice. The American Nurses Association (ANA) Code of Ethics for Nurses (2015a) is also a source of professional values for nurses. The values in this Code include (1) commitment to public service, (2) autonomy, (3) commitment to lifelong learning and education, and (4) a belief in the

32 21 dignity and worth of each person (Masters, 2014, p. 158). The National League for Nursing (NLN) Outcomes and Competencies for Graduates identified seven core values: caring, diversity, ethics, excellence, holism, integrity, and patient-centeredness. The core values feed into the four program outcomes, one of which is professional identity (NLN, 2012). The ANA Nursing: Scope and Standards of Practice (2010) and ANA Nursing s Social Policy Statement (2015b) also provide professional nursing values that are fundamental to developing a professional identity. Although several studies have compared professional values in nursing students and nurses at different levels of education, their results are difficult to compare since there is no consistency in the instruments used to measure professional values. Kubsch et al. (2008) compared professional value scores in nurses with a diploma or ADN, BSN, and MSN degrees to nurses enrolled in an RN/BSN program. They believed that, since the curricula are different, the type of prelicensure nursing education a nurse obtains may make a difference in professional value development. Associate degree and diploma nursing programs focus on technical skills needed to perform basic nursing care. BSN programs include these technical skills as well as liberal education, theory, and scholarship to allow nurses to provide more complex care. Baccalaureate programs also support the AACN s core nursing values of human dignity, integrity, autonomy, altruism, and social justice (Kubsch et al., 2008, p. 376). Kubsch et al. (2008) used the Professional Values Survey that they developed to measure professional values scores. Items on this scale measure professional characteristics from key nursing documents: the ANA Code of Ethics, ANA Social Policy

33 22 Statement, ANA Standards of Practice, and the AACN Essentials of Baccalaureate Nursing Education for Professional Nursing Practice. Items on this survey also reflected the characteristics of a profession and Hall s Core Circle which focuses on the social, emotional, spiritual, an intellectual needs of the family, community, an world and the therapeutic use of self (Kubsch et al., 2008, p. 377). They found that level of education made a significant difference in perceived professional values with RN/BSN students having the highest perceived professional values. Those with membership in a professional organization also had a significantly higher perception of professional values. An interesting finding was the drop in perceived professional value scores after nurses graduated from an RN/BSN program. Kubsch et al. (2008) suggested that following graduation, nurses are quickly resocialized into the medical model of the workplace which does not support nursing professional values. Kubsch and colleagues suggested that the professional values learned in nursing programs are especially vulnerable because they are not yet clarified (p. 376). In contrast to Kubsch et al., Martin, Yarbrough, and Alfred (2003) found that ADN graduates had higher scores than BSN graduates on professional values. Martin and colleagues used the Nurses Professional Values Scale (NPVS) to determine congruency in value orientation in ADN and prelicensure BSN program graduates. Although they found no significant difference in total NPVS scores, ADN graduates had higher scores on 5 of 11 subscales (right to privacy, assuming responsibility and accountability, exercising informed judgment, implementing and improving standards of

34 23 nursing, and collaborating with others) than the BSN program graduates. They did, however, find that males in both programs scored lower than women on total NPVS scores and ethnic groups in both programs differed on response to the subscales of respect for human dignity, safeguarding the client and public, and collaborating to meet public health needs. Martin et al. did not offer any possible explanations for their findings. The results of the findings by Kubsch et al. and Martin et al. are difficult to compare since different instruments were used to measure professional values. Fisher (2014) used the revised NPVS (NPVS-R) to compare professional value development in diploma, ADN, and BSN nursing students, at the start and end of the programs and found results that were not consistent with those of Martin et al. (2003). Diploma nursing students had significant differences in scores related to caring, trust, professionalism, and justice. Students in the ADN and BSN programs had no significant difference in professional value scores between the beginning and end of their programs. Koomey et al. (2015) observed that the findings of Fisher s study are not consistent with the expectation that socialization to professional values are key curricular components of ADN and BSN programs. Students in RN/SN programs were not, however, included in Fisher s study. Koomey et al. (2015) used the PVS, as did Kubsch et al. (2008), to explore the importance of professional values in nurses in an RN/BSN program. Overall mean PVS scores indicated that RN/BSN students viewed professional nursing values as highly important, with confidentiality, human dignity, and patients rights ranked as the most important professional values. They concluded that their findings were consistent with

35 24 Kubsch and colleagues who found the highest mean scores in RN/BSN students than the other levels of nursing education. Resocialization In contrast to socialization, the term resocialization has been used to describe the process that occurs when nurses, already socialized to the profession, return to school for a BSN, change work positions, or take on new roles and responsibilities (Hood, 2010). Resocialization also describes the process new nurses go through as they leave their education program and enter the workforce. As these new nurses take their knowledge, values, and behaviors learned in nursing school and integrate them into the values and behaviors of the workplace, they often experience a period of conflict and role stress (Kramer, 1975). Hinshaw (1977) reported that nurses experience resocialization throughout their careers, in both the practice and educational settings. During the resocialization process, the nurse learns new values, skill, and attitudes (Marquis & Huston, 2015). New social rules may also need to be learned if the nurse has a change of role or responsibility within the same organization or a new organization. Resocialization may also occur in the nurse who returns to school, such as the nurse with an ADN pursuing a BSN degree. These nurses may need to work through negative feelings, especially if they felt forced to return to school. For example, many ADN nurses feel that they are already professionals and harbor resentment at having to pursue a BSN degree (Lillibridge & Fox, 2005). Likewise, Rush et al. (2005) reported that nurses in RN/BSN programs often felt unfinished, not quite a professional nurse.

36 25 The need to obtain a BSN may make ADN nurses question the credibility of their previous nursing education and their competence as a nurse (Megginson, 2008). Several models exist to explain the ongoing socialization that occurs as the new nurse graduates and begins to work in the clinical setting. These models include Kramer s postgraduate resocialization model, Dalton s career stages model, and Benner s novice to expert model (Blais & Hayes, 2016). However, these models do not explain the experiences of the nurse with an ADN returning for a BSN. Kramer s Postgraduate Model is a four-stage model that seeks to explain the reality shock that new nurses often experience when their expectations and the realities of the work setting do not match. In the first stage of this model, skill and routine mastery, the new nurse focuses on developing technical skills. In the second stage of social integration, the emphasis is on being accepted and having competence recognized. In moral outrage, the third stage, the new nurse identifies inconsistencies between the bureaucratic role (rules, regulations, and organization loyalty), the professional role (continued learning and professional loyalty), and the service role (compassion, caring, and loyalty to the patient as a person). In the final stage of conflict resolution, the new nurse resolves the conflicts of stage 3 by meshing the values and behaviors of the organization with those of the profession (Blais & Hayes, 2016). Dalton s Career Stages Model is a four-stage model that identifies four sequential stages of a professional career: the entry, colleague, mentor, and sponsor stages. As a person moves through these stages, activities, relationships, and psychological issues change (Blais & Hayes, 2016). Benner s Novice to Expert Model describes five levels of nursing competency based on the Dreyfus model of skill

37 26 acquisition: novice, advanced beginner, competent practitioner, proficient practitioner, and expert practitioner (Blais & Hayes, 2016). Although these models help us consider resocialization in nursing broadly, a review of the literature revealed one model specifically developed to describe resocialization in nurses returning for a BSN degree and the unique challenges they bring with them to the classroom. This model, developed by Throwe and Fought (1987), was based on Erikson s theory of developmental stages. Although they called it a socialization model, I have included it here because it specifically describes the process of nurses, who have already been socialized in their prelicensure nursing program, returning for a BSN degree. As educators, Throwe and Fought (1987) noted that nurses who returned to school for a BSN experienced tension and anxiety in gaining new knowledge, behaviors, and roles. They used Erickson s Developmental Model to help faculty and students identify resisting and accepting behaviors. For each of Erikson s eight developmental stages, they devised behaviors that nurses and faculty could use to assess progress and to identify role-resisting and role-accepting behaviors. The final stage, equivalent to Erikson s stage of ego integrity/despair, is that of consistent role enactment in which the nurse is able to incorporate the professional role into self (p. 16). A little troublesome was the conclusion by Throwe and Fought that by reaching this final stage the RN as learner has undergone a socializing process and is now capable of being a contributing member of the nursing profession (p. 16), implying that the ADN nurse was not a capable nurse nor a professional nurse before returning for a BSN degree.