Nurse Educator
Nurse Educator Vol. 40, No. 1, pp. 26-30 Copyright * 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins
Becoming a Nurse Role Formation Among Accelerated Baccalaureate Students Tanya L. Ostrogorsky, EdD & Anjanette M. Raber, PhD, RN & Claire McKinley Yoder, MSN, RN Ann E. Nielsen, PhD, RN & Kristin F. Lutz, PhD, RN & Peggy L. Wros, PhD, RN To understand nursing role formation for students enrolled in an accelerated baccalaureate nursing program, end-of-term narrative reflections from 34 students were analyzed over the course of the 15-month program. Using thematic analysis, 4 major themes were identified: evolving role perception, extending nursing student-patient interaction, engaging with health care team and systems of care, and expanding clinical thinking. Keywords: accelerated nursing program; nursing students; role formation; social development; social identity
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his study examined accelerated baccalaureate (AB) nursing students’ role development trajectory throughout a 15-month program. Although recent AB graduates applied the necessary nursing knowledge and skills to be licensed and function competently in clinical settings, faculty members questioned whether students’ attitudes and nursing identity developed as rapidly as cognitive skills. These concerns were based on anecdotal feedback regarding readiness for practice and concerns about program length. In response, a study was developed to focus on AB students’ nursing role formation. This article presents the study findings and recommendations for nursing faculty.
Literature Review An abundance of literature is aimed at AB students and programs. Studies describe student outcomes, single program reviews, student demographics, characteristics, teaching strategies, and socialization. However, there is a paucity of research focused specifically on role formation in AB nursing education. Only 1 study1 specifically examined learning of formative skills in second-degree students in a master’s entry program in nursing (a similar demographic group to AB students). In that study, researchers focused on stages of professional identity development as they examined experiences that influenced the development of nursing identity. Author Affiliations: Assistant Vice Provost for Assessment and Evaluation (Dr Ostrogorsky), Research Associate (Dr Raber), Assistant Professor (Ms McKinley Yoder), Assistant Professor and Director of Undergraduate Program–Portland (Dr Nielsen), Assistant Professor (Dr Lutz), and Senior Associate Dean for Student Affairs and Diversity (Dr Wros), Oregon Health & Science University, Portland, Oregon. The authors declare no conflicts of interest. Correspondence: Dr Ostrogorsky, Oregon Health & Science University Office of the Provost, 3181 SW Sam Jackson Rd (L349), Portland, OR 97239 ([email protected]). Accepted for publication: August 22, 2014 Published ahead of print: October 4, 2014 DOI: 10.1097/NNE.0000000000000090
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Volume 40 & Number 1 & January/February 2015
Nursing Role Formation and the Developmental View Role formation during nonaccelerated nursing education programs has been described multiple ways including socialization,2 self-concept as a nurse,3,4 nursing identity,5,6 and professional nursing accountability.7 All of these concepts focus on the developmental process of moving from being a layperson to being a professional nurse.8 This process has been associated with ethical development, notions of good, and understanding nursing’s social contract for patients.5 Components of selfconcept or professional identity have been shown to increase over the course of time spent in the nursing program.3 Students’ perceptions, knowledge, skills, abilities, and their way of being in the world change over time from that of an outsider to an insider within the culture of nursing.5,9 This is consistent with the work of Seacrest et al,10 who identified 3 themes in the developmental trajectory: (a) belonging, (b) knowing, and (c) affirmation. Day et al2 found that students’ sense of professional nursing evolved over the course of 4 years with students beginning with a preconceived image of nursing that changed as they moved in defined sequential stages through the program. Students’ sense of identity was unclear and vulnerable in year 1 and was shaped by media images of nursing. It was not until year 3 that students demonstrated a personal sense of responsibility for care as they shifted from doing for others to working with the patient. As students gained a deeper understanding of the role and developed a professional nursing identity, they acquired the ability to articulate and defend their perspectives on patient condition and care needs. However, not until year 4 did students truly internalize the professional values, combined with a realistic rather than idealized understanding of their nursing practice. This trajectory aligns with Ware’s4 description of taking it all in. Ware found traditional baccalaureate students acquired new knowledge incrementally, reflected on that new knowledge before internalizing it, and then added it to their nascent self-concept of nursing over 5 semesters. Nurse Educator
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
While students’ role development evolves throughout the course of their nursing program, there is limited research focused on the process of becoming a nurse for students enrolled in AB programs, which are often significantly shorter in length. The purpose of this study was to examine AB students’ developmental trajectory in becoming a professional nurse.
Methods Sampling Of the 64 students in the AB cohort, 34 students were selected through a combination of sampling strategies. To ensure that students from the AB as well as the AB to master’s degree (AB-MN) track were recruited, the sampling selection was completed in 3 stages. In the first stage, all students in the AB-MN (n = 14; 13 females and 1 male) were recruited. All students who self-reported as being a racial/ethnic minority (n = 6 females) were recruited in the second stage. Remaining male students (n = 7) were recruited in the third stage. The final sampling stage used random selection to identify the remaining 7 students to be included (n = 7). Procedure The study was integrated into the students’ academic experience. Toward the end of each of the 5 academic terms, all students wrote a response to the prompt: ‘‘Describe a time during this academic term where you felt like a professional nurse. Be specific about what influenced your feeling and how the course content contributed to this feeling.’’ Students submitted written responses to course faculty who had the opportunity to review the reflection prior to being turned over to the study team. Analysis Method Individual study team members were provided with deidentified raw data to analyze using thematic analysis techniques.11
After independent analysis, all team members met and reached consensus about the themes and exemplars. The study team identified key indicators from each term, overall themes, exemplars, and negative cases. The study team examined the trajectory of themes across terms and made notes as a way to track how themes developed over time. Comparisons were also made between students in the AB and AB-MN program. There was neither intention nor attempt to compare the results by student gender or ethnicity.
Results More than half of the sample (n = 19, 56%) completed all 5 written reflections. Overall, 4 themes were identified regarding students’ perceptions of their role as nurses: (a) evolving role perception, (b) extending nursing student-patient interaction: mechanistic to holistic, (c) engaging with health care team and systems of care, and (d) expanding clinical thinking. A summary of the results by term is presented in the Table. There were no differences found between AB students and students in the AB-MN program.
Evolving Role Perception Evolving role perception describes the development of students’ understanding and acquisition of the professional nursing role over the 15-month program. Students’ perceptions and understanding of the responsibilities and demands of nursing expanded considerably from their first experiences. As described by a beginning nursing student: ‘‘There have been several times during this term when I have had twinges of feeling like I think I may feel when I am a nurse. My friends and I call it ‘feeling nursey’.’’ As students started the program, they focused primarily on the external trappings of looking like a nurse, such as wearing a uniform and carrying a stethoscope. Beginning students had a narrow understanding of the nursing role, and
Table. Thematic Analysis Across Terms for AB Students Themes Evolving role perception
Term 1 Narrow understanding of role ‘‘Fake it until you make it’’
Extending nurse-patient interaction: mechanistic to holistic
Greater focus on patient’s response to the student, and skill performance with little mention of the patient Little interaction with health care team. ‘‘Nursing care in isolation’’ Varied application of previous life skills and knowledge in their clinical setting
Engaging with health care teams Expanding clinical thinking and judgment
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Term 2 Increased confidence in technical skills. More comfortable ‘‘talking the talk’’
Term 3 Term 4 Developing sense of Developing sense of moral agency. empowerment and Internalizing ‘‘being moral imperative in a nurse’’ advocacy role. Uses ‘‘language of health care’’ Increasing understanding Increasingly holistic Developing awareness of of complexity of patient patient focus. the patient as a person. care. Continues building Integrating communication Understand ‘‘knowing relationships and skills; the patient’’ and relationship building value the personal with task and skill connection performance Contributing and adding Understanding professional Outsider to insider. value to the team Developing cultural roles. ‘‘Filling in humility the gaps’’ Increased focus on Beginning to make patient goals, patient interpretations and take action independently context, and prioritization of but needs reassurance. care. Increasing Getting the bigger autonomy picture of clients
Potentially inaccurate clinical decisions because of misplaced confidence. Deeper analysis and more flexible prioritization
Term 5 Refocus on skill mastery within the context of increased complexity ‘‘doing it all’’ Deeper reflection on the meaning of the clinical experience to their role development Collaborating as part of the team
Synthesis. More adept at and comfortable with anticipating and managing complications
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some admittedly adopted a ‘‘fake it until you make it’’ attitude. One student wrote, ‘‘[I] took a deep breath and just dove in, pretending that I had done this a million times before, and it was no big deal. It worked!’’ Students maintained an altruistic view of the profession, motivated by a desire to ‘‘contribute to society.’’ However, these students focused on development of motor skills and depended heavily on faculty support to accomplish basic nursing activities. By term 2, students had developed more confidence in their technical skills and identified feeling more comfortable ‘‘talking the talk’’ of nurses. Students began to assume the role of patient advocate by initiating and questioning care, when necessary, and seeing themselves as contributing to patients’ care. One student described an experience assessing an electrolyte issue and making consultations and wrote, ‘‘This experience made me feel like a professional nurse because I made a decision to alter the course of the patient’s care. I wasn’t simply going along for the ride.’’ Midway through the program, students were broadening their understanding of the nursing role and developing an appreciation for the complexity of being a nurse. They demonstrated increasing skill with the language of health care and developing sense of empowerment and moral imperative in their role and greater understanding of the importance of advocacy. Student reflections demonstrated that they understood they could make a significant difference in peoples’ lives by providing culturally sensitive and client-centered care. As students progressed into term 4, they began developing a sense of moral agency and expressed recognition of nurses’ privileged role. During this time, students increasingly identified with the nurse’s role, and began to internalize being a nurse instead of just doing nursing work. As described by 1 student, ‘‘I realized that I was listening with a nurse’s ear. I saw more than just the social/psychological impact of the disparities we identified.’’ In term 5, students were expected to increase the number and complexity of patients that they were caring for. Students tended to focus on skill mastery within the context of caring for multiple patients, time management, and setting priorities; however, advocacy continued to be important in their perception of role development. Students believed that they were expected to ‘‘do it all’’ and expressed appreciation for the full scope of the work and their ability to synthesize knowledge. Students became excruciatingly aware of their limits as graduation approached, as described by 1 student: ‘‘I have finally come to recognize what I do not know and when it is truly time to ask for assistance or if I am in a situation that I can power through based on what I know.’’ As demonstrated by these stories, students who participated in the study progressed in their perception of the nursing role from feeling like an imposter to being fully engaged in the responsibility of professional nursing practice over the 15-month program.
Extending Nursing Student-Patient Interaction: Mechanistic to Holistic During term 1, students focused on tasks and equipment, and the patient was almost invisible in their descriptions. Performance of motor skills and procedures was the primary concern. By term 2, students’ focus began shifting from self to patient, while developing their awareness of the patient as a 28
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person with unique context. One student, who reflected on providing care for a patient with dementia, came to realize ‘‘the importance of spending time with the patient (not just coming into the room to do something to the patient).’’ By the end of term 3, students had an increasingly holistic focus and recognized patients as individuals with their own health care needs and goals. Students described knowing the patient enhanced their ability to effectively provide patient care and improve outcomes. One student recounted, ‘‘Since I speak Spanish and became knowledgeable about the patient, I was able to make a connection with the parents that no one else on the floor had made.’’ Continuing on the trajectory, student narratives in term 4 showed an increasing understanding of the complexity of patient care and an appreciation that seemingly basic care can be complex given the patient’s background and circumstances. Students continued to build relationship skills, increasingly valuing personal connections, and the insight that patient stories provided for effective nursing care. One student wrote about doing foot care at a homeless clinic: From a physical assessment standpoint, it was educational and rewarding to see a foot covered in fungus and know to ask follow-up questions such as ‘‘Do you have shelter at night’’ and ‘‘Are you having a hard time keeping your feet dry?’’ During term 5, students increased their patient load and role responsibilities, and some began to reflect more deeply on clinical experiences as they related to role development and praxis. As they gained understanding of the nursing role, students assumed additional responsibility for anticipating and managing complications, authentically participating in care planning and implementation, and maintaining continuity of care as shared by this student: I was able to utilize our theory content [about] social determinants of health and culturally based care to add information as to why a family may be reacting or responding to the current [treatment] plan in the way they are versus simply calling them noncompliant. This theme shows that over the course of the programs students were able to extend their interactions from a selforiented, skill-focused perspective to one that takes into account the whole patient, their context and demonstrates evidence of a deepening appreciation of the nursing role.
Engaging With Health care Teams Few first-term students described any interactions with health care teams or systems of care. Instead, as if their nursing care occurred in isolation, most students focused on individual interactions with patients and families. The few who mentioned other health professionals made recommendations to a patient for follow-up care described support from clinical instructors or recounted collaboration with another student. However, term 2 students described engagement with members of the health care team and systems of care. These students were beginning to see themselves as ‘‘filling in the gaps.’’ Some students expressed a level of early acculturation to their clinical setting and the professional nursing role. Learning to navigate technical systems such as electronic medical records and medication dispensing systems, along with gaining a more complex understanding of the professional relationships and Nurse Educator
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roles in the health care team, was the focus for many of the students. Others described gaining a ‘‘bigger picture of our patients as unique individuals’’ and gave examples of the ways that they had incorporated patients and family members into care, reflecting a growing awareness of the contexts, resources, and needs of their patients. Many of the students expressed a beginning recognition of the health care team, including health professionals who were not nurses. This is demonstrated in a student response about a readmitted patient who was labeled as difficult: She hadn’t been moving a lot, and she agreed to walk with me. I talked to her [physical therapist] and her physician on my ownI. I realize that I have a long way to go, but on that day, in that unit, I felt like I belonged doing exactly what I was doing, and in that, I felt like a professional nurse. During term 3, the students began developing awareness of humility toward different cultures, vulnerable populations, and culturally competent care within the larger context of the health care teams. Students moved along a trajectory and shifted their perspective of the health care system and team. In the following exemplar, which reflects this shift, a student connected a young mother who was beginning a catheterization program for her son with a parent in a similar situation: This form of emotional support was incredibly effective because it came from a source that she could relate to and respect. Both of these women have a greater need for supportive services, as they must deal with unique issues not commonly shared by all parents. As a nursing student in a clinic that currently runs without a nurse or social worker because of budget cuts, I felt responsible for trying to bridge the gap that exists currently for this population in the areas of care coordination and patient education. As students moved through the program, they began to envision their role as more than just filling in the gaps and were able to see their contribution and value to the work of the health care team. In term 4, students acquired a growing awareness of their role and actively engaged as a member of the health care team. By the end of the program, students considered themselves to be functioning as part of the team— collaborating on the work, goals, and processes to improve patient, family, or community health and well-being. This is exemplified in the following example from a student in the operating room: [During] previous termsI I feel like we were learning how to understand our patients and their backgrounds. Now, knowing their comorbidities, labs, and procedures are integral pieces of how we approach their careI I take that information and apply it, and discuss it with colleagues. This quote illustrates how new students commonly approach their role, shifting from an etic perspective as an outsider to the health care team and moving toward an emic perspective, in which they are a partner in the health care team and systems of care.
Expanding Clinical Thinking and Judgment Early in the program, most students were challenged to apply their previous life skills and knowledge within their clinical setting. One student in a population-based setting described Nurse Educator
how she had to disregard prior experience in order to fit in as a student nurse: The term has been so busy, and on several occasions, I have felt that my varied life experience was not valued or appreciated. So, I focused primarily on what I needed to change about myself to fit into the program and put aside who I was, which in retrospect, is what actually got me into the program. Another student also reflected on the dissonance between being an expert in her previous career and being a novice nursing student: There were times when I felt fairly competent at whatever we were doing, but in those moments I was generally drawing on my skills from my ‘‘expert’’ skill set [from the previous career]. Most of the time, however, I felt like a clumsy neophyte and directed some significant energy to being okay with that. During term 2, students began to make clinical interpretations and sought out reassurance from preceptors and clinical faculty, ‘‘I learned a lot when I was assigned to a patient with a nurse who took the time to answer my questions and helped to guide my practice.’’ Early students also demonstrated an awareness of context and began synthesizing knowledge to get a ‘‘bigger picture of our patients as unique individuals and how different elements such as hope, mental health, cultural perspectives, family, and so on, make a [sic] impact on how a patient lives with his/her illness and makes decisions regarding his/her treatments.’’ By the end of term 3, students were increasingly focused on patient goals, context, and prioritizing care. Increasingly autonomous decision making and potential high-stakes outcomes are evidenced by the following example of a student’s advocacy for a patient who was experiencing ineffective pain management: In talking with this patient, I learned of a history where I thought another opioid would have a better clinical outcome. I talked with my clinical leader, preceptor, and pain specialist. The client was switched to methadone, which was more effective for him with fewer adverse effects. This scenario enlightened me to the fact that as nurses we are our patient’s advocate. Data from term 4 suggested that some students may have become overconfident in their clinical decision making because of misplaced confidence in their assessment skills, for example, independently delaying administration of timecritical medication or requesting new orders without first consulting with the preceptor or clinical faculty member. Although students made both appropriate and inappropriate prioritizations, they demonstrated expanded flexibility in their thinking. One student wrote, ‘‘Having a full caseload made me take notes during report, prioritize my day, communicate with interdisciplinary team members, and delegate tasks to the [certified nursing assistant].’’ As students reached the completion of term 5, they were more adept and comfortable anticipating and managing complications and were able to draw on their life skills. Students engaged more fully in professional nursing practice and appreciated their ability to synthesize knowledge and information gained through their education. This is exemplified in the following quote: Volume 40 & Number 1 & January/February 2015
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This experience made me feel like a nurse because I felt as though I was comfortable responding to the individual patient’s emotional needs in a therapeutic manner, collaborating with other members of the health care team, anticipating a plan of care, and managing the complications that arose in the neonate. Over time, students become better able to synthesize information from multiple sources and act on their interpretation. Students generally gained confidence, although some showed a tendency to be overconfident in their clinical thinking and judgment. Overall, these results describe how AB students’ understanding of the role of nursing expanded considerably as they progressed through the program despite the short program length. Early on, external trappings made students feel like nurses; over time, they were able to take on nursing roles of patient advocacy and delivering patient-centered care and had a greater appreciation for the full scope of the nursing role. Initial self-focus transitioned to relationship building and understanding the complexity of the patients’ context. Students moved from providing redundant task-focused care to filling in gaps to taking on an active role as part of the health care team. Over time, students became more autonomous, demonstrated ability to manage complexity, and increased their responsibility for patient care.
Discussion and Implications Whether students are doing highly technical care in a hospital setting or participating in a community event, students consistently described feeling like a nurse in the context of authentic clinical experiences. Providing students with rich, appropriately leveled, clinical experiences allows them to incorporate contextual and situational factors, which is critical to formation of identity as a nurse. Similarly, other researchers found that students’ ability to act relatively independently in a setting supports development of student agency as nurses.1 These findings underscore that level-appropriate clinical sites that allow students to provide independent care support their role development. Consideration of student development has implications for preceptors in the clinical setting. Practicing nurses who function as preceptors are often supervising students from multiple nursing programs and perhaps multiple levels of education within those programs. Faculty and preceptors must work closely to determine appropriate clinical experiences and structure them to the student’s developmental needs rather than relying on random access opportunities.12 For example, term 2 students began to make interpretations and respond to clinical situations, but they relied heavily on guidance and reassurance from faculty and preceptors. Faculty and preceptor support to help students draw on their previous life and work experience as well as their theoretical knowledge may increase self-efficacy, thus moving students along the developmental pathway. Our data suggest that during term 4, some students may have misplaced confidence in their clinical decision-making ability, leading them to not seek out necessary guidance from faculty and preceptors before responding and being over confident in their abilities. As preceptors and faculty create meaningful learning experiences, it is important to have an understanding of how students’ developing nursing identity 30
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affects the selection of clients, the student’s role in care, and preceptor/faculty supervision in that clinical situation. Early in the AB nursing program, many students expressed anxiety about how they will ‘‘become a nurse’’ in such a short period. Helping students to see the overall progression may help alleviate their anxiety. Cangelosi13 found that students were empowered ‘‘when faculty members helped them see their way toward their goal,’’ and they ‘‘needed little encouragement to move quickly along the path.’’13(p93) It has been found that novice nursing students are typically focused on their own performance and feelings as they begin to interact with patients, which was supported by the data in this study.5 Helping students to understand the developmental trajectory may promote an earlier shift to a more patient-centered focus. In term 5 of the program, which focuses on students’ integration of learning and application as well as moving toward a full patient assignment, students’ reflections were more task focused than in the previous term. Students expressed a deep sense of responsibility and worry about their ability to fulfill the role expectations.5,10 Pragmatic support for the safe organization and prioritization of care in the face of increasing care complexity may help students develop survival skills as they transition from student to new-graduate nurse. This study expands our knowledge regarding role formation specifically in AB degree programs, which are shorter than traditional nursing degree programs and are rapidly increasing. Despite the short length of AB programs, student role formation in this study was not dissimilar to traditional nursing programs. However, further research is needed focusing on AB students and how role formation can best be fostered.
References 1. McNeish S, Benner P, Chesla C. Learning formative skills of nursing practice in an accelerated program. Qual Health Res. 2011; 21(1):51-61. 2. Day RA, Field PA, Campbell IE, Reutter L. Students’ evolving beliefs about nursing: from entry to graduation in a four-year baccalaureate programme. Nurse Educ Today. 2005;25(8):636-643. 3. Hensel D, Laux M. Longitudinal study of stress, self-care, and professional identity among nursing students. Nurs Educ. 2014;39(5): 227-231. 4. Ware SM. Developing a self-concept in baccalaureate nursing students. J Nurs Scholarsh. 2008;5(1):1-17. 5. Benner P, Sutphen M, Leonard V, Day L. Educating Nurses: A Call for Radical Transformation. San Francisco, CA: Jossey-Bass; 2010. 6. Andrew N. Professional identity in nursing: are we there yet? Nurse Educ Today. 2012;32(8):846-849. 7. Krautscheid LC. Defining professional nursing accountability: a literature review. J Prof Nurs. 2014;30(1):43-47. 8. Johnson M, Cowin LS, Wilson I, Young H. Professional identity and nursing: contemporary theoretical developments and future research challenges. Int Nurs Rev. 2012;59(4):562-569. 9. Benner P, Sutphen M. Learning across the professions: the clergy, a case in point. J Nurs Educ. 2007;46(3):103-108. 10. Seacrest J, Norwood B, Keatley V. ‘‘I was actually a nurse’’: the meaning of professionalism for baccalaureate nursing students. J Nurs Educ. 2003;42(2):77-82. 11. Patton MQ. Qualitative Research & Evaluation Methods. 3rd ed. Thousand Oaks, CA: Sage; 2002. 12. Gubrud-Howe P, Schoessler M. From random access opportunity to a clinical education curriculum. J Nurs Educ. 2008;47(1):3-4. 13. Cangelosi P. Voices of graduates from second-degree baccalaureate nursing programs. J Prof Nurs. 2007;23(2):91-97. Nurse Educator
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Nurse Educator Vol. 40, No. 1, pp. 26-30 Copyright * 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins
Becoming a Nurse Role Formation Among Accelerated Baccalaureate Students Tanya L. Ostrogorsky, EdD & Anjanette M. Raber, PhD, RN & Claire McKinley Yoder, MSN, RN Ann E. Nielsen, PhD, RN & Kristin F. Lutz, PhD, RN & Peggy L. Wros, PhD, RN To understand nursing role formation for students enrolled in an accelerated baccalaureate nursing program, end-of-term narrative reflections from 34 students were analyzed over the course of the 15-month program. Using thematic analysis, 4 major themes were identified: evolving role perception, extending nursing student-patient interaction, engaging with health care team and systems of care, and expanding clinical thinking. Keywords: accelerated nursing program; nursing students; role formation; social development; social identity
T
his study examined accelerated baccalaureate (AB) nursing students’ role development trajectory throughout a 15-month program. Although recent AB graduates applied the necessary nursing knowledge and skills to be licensed and function competently in clinical settings, faculty members questioned whether students’ attitudes and nursing identity developed as rapidly as cognitive skills. These concerns were based on anecdotal feedback regarding readiness for practice and concerns about program length. In response, a study was developed to focus on AB students’ nursing role formation. This article presents the study findings and recommendations for nursing faculty.
Literature Review An abundance of literature is aimed at AB students and programs. Studies describe student outcomes, single program reviews, student demographics, characteristics, teaching strategies, and socialization. However, there is a paucity of research focused specifically on role formation in AB nursing education. Only 1 study1 specifically examined learning of formative skills in second-degree students in a master’s entry program in nursing (a similar demographic group to AB students). In that study, researchers focused on stages of professional identity development as they examined experiences that influenced the development of nursing identity. Author Affiliations: Assistant Vice Provost for Assessment and Evaluation (Dr Ostrogorsky), Research Associate (Dr Raber), Assistant Professor (Ms McKinley Yoder), Assistant Professor and Director of Undergraduate Program–Portland (Dr Nielsen), Assistant Professor (Dr Lutz), and Senior Associate Dean for Student Affairs and Diversity (Dr Wros), Oregon Health & Science University, Portland, Oregon. The authors declare no conflicts of interest. Correspondence: Dr Ostrogorsky, Oregon Health & Science University Office of the Provost, 3181 SW Sam Jackson Rd (L349), Portland, OR 97239 ([email protected]). Accepted for publication: August 22, 2014 Published ahead of print: October 4, 2014 DOI: 10.1097/NNE.0000000000000090
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Nursing Role Formation and the Developmental View Role formation during nonaccelerated nursing education programs has been described multiple ways including socialization,2 self-concept as a nurse,3,4 nursing identity,5,6 and professional nursing accountability.7 All of these concepts focus on the developmental process of moving from being a layperson to being a professional nurse.8 This process has been associated with ethical development, notions of good, and understanding nursing’s social contract for patients.5 Components of selfconcept or professional identity have been shown to increase over the course of time spent in the nursing program.3 Students’ perceptions, knowledge, skills, abilities, and their way of being in the world change over time from that of an outsider to an insider within the culture of nursing.5,9 This is consistent with the work of Seacrest et al,10 who identified 3 themes in the developmental trajectory: (a) belonging, (b) knowing, and (c) affirmation. Day et al2 found that students’ sense of professional nursing evolved over the course of 4 years with students beginning with a preconceived image of nursing that changed as they moved in defined sequential stages through the program. Students’ sense of identity was unclear and vulnerable in year 1 and was shaped by media images of nursing. It was not until year 3 that students demonstrated a personal sense of responsibility for care as they shifted from doing for others to working with the patient. As students gained a deeper understanding of the role and developed a professional nursing identity, they acquired the ability to articulate and defend their perspectives on patient condition and care needs. However, not until year 4 did students truly internalize the professional values, combined with a realistic rather than idealized understanding of their nursing practice. This trajectory aligns with Ware’s4 description of taking it all in. Ware found traditional baccalaureate students acquired new knowledge incrementally, reflected on that new knowledge before internalizing it, and then added it to their nascent self-concept of nursing over 5 semesters. Nurse Educator
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
While students’ role development evolves throughout the course of their nursing program, there is limited research focused on the process of becoming a nurse for students enrolled in AB programs, which are often significantly shorter in length. The purpose of this study was to examine AB students’ developmental trajectory in becoming a professional nurse.
Methods Sampling Of the 64 students in the AB cohort, 34 students were selected through a combination of sampling strategies. To ensure that students from the AB as well as the AB to master’s degree (AB-MN) track were recruited, the sampling selection was completed in 3 stages. In the first stage, all students in the AB-MN (n = 14; 13 females and 1 male) were recruited. All students who self-reported as being a racial/ethnic minority (n = 6 females) were recruited in the second stage. Remaining male students (n = 7) were recruited in the third stage. The final sampling stage used random selection to identify the remaining 7 students to be included (n = 7). Procedure The study was integrated into the students’ academic experience. Toward the end of each of the 5 academic terms, all students wrote a response to the prompt: ‘‘Describe a time during this academic term where you felt like a professional nurse. Be specific about what influenced your feeling and how the course content contributed to this feeling.’’ Students submitted written responses to course faculty who had the opportunity to review the reflection prior to being turned over to the study team. Analysis Method Individual study team members were provided with deidentified raw data to analyze using thematic analysis techniques.11
After independent analysis, all team members met and reached consensus about the themes and exemplars. The study team identified key indicators from each term, overall themes, exemplars, and negative cases. The study team examined the trajectory of themes across terms and made notes as a way to track how themes developed over time. Comparisons were also made between students in the AB and AB-MN program. There was neither intention nor attempt to compare the results by student gender or ethnicity.
Results More than half of the sample (n = 19, 56%) completed all 5 written reflections. Overall, 4 themes were identified regarding students’ perceptions of their role as nurses: (a) evolving role perception, (b) extending nursing student-patient interaction: mechanistic to holistic, (c) engaging with health care team and systems of care, and (d) expanding clinical thinking. A summary of the results by term is presented in the Table. There were no differences found between AB students and students in the AB-MN program.
Evolving Role Perception Evolving role perception describes the development of students’ understanding and acquisition of the professional nursing role over the 15-month program. Students’ perceptions and understanding of the responsibilities and demands of nursing expanded considerably from their first experiences. As described by a beginning nursing student: ‘‘There have been several times during this term when I have had twinges of feeling like I think I may feel when I am a nurse. My friends and I call it ‘feeling nursey’.’’ As students started the program, they focused primarily on the external trappings of looking like a nurse, such as wearing a uniform and carrying a stethoscope. Beginning students had a narrow understanding of the nursing role, and
Table. Thematic Analysis Across Terms for AB Students Themes Evolving role perception
Term 1 Narrow understanding of role ‘‘Fake it until you make it’’
Extending nurse-patient interaction: mechanistic to holistic
Greater focus on patient’s response to the student, and skill performance with little mention of the patient Little interaction with health care team. ‘‘Nursing care in isolation’’ Varied application of previous life skills and knowledge in their clinical setting
Engaging with health care teams Expanding clinical thinking and judgment
Nurse Educator
Term 2 Increased confidence in technical skills. More comfortable ‘‘talking the talk’’
Term 3 Term 4 Developing sense of Developing sense of moral agency. empowerment and Internalizing ‘‘being moral imperative in a nurse’’ advocacy role. Uses ‘‘language of health care’’ Increasing understanding Increasingly holistic Developing awareness of of complexity of patient patient focus. the patient as a person. care. Continues building Integrating communication Understand ‘‘knowing relationships and skills; the patient’’ and relationship building value the personal with task and skill connection performance Contributing and adding Understanding professional Outsider to insider. value to the team Developing cultural roles. ‘‘Filling in humility the gaps’’ Increased focus on Beginning to make patient goals, patient interpretations and take action independently context, and prioritization of but needs reassurance. care. Increasing Getting the bigger autonomy picture of clients
Potentially inaccurate clinical decisions because of misplaced confidence. Deeper analysis and more flexible prioritization
Term 5 Refocus on skill mastery within the context of increased complexity ‘‘doing it all’’ Deeper reflection on the meaning of the clinical experience to their role development Collaborating as part of the team
Synthesis. More adept at and comfortable with anticipating and managing complications
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some admittedly adopted a ‘‘fake it until you make it’’ attitude. One student wrote, ‘‘[I] took a deep breath and just dove in, pretending that I had done this a million times before, and it was no big deal. It worked!’’ Students maintained an altruistic view of the profession, motivated by a desire to ‘‘contribute to society.’’ However, these students focused on development of motor skills and depended heavily on faculty support to accomplish basic nursing activities. By term 2, students had developed more confidence in their technical skills and identified feeling more comfortable ‘‘talking the talk’’ of nurses. Students began to assume the role of patient advocate by initiating and questioning care, when necessary, and seeing themselves as contributing to patients’ care. One student described an experience assessing an electrolyte issue and making consultations and wrote, ‘‘This experience made me feel like a professional nurse because I made a decision to alter the course of the patient’s care. I wasn’t simply going along for the ride.’’ Midway through the program, students were broadening their understanding of the nursing role and developing an appreciation for the complexity of being a nurse. They demonstrated increasing skill with the language of health care and developing sense of empowerment and moral imperative in their role and greater understanding of the importance of advocacy. Student reflections demonstrated that they understood they could make a significant difference in peoples’ lives by providing culturally sensitive and client-centered care. As students progressed into term 4, they began developing a sense of moral agency and expressed recognition of nurses’ privileged role. During this time, students increasingly identified with the nurse’s role, and began to internalize being a nurse instead of just doing nursing work. As described by 1 student, ‘‘I realized that I was listening with a nurse’s ear. I saw more than just the social/psychological impact of the disparities we identified.’’ In term 5, students were expected to increase the number and complexity of patients that they were caring for. Students tended to focus on skill mastery within the context of caring for multiple patients, time management, and setting priorities; however, advocacy continued to be important in their perception of role development. Students believed that they were expected to ‘‘do it all’’ and expressed appreciation for the full scope of the work and their ability to synthesize knowledge. Students became excruciatingly aware of their limits as graduation approached, as described by 1 student: ‘‘I have finally come to recognize what I do not know and when it is truly time to ask for assistance or if I am in a situation that I can power through based on what I know.’’ As demonstrated by these stories, students who participated in the study progressed in their perception of the nursing role from feeling like an imposter to being fully engaged in the responsibility of professional nursing practice over the 15-month program.
Extending Nursing Student-Patient Interaction: Mechanistic to Holistic During term 1, students focused on tasks and equipment, and the patient was almost invisible in their descriptions. Performance of motor skills and procedures was the primary concern. By term 2, students’ focus began shifting from self to patient, while developing their awareness of the patient as a 28
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person with unique context. One student, who reflected on providing care for a patient with dementia, came to realize ‘‘the importance of spending time with the patient (not just coming into the room to do something to the patient).’’ By the end of term 3, students had an increasingly holistic focus and recognized patients as individuals with their own health care needs and goals. Students described knowing the patient enhanced their ability to effectively provide patient care and improve outcomes. One student recounted, ‘‘Since I speak Spanish and became knowledgeable about the patient, I was able to make a connection with the parents that no one else on the floor had made.’’ Continuing on the trajectory, student narratives in term 4 showed an increasing understanding of the complexity of patient care and an appreciation that seemingly basic care can be complex given the patient’s background and circumstances. Students continued to build relationship skills, increasingly valuing personal connections, and the insight that patient stories provided for effective nursing care. One student wrote about doing foot care at a homeless clinic: From a physical assessment standpoint, it was educational and rewarding to see a foot covered in fungus and know to ask follow-up questions such as ‘‘Do you have shelter at night’’ and ‘‘Are you having a hard time keeping your feet dry?’’ During term 5, students increased their patient load and role responsibilities, and some began to reflect more deeply on clinical experiences as they related to role development and praxis. As they gained understanding of the nursing role, students assumed additional responsibility for anticipating and managing complications, authentically participating in care planning and implementation, and maintaining continuity of care as shared by this student: I was able to utilize our theory content [about] social determinants of health and culturally based care to add information as to why a family may be reacting or responding to the current [treatment] plan in the way they are versus simply calling them noncompliant. This theme shows that over the course of the programs students were able to extend their interactions from a selforiented, skill-focused perspective to one that takes into account the whole patient, their context and demonstrates evidence of a deepening appreciation of the nursing role.
Engaging With Health care Teams Few first-term students described any interactions with health care teams or systems of care. Instead, as if their nursing care occurred in isolation, most students focused on individual interactions with patients and families. The few who mentioned other health professionals made recommendations to a patient for follow-up care described support from clinical instructors or recounted collaboration with another student. However, term 2 students described engagement with members of the health care team and systems of care. These students were beginning to see themselves as ‘‘filling in the gaps.’’ Some students expressed a level of early acculturation to their clinical setting and the professional nursing role. Learning to navigate technical systems such as electronic medical records and medication dispensing systems, along with gaining a more complex understanding of the professional relationships and Nurse Educator
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roles in the health care team, was the focus for many of the students. Others described gaining a ‘‘bigger picture of our patients as unique individuals’’ and gave examples of the ways that they had incorporated patients and family members into care, reflecting a growing awareness of the contexts, resources, and needs of their patients. Many of the students expressed a beginning recognition of the health care team, including health professionals who were not nurses. This is demonstrated in a student response about a readmitted patient who was labeled as difficult: She hadn’t been moving a lot, and she agreed to walk with me. I talked to her [physical therapist] and her physician on my ownI. I realize that I have a long way to go, but on that day, in that unit, I felt like I belonged doing exactly what I was doing, and in that, I felt like a professional nurse. During term 3, the students began developing awareness of humility toward different cultures, vulnerable populations, and culturally competent care within the larger context of the health care teams. Students moved along a trajectory and shifted their perspective of the health care system and team. In the following exemplar, which reflects this shift, a student connected a young mother who was beginning a catheterization program for her son with a parent in a similar situation: This form of emotional support was incredibly effective because it came from a source that she could relate to and respect. Both of these women have a greater need for supportive services, as they must deal with unique issues not commonly shared by all parents. As a nursing student in a clinic that currently runs without a nurse or social worker because of budget cuts, I felt responsible for trying to bridge the gap that exists currently for this population in the areas of care coordination and patient education. As students moved through the program, they began to envision their role as more than just filling in the gaps and were able to see their contribution and value to the work of the health care team. In term 4, students acquired a growing awareness of their role and actively engaged as a member of the health care team. By the end of the program, students considered themselves to be functioning as part of the team— collaborating on the work, goals, and processes to improve patient, family, or community health and well-being. This is exemplified in the following example from a student in the operating room: [During] previous termsI I feel like we were learning how to understand our patients and their backgrounds. Now, knowing their comorbidities, labs, and procedures are integral pieces of how we approach their careI I take that information and apply it, and discuss it with colleagues. This quote illustrates how new students commonly approach their role, shifting from an etic perspective as an outsider to the health care team and moving toward an emic perspective, in which they are a partner in the health care team and systems of care.
Expanding Clinical Thinking and Judgment Early in the program, most students were challenged to apply their previous life skills and knowledge within their clinical setting. One student in a population-based setting described Nurse Educator
how she had to disregard prior experience in order to fit in as a student nurse: The term has been so busy, and on several occasions, I have felt that my varied life experience was not valued or appreciated. So, I focused primarily on what I needed to change about myself to fit into the program and put aside who I was, which in retrospect, is what actually got me into the program. Another student also reflected on the dissonance between being an expert in her previous career and being a novice nursing student: There were times when I felt fairly competent at whatever we were doing, but in those moments I was generally drawing on my skills from my ‘‘expert’’ skill set [from the previous career]. Most of the time, however, I felt like a clumsy neophyte and directed some significant energy to being okay with that. During term 2, students began to make clinical interpretations and sought out reassurance from preceptors and clinical faculty, ‘‘I learned a lot when I was assigned to a patient with a nurse who took the time to answer my questions and helped to guide my practice.’’ Early students also demonstrated an awareness of context and began synthesizing knowledge to get a ‘‘bigger picture of our patients as unique individuals and how different elements such as hope, mental health, cultural perspectives, family, and so on, make a [sic] impact on how a patient lives with his/her illness and makes decisions regarding his/her treatments.’’ By the end of term 3, students were increasingly focused on patient goals, context, and prioritizing care. Increasingly autonomous decision making and potential high-stakes outcomes are evidenced by the following example of a student’s advocacy for a patient who was experiencing ineffective pain management: In talking with this patient, I learned of a history where I thought another opioid would have a better clinical outcome. I talked with my clinical leader, preceptor, and pain specialist. The client was switched to methadone, which was more effective for him with fewer adverse effects. This scenario enlightened me to the fact that as nurses we are our patient’s advocate. Data from term 4 suggested that some students may have become overconfident in their clinical decision making because of misplaced confidence in their assessment skills, for example, independently delaying administration of timecritical medication or requesting new orders without first consulting with the preceptor or clinical faculty member. Although students made both appropriate and inappropriate prioritizations, they demonstrated expanded flexibility in their thinking. One student wrote, ‘‘Having a full caseload made me take notes during report, prioritize my day, communicate with interdisciplinary team members, and delegate tasks to the [certified nursing assistant].’’ As students reached the completion of term 5, they were more adept and comfortable anticipating and managing complications and were able to draw on their life skills. Students engaged more fully in professional nursing practice and appreciated their ability to synthesize knowledge and information gained through their education. This is exemplified in the following quote: Volume 40 & Number 1 & January/February 2015
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This experience made me feel like a nurse because I felt as though I was comfortable responding to the individual patient’s emotional needs in a therapeutic manner, collaborating with other members of the health care team, anticipating a plan of care, and managing the complications that arose in the neonate. Over time, students become better able to synthesize information from multiple sources and act on their interpretation. Students generally gained confidence, although some showed a tendency to be overconfident in their clinical thinking and judgment. Overall, these results describe how AB students’ understanding of the role of nursing expanded considerably as they progressed through the program despite the short program length. Early on, external trappings made students feel like nurses; over time, they were able to take on nursing roles of patient advocacy and delivering patient-centered care and had a greater appreciation for the full scope of the nursing role. Initial self-focus transitioned to relationship building and understanding the complexity of the patients’ context. Students moved from providing redundant task-focused care to filling in gaps to taking on an active role as part of the health care team. Over time, students became more autonomous, demonstrated ability to manage complexity, and increased their responsibility for patient care.
Discussion and Implications Whether students are doing highly technical care in a hospital setting or participating in a community event, students consistently described feeling like a nurse in the context of authentic clinical experiences. Providing students with rich, appropriately leveled, clinical experiences allows them to incorporate contextual and situational factors, which is critical to formation of identity as a nurse. Similarly, other researchers found that students’ ability to act relatively independently in a setting supports development of student agency as nurses.1 These findings underscore that level-appropriate clinical sites that allow students to provide independent care support their role development. Consideration of student development has implications for preceptors in the clinical setting. Practicing nurses who function as preceptors are often supervising students from multiple nursing programs and perhaps multiple levels of education within those programs. Faculty and preceptors must work closely to determine appropriate clinical experiences and structure them to the student’s developmental needs rather than relying on random access opportunities.12 For example, term 2 students began to make interpretations and respond to clinical situations, but they relied heavily on guidance and reassurance from faculty and preceptors. Faculty and preceptor support to help students draw on their previous life and work experience as well as their theoretical knowledge may increase self-efficacy, thus moving students along the developmental pathway. Our data suggest that during term 4, some students may have misplaced confidence in their clinical decision-making ability, leading them to not seek out necessary guidance from faculty and preceptors before responding and being over confident in their abilities. As preceptors and faculty create meaningful learning experiences, it is important to have an understanding of how students’ developing nursing identity 30
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affects the selection of clients, the student’s role in care, and preceptor/faculty supervision in that clinical situation. Early in the AB nursing program, many students expressed anxiety about how they will ‘‘become a nurse’’ in such a short period. Helping students to see the overall progression may help alleviate their anxiety. Cangelosi13 found that students were empowered ‘‘when faculty members helped them see their way toward their goal,’’ and they ‘‘needed little encouragement to move quickly along the path.’’13(p93) It has been found that novice nursing students are typically focused on their own performance and feelings as they begin to interact with patients, which was supported by the data in this study.5 Helping students to understand the developmental trajectory may promote an earlier shift to a more patient-centered focus. In term 5 of the program, which focuses on students’ integration of learning and application as well as moving toward a full patient assignment, students’ reflections were more task focused than in the previous term. Students expressed a deep sense of responsibility and worry about their ability to fulfill the role expectations.5,10 Pragmatic support for the safe organization and prioritization of care in the face of increasing care complexity may help students develop survival skills as they transition from student to new-graduate nurse. This study expands our knowledge regarding role formation specifically in AB degree programs, which are shorter than traditional nursing degree programs and are rapidly increasing. Despite the short length of AB programs, student role formation in this study was not dissimilar to traditional nursing programs. However, further research is needed focusing on AB students and how role formation can best be fostered.
References 1. McNeish S, Benner P, Chesla C. Learning formative skills of nursing practice in an accelerated program. Qual Health Res. 2011; 21(1):51-61. 2. Day RA, Field PA, Campbell IE, Reutter L. Students’ evolving beliefs about nursing: from entry to graduation in a four-year baccalaureate programme. Nurse Educ Today. 2005;25(8):636-643. 3. Hensel D, Laux M. Longitudinal study of stress, self-care, and professional identity among nursing students. Nurs Educ. 2014;39(5): 227-231. 4. Ware SM. Developing a self-concept in baccalaureate nursing students. J Nurs Scholarsh. 2008;5(1):1-17. 5. Benner P, Sutphen M, Leonard V, Day L. Educating Nurses: A Call for Radical Transformation. San Francisco, CA: Jossey-Bass; 2010. 6. Andrew N. Professional identity in nursing: are we there yet? Nurse Educ Today. 2012;32(8):846-849. 7. Krautscheid LC. Defining professional nursing accountability: a literature review. J Prof Nurs. 2014;30(1):43-47. 8. Johnson M, Cowin LS, Wilson I, Young H. Professional identity and nursing: contemporary theoretical developments and future research challenges. Int Nurs Rev. 2012;59(4):562-569. 9. Benner P, Sutphen M. Learning across the professions: the clergy, a case in point. J Nurs Educ. 2007;46(3):103-108. 10. Seacrest J, Norwood B, Keatley V. ‘‘I was actually a nurse’’: the meaning of professionalism for baccalaureate nursing students. J Nurs Educ. 2003;42(2):77-82. 11. Patton MQ. Qualitative Research & Evaluation Methods. 3rd ed. Thousand Oaks, CA: Sage; 2002. 12. Gubrud-Howe P, Schoessler M. From random access opportunity to a clinical education curriculum. J Nurs Educ. 2008;47(1):3-4. 13. Cangelosi P. Voices of graduates from second-degree baccalaureate nursing programs. J Prof Nurs. 2007;23(2):91-97. Nurse Educator
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