Professional socialization in nursing: A qualitative content analysis

Abstract

Background:

Being a nurse is more than just a series of business activities and skills. In fact, it is a part of the process of socialization, which is internalization and development of professional identity. Professional socialization is necessary for involving the students in professional practices. Thus, the purpose of this qualitative research was to increase the understanding of professional socialization in nursing and explore the related factors from the perspective of registered nurses and nursing students.

Materials and Methods:

In this qualitative design, data were collected on 43 nurses with a variety of experiences using semi-structured interviews and focus groups in the Shiraz University of Medical Sciences in 2012. Data were analyzed through inductive content analysis.

Results:

The data analysis revealed two main categories: (1) sense of belonging with three sub-categories of theory-practice incongruence, educational experiences and tacit knowledge and (2) forming professional identity consisting of three sub-categories of relatedness, internal motivation and role model.

Conclusions:

This study demonstrates that in nursing, sense of belonging and professional identity contributes to professional socialization; it is suggested that these factors, which improve socialization in nurses, be taken into account by authorities.

INTRODUCTION

Professionalism is a fundamental concept in nursing and arises from individual-workplace, interaction and interpersonal relationships.[1] From the professional perspective, “being a nurse” is more than just a series of business activities and skills; it is, in fact, a part of the process of “socialization”,[2] which involves internalization and development of professional identity. It can indeed be associated with passing through certain experiences that occur during socialization. Developing as a nurse is a sense of becoming, involving personal commitment and internalization of values during the process of professional socialization. Professional identity entails the way in which an individual views him/herself as a nurse, who can perform nursing functions skillfully and responsibly.[3] From Cohens’ perspective, professional socialization is the process of acquiring skills and required knowledge to achieve a professional role with valued and professional norms. This occurs through professional education[4] and experience in work environment.[5] Indeed, professional socialization is necessary for involving the students in professional practices.[6] Socialization begins upon entry into the nursing program.[7] During this period, students are engaged in formal nursing programs[6] that do not end with the completion of nursing education but continue as the graduates are employed in the work setting.[7] The process of socialization begins with students’ expectations from their collegiate experience. Once in college, students are exposed to various socializing agents, including peers, faculty, parents and interactions with individuals outside the collegiate environment. These agents of socialization convey norms and expectations related to their membership in the college community to students and influence goals and objectives students have for attending college.[8] Internalizing values of the nursing profession is paramount to professional development because such values provide a foundation for behavior. Students are exposed to nursing values during the nursing program as they observe the behavior of the nursing faculty.[7] Nursing students, through professional socialization, can obtain the necessary commitment in the profession with problem solving and critical thinking practices like a “nurse”.[5] Nursing socialization is described as themes of belonging, knowing and affirmation.[1] However, little attention is paid to the acquisition of values, behaviors and attitudes necessary to attain the professional role. The results of Shinyashiki's study, which aimed to increase the understanding of the professional socialization process, indicated that some professional values, norms and behaviors are influenced by the college years. Actually, studying at a College of Nursing over a period of 4 years leads to a difference in values, norms and professional behavior.[9] In another qualitative study with the purpose of investigating the process of professional socialization among Japanese nursing students, it was revealed that socialization of nursing students is a multidimensional process, with classroom experience, clinical practice and extracurricular elements being influential.[10] Indeed, professional socialization in nursing plays an important role in the development of nursing identity.[11] In other words, socialization is the basis for clinical practice; it is essential in that it assesses features from the nurses’ perspectives. However, most of the previous studies focused on the process of professional socialization of nursing students since entering college and continued after graduation; accordingly, in this content analysis study, our aim was to increase the understanding of professional socialization and feeling of being a nurse in nursing as well as exploring factors that relate to it from the perspective of registered nurses and nursing students. This, in practice, can help officials and educational designers plan effective programs in nursing to reach socialization.

Nursing background

The Shiraz School of Nursing was established in 1332. Currently, it has 45 faculty members and 605 students studying at the undergraduate level and 217 postgraduate students. In Iranian universities including the Shiraz University, the baccalaureate program is the basic nursing program at the academic level. Students are admitted to these programs on the basis of their ranking in the competitive National Higher Education Entrance Examination.[12] The nursing education program lasts for 4 years and nursing students begin clinical training from the second semester that is concurrent with theoretical courses until the end of the third year. They learn in the clinical environment under the direct guidance and supervision of a nurse instructor in all of the courses.[13]

In Shiraz, courses are to be such that the students first study the theoretical courses and continue to do so after being taken to the bedside, but sometimes the transmission distance is long and the students cannot use theoretical principles at the bedside. The fourth year is allocated exclusively to clinical placement training under the direct supervision of the instructor. In the Shiraz School of Nursing, it has been about 1 year, i.e. preceptorship method, is also used in the fourth year under the supervision of an experienced nurse under the Department of Education in teaching hospitals. In the clinical field, they are assigned to care for patients based on nursing processes and in intensive care units, the case method is applied.[13]

MATERIALS AND METHODS

Design and data collection

This qualitative content analysis was performed in the Shiraz University of Medical Sciences in 2012. Data were collected on 43 nurses (35 nursing students second to eighth semesters and 8 registered nurses with a variety of work experience between 8 and 25 years, involving 18 males and 25 females). Sampling was performed with purposeful strategy and maximum variation (based on differences in organizational levels such as staff, head nurse, metron and supervisor as well as difference in experience and types of wards) through 16 semi-structured interviews. Because we were seeking a range of views on the research issues and in depth exploration of a topic, focus groups were also performed. In group discussions, each participant was essentially probing other participants for more information, explanation or justification about the topic discussed, and thereby provided a deeper understanding of the issue and produced richer data. As a result, they revealed dimensions of understanding that had often remained untapped by one to one interviews.[14] Thus, this method could give greater depth data in comparison with individual interviews in our study. Additionally, collaborative discussions allow to elicit participants’ views and conversational exchanges with one another in depth.[15] Therefore, three focus group interviews were conducted (nine students) by an interviewer who had experiences in qualitative research and qualitative interview in the nursing context.

First, interviews began with general questions such as “could you describe a typical day at work as a nurse?”; then, according to the participants’ responses, the interviews were continued and more detailed questions were asked such as “what factors help you feel like a nurse?” and “In what circumstances do you feel you are a nurse?”, “what are facilitating and inhibiting factors in this process?”; interviews continued with exploratory questions such as how and what questions. Focus group interviews began by establishing a two-way relationship and ensuring the confidentiality of conversations and providing information about the study. The researcher moved the group from topic to topic, probing as needed to extract the respondents meaning and to gain greater details, clarify points and promote discussions such as “dose anyone else have a different opinions?” The research questions were the same as individual interviews and data were transcribed, coded and analyzed like the individual interviews.

ETHICAL CONSIDERATIONS

Permission of the Ethics Committees at our university was obtained and then interviewers and interviewees agreed on the time and place of the interviews. To ensure privacy, interviews were carried out in a peaceful and private environment. Besides, informed written consent was obtained from the participants. Voluntary participation, confidentiality and anonymity were emphasized as well. The purpose of the interview was described to the interviewees. Also, they were assured that the recorded audios would not be accessible by anyone except the researcher.

DATA ANALYSIS

The data were analyzed through inductive content analysis.[16] The unit of analysis was recorded interviews, varying in time from 45 to 60 min. After each recorded interview was transcribed, they were analyzed and then were read several times to obtain a comprehensive view of the whole. According to the units of analysis, which was the whole body of the interviews, the texts were divided into condensed meaning units as words, sentences or paragraphs containing aspects related to each other through their content. Then, each condensed unit was abstracted and labeled with a code. Various codes were then compared based on relationship aspects of underlying meanings, and the same meanings were grouped together, which formed subcategories. The sub-categories were combined to create categories that were based on the nurses’ expressions and the qualitative content of their meaning. Finally, seven sub-categories and two main categories were formed with the unanimous agreement of the researchers.

TRUSTWORTHINESS

Credibility is the effort to establish confidence in interpretation of meaning of the data.[13] In our study, full descriptions were taken that reduced the chance of losing important information. Member check was another method in which we sent a copy of the transcript with extracted codes to some participants and asked them to assess researchers’ understanding with their own ideas. Peer check was also performed by the researchers; to do so, codes and categories were checked by a researcher familiar with the qualitative method. In order to reach dependability, in-depth methodological description was used to allow the repetition of the study. In transferability, which refers to the extent to which study findings can fit into contexts outside the study situation,[17] thick description of the phenomenon under investigation was provided to allow readers to have a proper understanding of it, thereby enabling them to compare the instances of the phenomenon described in the research report with those they had typically observed to emerge in their situations.

RESULTS

In this study, from the data analysis, two main categories emerged: (1) sense of belonging that consists of three sub-categories of theory-practice incongruence, educational experiences and tacit knowledge and (2) forming professional identity that consists of three sub-categories of relatedness, internal motivation and role model.

Sense of belonging

Sense of belonging from the perspective of our participants is acceptance of the profession; this factor can influence the process of socialization and being a nurse. It consists of three categories of theory-practice incongruence, educational experiences and tacit knowledge. For example, a nurse (5) in an individual interview said:

“When you have a sense of belonging it means that you accept your profession …. this leads to respect for your profession; therefore, you accept it, are finally committed to it, and then try to improve it and yourself”.

Theory-Practice incongruence

Participants in our study also mentioned that they find themselves torn between the demands of their theoretical courses and clinical settings. Actually, they faced real clinical situations in which they are unable to use what they have learned in theory, and sometimes they lack practical knowledge for real contexts. They mentioned that in situations that they cannot show themselves as a nurse, they do not have a sense of usefulness, and as a result they do not have a sense of dependence and devotion to their profession.

“If I can show what I have learned through my studies in practice …it can increase my sense of belonging and its formation. I mean knowledge and practice must be together”; alternatively, a nurse (6) in an individual interview said “When I see that by using the knowledge I have already acquired I can understand where the problem is and what the solution can be, and I can then help and guide others. I feel I am useful;… this can affect my sense of belonging to the profession”.

Educational experiences

In the opinion of our participants, educational experiences are important factors that influence the formation and development of sense of being a nurse. They described that during early stages of academic studies when they have patients with whom they cannot communicate, they do not get a feeling of usefulness about their profession and nursing; this, in turn, can negatively influence their perspective about the profession. For example, a student (9) in a FG interview stated: “If we have patients with whom we can communicate more easily …. we can get more satisfaction; I mean, this sense of being useful can improve internal satisfaction about our profession…. influence my perspective and devotion…. when a patient is unconscious or cannot talk, I feel I cannot do anything ….”

Thus, individuals should have a sense of being useful and can get feedback in their work, and thereby conditions must be provided to involve them in educational experiences.

Also, during work, when they have a responsibility of all of a patient's works, not one part of them, and can see them systematically, they can overall see the outcome of the work; this, in turn, leads to an increase in their self-esteem and helps them feel they can make a difference. As a result, they can improve their dependence and belonging to the profession.

For example, regarding how labor was divided, one of the nurses’ (2) mentioned:

“Functional methods in education lead to distance from patients and can have negative influences on the sense of belonging”.

Also, when nursing students and graduate nurses cooperate with an expert nurse in the clinical environment and observe their behavior and practices, this can help in acceptance of the profession and can improve their sense of belonging.

For example, one nurse (1) in an individual interview said:

“It is important that the new staff function shoulder to shoulder with experienced and faithful staff; it helps to form a sense of belonging”. Another nurse (4) stated:

“…A few months of work with an expert and following him/her step by step leads not only to transfer of work experience, but also to enhancement of the sense of belonging”.

Allocation of patients and attention to the severity of disease, ways of division of labor and methods of education such as preceptorship; all these were the most common expressions mentioned by the participants that contribute to the process of socialization.

Tacit knowledge

In our study, some participants noticed that informal discussions in work environment, people's beliefs and attitudes and individuals’ actions in specific contexts can shape their views about the profession and contribute to role acceptance and professional dependence. One student (13) in an individual interview said:

“In our clinical settings we see that there is negative feedback from staff and nurses, and this tacit curriculum affects our perception in the profession …”

This statement showed that negative beliefs and behaviors about the profession influenced members’ attitudes about nursing.

Forming professional identity

Participants in our study mentioned that the in the process of socialization, they seek the meaning of being a nurse. In this process, some factors such as communication with others, especially in health care teams, and having some role models can contribute to identity construction. Most of the students in individual interviews believed nursing students are confused until the fourth semester. They do not know what they are doing and do not have any purpose; after 4 or 5 semester they begin to understand what being a nurse means.

One student (15) said: “Unfortunately, I encountered teachers in semester 1 and 2 who I feel did not want students to continue and practice nursing; my feeling was and still is that they taught compulsorily”.

In the view point of our participants, the subthemes of role model, internal motivation and relatedness have influenced their professional identity.

Relatedness

Our study showed that the experience of social connectedness and cooperation among nursing and other health care teams leads to self-confidence, sense of being valued and progress in the process of socialization. When they have cooperation with other health care professionals, for example by participating in clinical rounds, their motivation increases and they feel that they have an important role in the treatment; these, in turn, can help to form identity as a nurse. One nurse (6) in an individual interview stated:

“In fact, in team work, in spite of scientific education we learn other things such as kindness, and effective communication … this leads to an increase in transfer of positive energy, retention and more success in our profession…and helps to see ourselves as a nurse,…as a useful person…. Team work leads to cooperation among individuals, resulting in motivation; we can actually find different ideas from different thoughts”.

Internal motivation

Many participants mentioned that increased motivation leads to a high level of role acceptance, which can in turn result in forming identity; for example, high clinical knowledge leads to high value and increased confidence as a nurse. A student (15) in an individual interview said:

“If I attain more knowledge, it can help me to trust myself. Far beyond being illiterate, with higher education higher efficiency can be gained and one can more comfortably say I am a nurse”.

Another nurse (13) in an individual interview said: “When I feel I have sufficient knowledge about one particular drug, I feel satisfied. I try to acquire the knowledge if I have low level of knowledge because it can give me confidence”.

Role model

In our participants’ opinion, role models assist in developing understanding of work roles and professional identity. They really make a difference in the way in which students view their roles in the workplace. A student (16) in an individual interview mentioned:

“When we see a teacher is knowledgeable and good tempered, we try to be similar to her or him rather than to the knowledgeable teachers who are impatient and have a feeling of false pride….”

Another student (8) in an individual interview said:

“We did not have any interest, but after we attended hospitals and saw the behavior of our faculty with patients, we became interested in the field”.

Especially novice nursing students and registered nurses in workplace need to have positive role models throughout their careers in order to see and understand the features of the profession; consequently, they can perceive the future of the profession.

DISCUSSION

Results showed that in nursing, attention to professional identity and sense of belonging can improve professional socialization. Factors such as role model, internal motivation, relatedness, tacit knowledge, educational experiences and theory-practice incongruence are important factors in this respect. Although this study was performed in Iran, some findings are shared with other countries. Besides, some of the problems that are still unresolved in Iran require planners’ consideration.

Basically, a professional perception forms in the first 2-3 years of professional activity, and this in turn forms the basis of professional identity and leads to professional practice.[2] Similarly, our study showed that nurses search for their identity in the preliminary courses of their educational period and, in this process, interaction with others have an indispensable influence on forming their identity.

In addition, the results showed that role models have an influence on nurses’ practices and the sense of being a nurse. Similar studies have shown that nurses develop their social identity and nursing roles through their senior role models, in particular the way senior nurses provide care.[18] Based on Bandura's social learning, the influence of role models on students is significant with regard to professional socialization.[19] In a metastudy performed by Adams et al.,[20] it was shown that role models were a great source of support to individuals and often made a difference in their decision to remain in the nursing profession. Also, in a students’ evaluation of a mentorship program,[21] confirming the value of role models in undergraduate nursing help the students to put theory into practice.[22] The results of Henderson's study also showed that role models can influence transfer of theoretical knowledge of holistic care into practice.[18] As shown in our study, this transfer can lead to closeness to the patient and, as a result, can improve professional identity. In another study, it was also shown that the link of theory-practice has influences on motivation and dignity of work. If nurses are not well equipped theoretically, and do not show proficient skills, their identity fails to shape.[23] A professional identity helps to construct the core or essential aspects of an individual's meaning and existence.[24] Unfortunately, in Iran, the issue of integration between theory and practice in nursing has not been resolved yet.[25,26,27] Peyrovis’ study showed that the ultimate goal of nursing knowledge implement their knowledge in practice for the patient, otherwise it would be meaningless[13]; therefore, it seems necessary that authorities should take this into consideration.

Experiencing a sense of belonging in any person occurs individually and depends on the context in which the experience has happened, communication with group and their professional values.[28,29] The study of Levett-Jones (2005) showed that students with a sense of belonging have greater motivation to try harder and perform better.[30]

Sense of belonging needs to be adapted in clinical and educational environments, and this is required at the beginning of the professional journey.[31] In our study, it was revealed that motivation is involved in the professional identity and in fact improvement of internal motivation leads to increased sense of being a nurse. In many studies, it is also indicated that motivation is related to identity and can affect it. For example, in a study conducted by Smitina,[32] it was shown that there is a correlation between the high level of a student's vocational identity, intrinsic motivation for study choice and higher satisfaction with university, teachers, the selected study program and also the perception of fewer barriers in continuing their education. In our study, communication between nursing and other health care teams, especially physicians, can contribute to nurses’ self-confidence and process of socialization. However, despite the reality in Iran, little attention is paid to teamwork in action. Some of the reasons can be current views about nursing and unfamiliarity of nursing roles for other health care teams.[33,34] It was shown that these relationships influence their work motivation[25] as well as job satisfaction.[33]

Sedgwick, Yonge (2008) showed that nurse preceptors assist students to become members of the team.[28] Similarly, Andrew et al. highlight the fact that students want to feel they belong to and are a part of a community.[35]

The overriding goal of education is to teach one to think like a nurse, to see the world of healthcare through the lens of nursing and to respond to the effects of both educational and clinical experiences by developing professionalism.[6] The participants in this study repeatedly mentioned that student-cantered methods as compared with traditional methods in clinical environments have an important role in authenticity, sense of belonging and being self-directed. Among them, preceptorship method has a special status. The participants mentioned that this method has an important role in sense of belonging to the profession and in being a nurse. Studies have shown that working with a preceptor will help students to uncover tacit knowledge embedded in clinical practice.[36] Their findings also showed how preceptors aimed at professionalism and confidence in their students and how they stressed the importance of the students’ perception of nursing as a profession to be proud of. On the more pragmatic side, preceptors tried to encourage their students to become good and competent nurses with the knowledge, skills and values necessary for the nursing roles.[37]

CONCLUSION

The present study led to an increase in the understanding of professional socialization and factors that relate to it from the perspective of registered nurses and nursing students. These finding show that in Iran, nursing profession still struggles with problems that can alter in professional identity. Most of them are related to the dominant educational system; therefore, it is necessary that authorities take it into account. They must aim at providing conditions in the Department of Nursing in which role models are alongside newcomers. Besides, they must consider educational experiences that are provided for them and also improve relatedness with other health care teams that can increase professional identity. Overall, factors that affect sense of belonging and professional identity in nursing can have a special contribution to professional socialization; therefore, nursing education must take them into account.