Professional responsibility-acquiring process among bachelor degree nursing students: A grounded theory study

Abstract

INTRODUCTION:

Professional responsibility-acquiring process among bachelor degree nursing students is important for their current and future performance and educational and health-care system, but this process has not been explored in the literature. The aim of the current study is to explore the process of acquiring professional responsibility among bachelor degree nursing students.

METHODOLOGY:

The study design was based on grounded theory (Corbin and Strauss 2015). Purposive and theoretical sampling led to the inclusion of 18 individual interviews and a focus group interview with bachelor degree nursing students, their instructors, and key informants in a nursing school and university, an educational hospital, and a health comprehensive service center in Tehran in 2019–2020.

RESULTS:

After data analysis, 6 categories, 17 primary categories, 64 subcategories, and 1747 initial codes were extracted. Trying to optimal use of the educational period was the main category of this study and its primary categories were responsible learning and performance management strategies, there were facilitators and inhibitors categories for applying these strategies. Personal, educational, and professional context factors were primary categories that may lead to the main concern (uncertain productivity of the educational period) with regard to acquiring professional responsibility. Protection of the students and others versus irresponsibility was consequence category of this process.

CONCLUSION:

Knowing the process of acquiring professional responsibility among bachelor degree nursing students can be used to facilitate the formation, promotion, and evaluation of professional responsible behaviors. Further researches in these areas are recommended.

Introduction

Professional responsibility is one of the most important professional competencies and values[1,2,3] and ethical codes for bachelor degree nursing students,[3] which facilitates the learning and education process, ensures the nursing profession life, promotes the health level of clients, and improves the performance of bachelor degree nursing students.[2] On the other hand, irresponsible behaviors in the nursing students have been reported as a common problem and have a high impact on the education and learning processes in the entire class.[4,5] Ibrahim and Qalawa reported (60.2%) of the nursing students have irresponsible behaviors.[5] Findings of another study showed that majority of nursing students engaged in some forms of academic dishonesty or irresponsibility behaviors in the classroom setting (64.7%) and in the clinical setting (54%).[6] Furthermore, such behaviors have been common among the students of other disciplines[4] or its rate has been alarming.[7]

Universities are often evaluated based on the knowledge quality and teaching techniques and little attention is paid to the values, behaviors, and attitudes required for the professional roles including responsibility.[8] Responsibility must be conceptualized and included in the core values of the schools, the design of the educational system, student admission standards, student and professor evaluation standards, and clinical practice in nursing schools.[9] Perception of the formation and absorption of professional values, specifically the responsibility of nursing students who are part of the health-care team, is important for the future of nursing.[10,11]

Acquisition of the professional values of nursing students is a procedural.[12] The responsibility among bachelor degree nursing students is also one of these professional values, which is a procedural, dynamic, complex, and multidimensional concept that multiple factors affect the formation of this concept.[2] Furthermore, in other disciplines such as medicine, several contextual factors including personal strengths or weaknesses, academic education effectiveness, and intervention factors such as lack of concentration and nonstandard working conditions affect the responsibility of medical students in clinical settings.[13]

Few of the various factors that have been expressed for the development of professional responsibility concept among bachelor degree nursing students and other educational disciplines were investigated in each study and findings about the role of these factors for developing the process of acquiring professional responsibility were varied, for example, the finding of the study by Ibrahim and Qalawa showed that there are multiple factors contributing to irresponsible behaviors in nursing students, and one of the most important of them is the performance of the educational system.[5] However, Bang et al. stated that there was no correlation between professional values, including responsibility with academic year and academic performance. The researchers suggested further in-depth studies to understand the underlying reasons.[14] The findings about other factors in this process are similar to the factors that mentioned.

More accurate of literature and various studies indicates that the process of acquiring professional responsibility among bachelor degree nursing students is important for their current and future performance and educational and health-care system. Although many factors have been explained for the formation of responsible behaviors in nursing students, the formation, type of responsible behaviors, mediating factors, and consequences of these behaviors have been mostly studied generally and process is not determined. The question is, how do bachelor degree nursing students acquire professional responsibility?

Given what was said, in this study, we are seeking to explore the process of acquiring professional responsibility among bachelor degree nursing students.

Methodology

Study design

The study design was based on the qualitative research method and the grounded theory approach. The grounded theory is a method of thinking and studying about social phenomena, which leads to the understanding of general concepts and generates insight into phenomena and experiences.[15] This method is useful for discovering behaviors, social relations, and social processes.[16] Thus, it is appropriate for exploring the process of acquiring professional responsibility among bachelor degree nursing students.

Participants and research environment

The participants in this study were bachelor degree nursing students, instructors, and key informants. The inclusion criteria for students consisted of experience of presence in the clinical education and desire to share experiences. The inclusion criteria for the instructors consisted of the desire to share the experiences. The study environment included a nursing school, an educational hospital, and a health comprehensive service center in Tehran. The data collection method involved unstructured and semi-structured in-depth interviews with participants. Interviews were conducted in a quiet environment. Prior to the interviews, about the subject, goal, time, and location of the interview, coordination was made through phone calls. Interviews were recorded and transcribed verbatim with the permission of the participants.

Bachelor degree nursing students consisted of both genders and were in different academic years. Instructors with different professional and clinical experiences were also interviewed and they were in various educational departments. Three instructors were middle manager (executive position in nursing school) and one instructor was senior manager in the university (executive position in university). A head nurse was also interviewed, for theoretical sampling. This interview was written by hand because he did not consent to the voice recording.

Eighteen individual interviews (10 bachelor degree nursing students, 7 instructors and educational manager, and a head nurse) as well as one focus group interview with 6 junior (3^rd year of university) nursing students were performed in 2019–2020. Focus group interview was done because of more exploring the educational and professional factors and problems that students were faced with them in the context. Interview durations varied between 33 and 96 min depending on the willingness of the participants.

Some of questions that applied in the interviews were general questions (please explain your ordinary daily as a bachelor degree nursing student; or please explain an experience that indicates your appropriate or inappropriate behavior in the class or in the clinical environment); guiding questions (why did you show this type of behavior against the client? Why did you show this behavior? How did you feel?); and confirmative questions (Can you please provide an example? Please explain). Theoretical questions were also used to complement the findings and theoretical sampling.

Data collection and analysis

In the grounded theory, data collection and analysis were mutually formed each other through a repetitive, cyclic, and interconnected process.[15,17] Purposeful sampling was first initiated with bachelor degree nursing students and their instructors and then continued to theoretical sampling with educational manager and executives, other students, other instructors, and a head nurse based on the findings emerged until data saturation; no new data were obtained in the three last interviews. Theoretical sampling was conducted to select the next participants or ask exploratory questions in the same or other interview. For example, a student explained the impact of educational regulations on his behaviors. That leads to ask more exploratory questions about the regulations from the same student and other participants and then another student commented on non-flexibility regulations just for nursing students and not for other disciplines, based on this note interviews were conducted with senior manager in the university (executive position in university).

In Corbin and Strauss's 2015 methodology, the analysis included identifying concepts, developing concepts in terms of their properties and dimensions, analyzing data for context, bringing process into the analysis, and integrating categories.[15]

In this study, the transcribed interviews were initially read several times to gain a general perception about the data. Then, the data were broken down and the initial codes were extracted. Comparative analysis and asking question were used to classify the extracted codes. At this point, similar codes were categorized in the same groups where a suitable and relevant name was chosen for each group and conceptualized was taken. Memos as part of the analytic process were used in this stage and stages ahead. In the stage of analyzing data for context, the researchers explored the conditions and effective factors for creating the main concern. Then, process bringing into the analysis and students’ strategies for overcoming the main concerns, consequences of the strategies and mediating factors were extracted. At final stage categories integrating to each other and main category was extracted.

Trustworthiness of the data and findings

Four criteria were used to trustworthiness of the data and findings. To ensure the credibility, typed interviews and initial codes sent to eight participants and were confirmed by these participants. Initial codes along with formation and names of the subcategories and categories were given to three experts outside the research project. Then, their views were reviewed and the findings were confirmed by them. Engagement of the researchers with the professional responsibility concept and constant comparative analysis were other ways to enhance the credibility. Moreover, it was attempted to select the participants with the maximum of variances from different groups of participants.

Ethical considerations

The present research project was approved by the Ethics Committee of Baqiyatallah University of Medical Sciences with the code IR.BMSU.REC.1397.309. Consent forms were obtained from all participants, the principles of voluntary participation, anonymity, and confidentiality for the participants, and accuracy and bailment for the texts were respected throughout the study.

Results

After data analysis, 6 categories, 17 primary categories, 64 subcategories, and 1747 initial codes were extracted. According to the research method, the main category of the study, context, main concern, mediating factors, and consequences regarding the process of acquiring professional responsibility among bachelor degree nursing students were extracted and the process was determined [Figure 1].

Figure 1.

Professional responsibility acquiring process among bachelor degree nursing students and its concepts. †This concept encompasses uncertain efficacy and uncertain effectiveness. ††Facilitator concept encompasses individual and internal facilitators, the nature of tasks, instructor educational performance, educational system performance and nursing profession performance. ††Inhibitor concept encompasses internal and external inhibitors. ¶This concept encompasses responsible learning management and responsible performance management

Main category

After sifting and sorting through all the memos, looking for clues of how the categories fit together, rereading memos, creating the story line, doing diagrams, and plain thinking, main category of the study was extracted. To overcome the main concern, bachelor degree nursing, in a process, try to optimal use of the educational period through responsible learning and performance management strategies and this is the main category, because interaction, actions, and emotions all matched with this class. This category encompasses two primary categories: responsible learning management and responsible performance management.

In the primary category of responsible learning management, there were 3 subcategories: committing, planning, and trying for self-learning. For example, the responsible nursing student knows that before entering the clinic, he/she must master some of theoretical principles or sets goals for self-learning and tries to achieve them, or studies the courses during the semester and not just for exam night.

With regard to subcategory of planning for self-learning, one of the participants stated:

When I have presentation in the class, I prepare my Power Point 4 weeks prior to the presentation time and plan for my duties. I do my assignments on a plan (P3, female, senior student). In this quotation, planning for doing assignments is one of the initial codes.

In the primary category of responsible performance management, there were 9 subcategories with following names: internal sense of ethical/legal commitment to doing duties, participation in teamwork and social activities, and trying to do the right thing and do the things right, appropriate communication with others, sensitive to environment and sometimes being volunteer for perform tasks.

With regard to trying to do the things right subcategory, one of the participants stated:

In measuring vital signs, I always measure, document and report vital sign precisely (P1, male, senior student). In this quotation, doing care procedure correctly is one of the initial codes.

Or in the subcategory of participation in social activities, one of the participants stated:

In Nursing Organization we made a student card that students who were member of Nursing Organization could buy books, nursing shoes, use pools and dentistry with good discounts from contractor stores, publication and places (P9, male, junior student). In this quotation, trying to provide welfare for other students is one of the initial codes.

Context

This category indicates the factors that lead to the main concern (uncertain productivity of the educational period) and encompasses three primary categories with following names: personal, educational, and professional context factors.

In the primary category of personal factors, there were 5 subcategories with names: inadequate perception of competitive atmosphere for learning, the inflexibility and complexity perception of educational rules, worrying about the professional future, and inadequate familiarity with the educational environment and lack of motivation and interest in nursing discipline.

For example, living in the dormitory and being intimate with friends and spending a lot of time with them can cause less attention to education and ignorance about learning and lead to students’ uncertain efficacy.

With regard to inadequate perception of competitive atmosphere for learning subcategory, one of the participants stated:

Last night one of my friends in our dormitory room, wanted and prepared to read a dialysis book. some of my friends came to our room and said gather yourself. what is this. what are you doing. and then my friend didn't read his book (P9, male, junior student). Negative effect of close communication with friends in dormitory for learning is one of the initial codes.

In the primary category of educational factors, there were three subcategories: disrespect in the educational environment (by anyone), illogical educational courses, and lack of justification for learning needs. For example, the student may think that for some health-care procedures, such as measuring vital signs, there is no need to study 4 years.

In illogical educational courses subcategory, one of the participants stated:

In the dialysis lesson (one of the most important of nursing lessons), we just spend 6 sessions in the class for learning, but for another general lessons that are unimportant, we spend 18 sessions in the class, and it's not logic (P7, male, junior student). In this quotation, few educational sessions for some important lessons are one of the initial codes.

In the primary category of professional factors, three subcategories were extracted with following names: discrimination against nurses in health-care system, an ambiguous position of nursing, and lack of hope about the future of nursing among the students.

With regard to lack of hope about the future of nursing among the students subcategory, one of the participants stated:

Exactly….one of my instructors. being a Nursing PhD…I asked …. whether we should continue our studies up to the higher levels and higher education?…. She says… whatsoever … Nursing has nothing…hasn't any future (Junior student, male, one of participant in focus group). To disappoint the student by instructor about the future is one of the initial codes.

Main concern

Bachelor degree nursing students are in the educational and health-care system and gain some of educational and professional experiences that may lead to an uncertain productivity of the educational period and this category is the main concern of professional responsibility process among bachelor degree nursing students. This category encompasses two primary categories: uncertain efficacy and uncertain effectiveness.

In the primary category of uncertain efficacy, there were three subcategories: performing student duties improperly, not performing some of duties deliberately, and factitious performance of duties.

With regard to performing student duties improperly subcategory, one of the participants stated:

When we say you (student) have to present a matter for class… some students. a burden only just want to putting down. they write something. they make a just Power Point slide and then they read it verbatim in the class rather than acting as a teacher and presenting the matter correctly….without any qualification… without mastering the matter (p17, MSc, female, psychiatric nursing department, middle educational manager). In this quotation, perfunctory effort for doing assignment is one of the initial codes.

Or in the subcategory of factitious performance of duties, one of the participants stated:

some of students that should change the Iv Line after three days, he/she just removes the previous glue of Iv Line and puts another new glue with new date, without changing the Iv Line (P11, male, Sophomore student). In this quotation, documentation of the care that not delivered is one of the initial codes.

In the primary category of uncertain effectiveness, there were five subcategories with names: disrupting the discipline of educational process, inappropriate communication with others, repeating inappropriate behavior, incurious and inattentive to the duties, and environment.

In the subcategory of disrupting the discipline of educational process, one participant stated:

Some of students ridiculing or laughing at anything in every situation (in the class or in the clinical unit), they are disrupting the discipline of the education for all (p12, Ph. D., female, community health nursing department). Ridiculing everything in the class or in the clinical unit is one of the initial codes in this quotation.

Mediating factors

Mediating factors are facilitators and inhibitors concepts that exist when students apply the strategies for overcome the main concern. Facilitator is category encompasses 5 primary categories with following names: individual and internal facilitators, the nature of tasks, instructor educational performance, educational system performance, and nursing profession performance.

In the primary category of individual and internal facilitators, one participant stated:

I delivered cares exactly for one patient after surgery in the last week, checked the location of his surgery and his limbs, measured and recorded vital signs every 15 min and etc. I delivered these cares because of prevention the complications that may have existed for the patient (P2, male, junior student). Mastering the results of doing or not doing duties is one of the initial codes in this quotation.

Or in another example regarding to the instructor educational performance primary category, one of the instructors said about his teaching method:

We need to check vital signs every day. I explain the importance of vital signs to the student. For example, in the paediatric ward, vital signs are very important and one of the most important is body temperature. If the baby's temperature is high, it can cause seizures, harms to the child…. or even death, it hurts him/her. I tell them if you don't do this correctly, the baby may get hurt. This makes them (students) sensitive; this had a great effect on checking the vital signs precisely and correctly (P15, Assistant professor, male, paediatric nursing department, and middle educational manager). In this quotation, emphasizing on important parts of the lesson is one of the initial codes.

Inhibitor is category encompasses primary categories with names internal and external inhibitors. In the primary category of internal inhibitors, there were three subcategories with names physical and mental fatigue and stress resulting from the use of some responsible strategies, and in the primary category of external inhibitors, there were three subcategories with names blaming and abusing by others, and increased workload of students in the educational environment because of responsibility.

In the subcategory of blaming by others, one participant stated:

Of course, I don't study so much. Because of my wife's words, he says: are you studying what? Finally, you and I are similar. I don't read this and you read it, you are no different from me in the future. My wife hates nursing (P3, female, senior student). Negative impulses by others, is one of the initial codes in this quotation.

Consequences

When students apply the strategies (responsible learning and performance management strategies) for overcome the uncertain productivity of the educational period, they will protect themselves (students) and others versus irresponsibility. Protection of the student and others versus irresponsibility is a category encompasses three primary categories: smart performance, optimal effects for students, and optimal effects for stakeholders.

In the primary category of smart performance, there were three subcategories with names situational scientific and clinical domination and discovering environmental problems.

In the primary category of optimal effects for students, there were four subcategories with names more learning, academic achievement, higher internal satisfaction, and increased opportunity for professional advancement.

For example, in the more learning subcategory, one of the participants stated:

Yesterday, for example, we had a meeting in the Nursing Organization (Islamic Republic of Iran), and I see many of senior nursing managers and I learn many things from there, for example communication, management, the paths for development in the nursing and etc.(P9, male, junior student). Learning communication with others is one of the initial codes.

Or in the higher internal satisfaction subcategory, one of the participants stated:

After I changed the dress of the infected wound of one patient, he thanked me and prayed for me, and this made me happy (P2, male, junior student). Positive inner sense because of patient satisfaction is one of the initial codes.

In the primary category of optimal effects for stakeholders, there were 4 subcategories with names: improvement of the instructor's educational performance, helping for provide complete and safe health care to the clients, better communication with others, and better effects on others learning.

With regard to improvement of the instructor's educational performance subcategory, one of the participants stated:

It feels so much better, (When you work with these students), you get excited, it gives energy and motivation to you to continue this style, you will also motivate other colleagues (p18, Professor, male, management nursing department, senior educational manager). Students motivating instructor is one of the initial codes.

Discussion

Bachelor degree nursing students are in the educational and health-care system and gain some of the educational and professional experiences that may lead to an uncertain productivity of the educational period (main concern) because of the personal, educational, and professional context factors. To overcome this main concern, the professional responsible students, in a process, try to optimal use of the educational period through responsible learning and performance management strategies. There are numerous mediating factors in the process of applying these strategies. The consequence of this process is to protect the student and others versus irresponsibility. This process is shown Figure 1.

With regard to main category of this study (trying to optimal use of the educational period), Ghasemi et al. explained five attributes (smart thinking, appropriate managerial behaviors, appropriate communicational behaviors, situational self-mandatory, and task-orientation behaviors) for the concept of responsibility among nursing students.[2] The findings of their study are consistent with our study in some aspects such as committing and planning for learning, the reasons for the inconsistent of the two studies with each other may be due to the nature of the study, as their study design was based on concept analysis and didn't look at the acquiring professional responsibility of nursing students in a procedural way. Furthermore, Ghasemi et al. did not mention some of the issues of today's world such as participation in informal professional organization and social activity of the student. Asemani et al. stated that approaches of medical students toward their responsibilities are an effort to accept the educational expectations, to meet educational expectations, and to try to adapt to unacceptable expectations.[18] In their study, only the educational expectations were explained while the important issues and concepts such as creativity, innovation, and social activity are not discussed.

With regard to context factors category and its 3 subcategories (personal, educational, and professional factors), Rassouli et al. analyzed the literature from 1995 to 2014 on nursing education challenges and explained the non-clarity of student duties based on the educational goals, non-access to instructors, the gap between theory and practice, inappropriate behavior of health-care personnel with students and their instructors, inadequate facilities and equipment in the clinical setting, and the lack of a definitive evaluation process as the nursing education challenges.[19] In a descriptive study in Pakistan, traditional teaching methods, gap between theory and practice, no application of theoretical aspects of the nursing process in practice and learned things in clinical setting as the most nursing students challenges at educational and clinical environment.[20] Bvumbwe and Mtshali, in a review of 25 resources on the challenges of nursing education, concluded that the challenges of nursing education are usually same across the countries;[21] the results of these studies confirm the role of personal, educational, and professional factors for creating uncertain productivity of the educational period.

Andersen et al., in a study on three nursing schools (two schools in Australia and one in the USA), explained, delay to attend the classroom, inattention in the clinical setting, unjustified absenteeism, cheat on doing the assignments or in the exams, inappropriate verbal or bodily behavior toward the professor, clients, health-care personnel or friends, factitious documentation of vital sign that not measure or care not delivered as the incivility behaviors among nursing students in these two countries.[22] These behaviors are also evident in students of other disciplines and educational levels. For example, in a systematic review of 46 resources, failure to engage, dishonest behavior, disrespectful behavior, and poor self-awareness were regarded as the most important unprofessional behaviors in medical students.[23] The results of this and other studies suggest that the students’ uncertain productivity of the educational period is not only a main concern and concept for some Iranian bachelor degree nursing students and is a common problem in other countries and disciplines with different name but similar meaning. In most of these behaviors, the student either has uncertain efficacy or effectiveness or both of them. Regardless of the type and extent of this behavior, it is important to resolve the context factors of these behaviors and to assist the student in applying strategies to reduce or prevent such behavior. The findings of these studies are consistent with the uncertain productivity of the educational period category and its subcategories.

In different studies, ineffective communication (inadequate communication and discrimination), insufficient preparation (inadequate knowledge, inadequate clinical skills, and inadequate communication skills), and emotional reactions such as stress are considered as the most important problems of nursing students in clinical education.[24] Models that stimulate student's interests are academic variables for enhancing nursing students’ satisfaction.[25] Modification of curriculum and professional regulations, transformative teaching strategies, collaboration, and capacity building are the most ways for resolve the challenges of nursing education.[21] Webster et al. stated that clinical nurses can have a positive/negative impact on clinical education, socialization, and willingness of nursing students to stay in nursing discipline.[26] Also, negative peer group[27] and stress perceptions lead to poor academic performance in nursing students.[28] All of the findings of the mentioned studies are in agreement with the mediating factor categories of this study in the process of acquiring professional responsibility among nursing students.

With regard to protection of the student and others versus irresponsibility category and its subcategories findings of this study showed consistent with other study in some aspects. Completing the student tasks, providing health care comfortably in social and enhancing students’ self-esteem are the results of only a part of using responsibility student strategies.[29] Promotion of learning, and health of the students and clients and facilitation the process of learning and education have been highlighted as the results of responsibility concept among bachelor degree nursing students, which is consistent with the findings of this study. Ghasemi et al. also mentioned other abstract consequences, such as ensuring professional life and promoting community health, which were not obtained in the present study.[2] The reason for this inconsistency can be attributed to the differences in the type of study design. This study is a grounded study based on individual's experiences and some abstract consequences may not exist among the experiences of participants.

Conclusion

The process of acquiring professional responsibility among bachelor degree nursing students has been determined. Knowing the professional responsibility process among bachelor degree nursing students can be used to facilitate the formation, promotion, and evaluation of professional responsible behaviors, as well as the findings can be useful for the evolution of academic and clinical education and modeling in the field of education. The objective impact of each of the context, mediating factors on professional responsibility and consequences of responsible behaviors of nursing students can be more accurately investigated through quantitative researches; further researches in these areas are recommended.

Limitations

Maybe some of participants especially students had not declared complete experience because of the some considerations in their thoughts and this is limitation of this study.

Financial support and sponsorship

We are heartily grateful to the Baqiyatallah University of Medical Sciences for financially supporting the study.

Conflicts of interest

There are no conflicts of interest.