Nurse Educator
Nurse Educator Vol. 39, No. 5, pp. 227-231 Copyright * 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Longitudinal Study of Stress, Self-care, and Professional Identity Among Nursing Students Desiree Hensel, PhD, RN, PCNS-BC, CNE & Marcia Laux, MSN, RN, CNE This longitudinal study describes the factors associated with the acquisition of a professional identity over the course of prelicensure education among 45 baccalaureate nursing students. At every time point, personal spiritual growth practices and the students’ perceptions of their caring abilities predicted sense of fit with the profession. Even as there is a growing emphasis of quality and safety education, caring and spirituality remain central to nurses’ professional identities on entry to practice. Keywords: caring; nursing education; professional ethics; professional identity; professional role; QSEN; spirituality
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priority outcome of nursing education is the acquisition of an identity consistent with the profession’s core knowledge, skills, values, and attitudes.1-4 This identity is thought to support optimal practice and be a key factor in job retention.5,6 Still, what exactly comprises a nurse’s professional identity and how it forms is poorly understood.7,8 Cowin9 proposed that a nurse’s professional identity arises from self-perceptions of one’s nursing abilities known as a nurse self-concept. The perceptions include self-confidence with caring, staff relations, communication, leadership, knowledge, and nurse general self-concept. Within this framework, caring refers to responding with empathy and concern, whereas nurse general self-concept is defined as positive feelings about nursing and sense of fit with the profession.5,9 More recently, experts have suggested that a nurse’s professional identity should be grounded in quality and safety knowledge, skills, and attitudes known collectively as the Quality and Safety Education for Nurses (QSEN) competencies.1 That framework includes the 6 general domains of patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, informatics, and safety. Cowin’s factors and the QSEN competencies have many overlapping aspects. For instance, Cowin5,9 defined staff relations in terms of maintaining relationships with coworkers and communication as the ability to share information with patients and the healthcare team. Together, these factors reflect fostering open commuAuthor Affiliations: Assistant Professor (Dr Hensel) and Assistant Clinical Professor (Ms Laux), School of Nursing, Indiana University, Bloomington, Indiana. The authors declare no conflicts of interest. Correspondence: Dr Hensel, Indiana University, 1033 E 3rd Street, SY444, Bloomington, IN 47405 ([email protected]). Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.nurseeducatoronline.com). Accepted for publication: April 17, 2014 Published ahead of print date: May 23, 2014 DOI: 10.1097/NNE.0000000000000057
Nurse Educator
nication and functioning effectively within teams and exemplify the QSEN competency of teamwork and collaboration.1 However, the QSEN model does not address a nurse’s sense of fit with the profession, which is highly associated with job retention.5 It has been postulated that the acquisition of a professional identity is a developmental process.8,10,11 Socialization and belonging to a community are thought by some to be mechanisms by which students acquire this identity,12,13 but others have found that students enter prelicensure education with a fairly well-formed sense of the nurse that they aspire to become.14,15 In fact, some research suggests that sense of fit with the profession and the humanistic values found in beginning nursing students tend to be fairly stable.15,16 Several studies have found that stress poses a threat to the optimal development of a professional identity during prelicensure education and as new nurses transition to practice.17-21 Conversely, self-care has been associated with stronger perceptions of professional adequacy and has been deemed prerequisite to the practice of professional nursing.22-25 Self-care includes lifestyle activities geared at optimizing one’s health status and enhancing higher levels of wellness and personal growth.25-27 These activities include taking responsibility for one’s health, eating a healthy diet, participating in regular physical activity, using stress management techniques, maintaining healthy interpersonal relationships, and engaging in spiritual growth practices.26,27 Interpersonal relations refer to communicating with others to achieve closeness, whereas spiritual growth is characterized by developing inner resources, cultivating an awareness of personal values, and connecting with some greater force.26,27 Thus, both concepts involve a sense of connecting to enhance well-being.27 Caring, spirituality, and the transformation of the professional nurse have long been linked in nursing.25,28,29 Touch, presence, and competence are requisite to fulfilling high-quality nursing practice standards and are the basis for competency in the cognitive, affective, and psychomotor learning domains.30 Volume 39 & Number 5 & September/October 2014
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It also has been theorized that caring is at the core of a nurse’s identity and leads the nurse toward self-actualization.28,31 Watson’s Carative Factors and Caritas Processes clearly link spirituality and caring, proposing that care for the self and for the one being cared for defines competency and selfactualization as actions of the professional nurse.28 Evidence suggests that nursing students engage in spiritual growth, discussing spiritual matters regularly and finding it important for guidance and answering life’s questions.32 Still, in the face of modern healthcare systems that emphasize competence in quality and safety, it is unknown what factors most support the development of a nurse’s professional identity during prelicensure education.
Purpose The purpose of our study was to describe how self-care and stress were associated with the acquisition of a professional identity in a sample of students over the course of their prelicensure education. The 2 research questions that guided this study were as follows: (1) How do professional identities, selfcare practices, and perceptions of stress change during prelicensure education? and (2) how are professional identities, self-care practices, and perceptions of stress related?
Methods Approval to conduct this longitudinal study was obtained by the university’s institutional review board. A serial survey design was used to capture changes over time. The convenience sample was drawn from a cohort of 60 BSN students enrolled at a large Midwestern university. Data were collected during the first, second, and last year of nursing major courses during regularly scheduled class time. The final data collection point was during the last week of class just before graduation.
Instruments The Nurse Self-concept Questionnaire (NSCQ) was used to measure professional identity in this study. The NSCQ is a 36-item, 8-point, summative Likert scale. With responses ranging from 1 (definitely disagree) to 8 (definitely agree), the NSCQ is designed to measure the 6 dimensions of nurse self-concept defined by Cowin.9 The scale has evidence of construct validity, and published Cronbach’s ! scores have ranged from .83 to .93.9 For consistency and clarity, we refer to the dimension Cowin called ‘‘nurse general self-concept’’ as ‘‘sense of fit.’’ Self-care practices were measured using the Health Promoting Lifestyle Profile II (HPLPII). Arising from Pender’s Health Promotion Model, the HPLPII is s 52-item, 4-point Likert response scales designed to measure 6 aspects of a healthy lifestyle. Responses range from 1, rarely, to 4, routinely. The tool has been used in more than 200 studies and has evidence of construct and convergence validity and reported Cronbach’s ! scores from .79 to .87.27 Stress levels were measured using the Perceived Stress Scale (PSS). This 10-item, 5-point ordinal scale has responses ranging from 0 (never) to 4 (very often) and measures the degree to which participants perceive their life is stressful by asking how often they have felt certain ways in the past month. Higher scores indicate greater stress.33 The PSS has 228
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construct validity and published internal reliabilities ranging from .78 to .91.34
Data Analysis SPSS Statistics for Windows version 21.0 (IBM Corporation, Armonk, New York) software was used to complete the data analysis. Descriptive statistics, repeated-measures analysis of variance (ANOVA), Pearson product-moment correlations, and linear regression tests were used to answer the research questions. Findings were considered significant at P G .05 (2 tailed).
Results Originally, 57 of the 60 eligible students volunteered to participate in the study. Only data from the 45 students who completed questionnaires at all 3 collection points were used for analysis. The mean (SD) age of the participants at the beginning of the study was 20.4 (1.05) years. All participants who declared their gender reported it as female. Seven students (15%) did not identify a gender. Research question 1 asked how professional identities, self-care practices, and perceptions of stress changed during prelicensure education. A repeated-measures ANOVA test was done to evaluate differences in the study variables at 3 time points (Table 1). All aspects of students’ professional identities became stronger over time with the noted exception of sense of fit with the profession, which remained fairly stable. Students also engaged in more self-care behaviors and experienced decreased stress as they progressed through the program. Polynomial contrasts showed a linear effect in these variables, meaning changes increased from beginning to midpoint and then again from midpoint to program end. Research question 2 examined how professional identity, self-care practices, and perceptions of stress were related. The Table, Supplemental Digital Content 1, shows the Pearson product-moment correlation coefficients for the study variables, http://links.lww.com/NE/A143. At every time point, spiritual growth was positively associated with increased sense of fit (r = 0.396-0.451) and staff relations (r = 0.323-0.445) and decreased perceived stress (r = j0.508 to j0.646). Linear regression was done to determine which factors most predicted sense of fit with the profession. To avoid problems of collinearity, models were tested using only 1 other professional identity and 1 self-care subscale variable at a time. Together, caring and spiritual growth predicted sense of fit with the profession at every time point (See Figure, Supplemental Digital Content 2, http://links.lww.com/NE/A144). At program entry, the model was significant (F2, 42 = 22.61; P = .001) and explained 49% of the variance. At midprogram, the model explained only 38% of variance (F2, 42 = 14.26; P = .001). At both time points, spiritual growth was a stronger predictor of sense of fit than were stress management, interpersonal relations, or perceived stress. At program end, spiritual growth and caring continued to predict sense of fit with the profession (F2, 42 = 22.43; P = .001) and explained 49% of the variance. However, combining interpersonal relations with caring explained slightly more variance (r 2 = 0.50), as did combining knowledge with spiritual growth (r 2 = 0.50). These findings suggest that individuals who entered the program with a compassionate concern for others and strong Nurse Educator
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Table 1. Differences in Professional Identity, Self-care, and Perceived Stress Over Time T1 Professional identity (NSCQ) Sense of fit Caring Communication Knowledge Leadership Staff relations Self-care (HPLPII) Health responsibility Interpersonal relations Nutrition Physical activity Spiritual growth Stress management Perceived stress (PSS)
227.5 43.2 35.6 37.2 38.8 32.7 39.7 2.6 2.3 3.3 2.6 2.3 3.1 2.2 20.3
(23.29) (4.84) (5.24) (5.63) (4.45) (5.08) (5.46) (0.29) (0.51) (0.52) (0.49) (0.50) (0.46) (0.44) (7.48)
T2 233.1 43.6 38.2 38.0 40.1 34.2 38.8 2.8 2.4 3.4 2.8 2.5 3.2 2.4 19.3
T3
(19.14) (4.08) (3.06) (4.24) (3.16) (4.31) (4.95) (0.32) (0.44) (0.42) (0.46) (0.53) (0.43) (0.54) (5.94)
247.9 43.9 41.2 41.1 42.0 36.9 42.5 3.0 2.6 3.5 3.0 2.7 3.3 2.5 16.3
(15.14) (3.94) (3.07) (3.57) (3.34) (3.70) (3.27) (0.36) (0.46) (0.37) (0.66) (0.51) (0.45) (0.53) (6.20)
F
P
20.02 0.566 24.12 16.90 8.77 12.99 20.69 19.66 9.54 7.43 9.30 12.80 7.17 15.37 9.69
.001 .572 .001 .001 .001 .001 .001 .001 .001 .002 .001 .001 .002 .001 .001
Data are presented as mean (SD).
spiritual growth practices also felt well suited for the nursing profession throughout their prelicensure education and as they entered practice.
Discussion Our study used a framework of professional identity that included aspects of caring, staff relations, leadership, communication, knowledge, and nurse general self-concept or sense of fit.9 We found that all components of professional identity, except sense of fit, increased from program entry to end. Questionnaire items to measure sense of fit generally reflected getting enjoyment from being a nurse. Participant responses reflected that sense of fit was the strongest aspect of the student’s identity at every measurement point and was relatively stable over time. On the other hand, the subscale that addressed enjoyment with nursing leadership responsibilities and self-confidence in the leader role received the lowest NSCQ scores at program entry and end. These findings are similar to those from 1 crosssectional study that found the strongest aspect of nursing students’ identity to be sense of fit and the weakest to be leadership across program levels.15 Beyond having implications for exploring more effective ways to build confident nurse leaders, the findings have ramifications for educators who are constantly seeking ways to craft admission criteria aimed at selecting candidates who will be most successful in their programs and who will best support nursing’s preferred future. With national calls for nurses to become stronger leaders, the professional identity acquisition trends found in this study lend support to the recommendation that attention needs to be paid to this personal characteristic and perhaps other nonacademic factors in candidate selection for prelicensure programs.35,36 On the HPLPII, questions designed to measure spiritual growth looked for evidence of transcending, connecting, and developing to achieve inner strengths, peace, and sense of purpose.27 Although multiple studies have discussed the hazards of stress during nursing education, our study illuminated the protective nature from developing inner resources. At every point, we found that stress was inversely related to interperNurse Educator
sonal relations and stress management, but the strongest relationship each time was between increased spiritual growth and decreased perceptions of stress. As educators seek the best methods to help students reduce stress, 1 study concluded that traditional methods for teaching stress management that were strong on theory but with too little practice were of little value.17 Successful stress management involves relaxation techniques that can be practiced to promote homeostasis and growth activities, or coping strategies, to help individuals develop the resources to deal with the underlying sources of stress.37 The findings of our study suggest that exploring approaches to teaching stress management that highly integrate spiritual growth practices and foster interpersonal relationships may be more effective than focusing primarily on relaxation activities. We found that caring and spiritual growth predicted sense of fit with the profession at every time point and, except at program end, explained the most variance of any model. The NSCQ measures caring in terms of self-perceptions of the ability to provide care with a sense of concern and empathy for others.5 Spirituality and caring are characteristics that can be traced back to Florence Nightingale and the inception of modern nursing.25 Watson28 writes that caring is an imperative humanistic value system to be combined with a scientific knowledge foundation as a requisite to effective nursing action and interventions. The combination of humanistic-scientific values and knowledge functions as the underpinnings of the science of caring. Watson’s assumptions include the dimensions of spirituality that lead to the growth and transformation of the professional nurse. Our study found that students still retain these traditional nursing values. There is a growing emphasis on integrating QSEN competencies into nursing curricula.1,10 Analysis of the QSEN framework reveals that several of the knowledge, skills, and attitudes in patient-centered care reflect the ability to provide compassionate care while calling for the nurse to engage in spiritual growth. Specifically, the competencies that reflect caring include valuing situations through the patient’s eyes, being willing to support patients’ values, and relieving pain and suffering. Statements that reflect sense of greater purpose, Volume 39 & Number 5 & September/October 2014
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although limited, include seeking opportunities to learn from diverse patients and recognizing one’s own beliefs about pain and suffering. Although research is just beginning to emerge on how students integrate the QSEN attitudes, 1 study found 3 patterns of identity in new nurse graduates: champions, collaborators, and individualists.2 That study found that champions had no major disagreements with the QSEN attitudes and most valued patient-centered attitudes. Collaborators, on the other hand, had a stronger sense of teamwork, and individualists remained committed to serving the patient but were skeptical about universal solutions to care issues. That study found that all participants valued safety, but quality improvement and informatics (ie, technology) attitudes played a minimal role in defining the new graduates’ identities. Our study supports the findings that on entry to practice, nurses still define themselves in terms of connections and relationships, whether it is with patients or colleagues. What is not known is how quality and safety attitudes change once new graduates are in the workforce.
Limitations This study used data collected on self-report questionnaires, which rely on students’ willingness to give honest answers and must be considered a study limitation. To best protect student privacy, we collected limited demographic data, making it difficult to determine if there were major differences between students who did and students who did not complete the study. Our study also used a convenience sample of all students entering a nursing program at 1 large Midwestern university, and therefore, the data may not be generalizable to other programs. Despite these limitations, this study contributes to the body of literature surrounding professional identity formation and helps set directions for future research. Larger studies are needed to help create models that best explain the professional identity of nurses in the 21st century and help predict what factors will make them most successful during prelicensure education and in practice. Acknowledgments The authors thank Phyllis Dexter for her editorial guidance and the Indiana University Stat Math department for assistance with data analysis.
References 1. Cronenwett L, Sherwood G, Barnsteiner J, et al. Quality and safety education for nurses. Nurs Outlook. 2007;55(3):22-131. 2. Hensel D. Typologies of professional identity among baccalaureate prepared nurses. J Nurs Scholarsh. 2014;46(2):125-133. 3. Iacobucci TA, Daly BJ, Lindell D, Griffin MQ. Professional values, self-esteem, and ethical confidence of baccalaureate nursing students. Nurs Ethics. 2013;20(4):479-490. 4. National League for Nursing. Outcomes for Graduates of Practical/ Vocational, Diploma, Associate Degree, Baccalaureate, Master’s, Practice Doctorate, and Research Doctorate Programs in Nursing. New York, NY: National League for Nursing; 2010. 5. Cowin LS, Johnson M, Craven RG, Marsh HW. Causal modeling of self-concept, job satisfaction, and retention of nurses. Int J Nurs Stud. 2008;45(10):1448-1459. 6. Jahanbin I, Badiyepeyma Z, Ghodsbin F, Sharif F, Keshavarzi S. The impact of teaching professional self-concept on clinical performance perception in nursing students. Life Sci J. 2012;9(4):653-659. 7. Andrew N. Professional identity in nursing: are we there yet? Nurse Educ Today. 2012;32(8):846-849.
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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. Cowin L. Measuring nurses’ self-concept. West J Nurs Res. 2001; 23(3):313-325. 10. Barton AJ, Armstrong G, Preheim G, Gelmon SB, Andrus LC. A national Delphi to determine developmental progression of quality and safety competencies in nursing education. Nurs Outlook. 2009; 57(6):313-322. 11. Cowin LS, Craven RG, Johnson M, Marsh HW. A longitudinal study of student and experienced nurses’ self-concept. Collegian. 2006;13(3):25-31. 12. Andrew N, Robb Y, Ferguson D, Brown J. ‘Show us you know us’: using the Senses Framework to support the professional development of undergraduate nursing students. Nurse Educ Pract. 2011;11(6):356-359. 13. Andrew N, Ferguson D, Wilkie G, Corcoran T, Simpson L. Developing professional identity in nursing academics: the role of communities of practice. Nurse Educ Today. 2009;29(6): 607-611. 14. Ware SM. Developing a self-concept of nurse in baccalaureate nursing students. Int J Nurs Educ Scholarsh. 2008;5(1):1-17. 15. Hensel D, Middleton MJ, Engs RC. Drinking patterns, prelicensure nursing education, and professional identity formation. Nurse Educ Today. 2014;34(5):719-723. 16. Bjo ¨ rkstro ¨ m ME, Athlin EE, Johansson IS. Nurses’ development of professional self–from being a nursing student in a baccalaureate programme to an experienced nurse. J Clin Nurs. 2008;17(10): 1380-1391. 17. Hensel D, Stoelting-Gettelfinger W. Changes in stress and nurse self-concept among baccalaureate nursing students. J Nurs Educ. 2011;50(5):290-293. 18. Deppoliti D. Exploring how new registered nurses construct professional identity in hospital settings. J Contin Educ Nurs. 2008; 39(6):255-262. 19. Cowin Pryjmachuk S, Richards DA. Predicting stress in preregistration nursing students. Br J Health Psychol. 2007;12(1): 125-144. 20. Edwards D, Burnard P, Bennett, K, Hebden U. A longitudinal study of stress and self-esteem in student nurses. Nurse Educ Today. 2010;30(1):78-84. 21. Watson R, Gardiner E, Hogston R, et al. A longitudinal study of stress and psychological distress in nurses and nursing students. J Clin Nurs. 2009;18(2):270-278. 22. Hensel D. Relationships among nurses’ professional self-concept, health, and lifestyles. West J Nurs Res. 2011;33(1):45-62. 23. Riley JB, Yearwood EL. The effect of a pedagogy of curriculum infusion on nursing student well-being and intent to improve the quality of nursing care. Arch Psychiatr Nurs. 2012;26(5): 364-373. 24. American Colleges of Nursing. The essentials for baccalaureate education for the professional practice of education. http://www .aacn.nche.edu/education/-resources/baccessentials08.pdf. Published October 8, 2008. Accessed April 2, 2014. 25. Dossey BM, Selander LC, Beck DM, Attewell BA. Florence Nightingale Today: Healing, Leadership, Global Action. Silver Springs, MD: American Nurses Association; 2005. 26. Pender NJ, Murdaugh CL, Parsons MA. Health Promotion in Nursing Practice. 6th ed. Upper Saddle River, NJ: Pearson; 2011. 27. Walker SN, Hill-Polerecky DM. Psychometric evaluation of the Health-Promoting Lifestyle Profile II. Omaha, NE: University of Nebraska Medical Center; 1996:120-126 . Unpublished Manuscript. 28. Watson J. Human Caring Science. 2nd ed. Sudbury, MA: Jones & Bartlett Publishers; 2011. 29. Vandenhouten C, Kubsch S, Peterson M, Murdock J, Lehrer L. Watson’s theory of transpersonal caring: factors impacting nurses professional caring. Holist Nurs Pract. 2012;26(6):326-334. Nurse Educator
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30. Brilowski GA, Wendler MC. An evolutionary concept analysis of caring. J Adv Nurs. 2005;50(6):641-650. 31. Cara C. A pragmatic view of Jean Watson’s Caring Theory. Int J Hum Caring. 2003;7(3):51-51. 32. Shores CI. Spiritual perspectives of nursing students. Nurs Educ Perspect. 2010;31(1):8-11. 33. Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983;24(4):385-396. 34. Cohen S, Janicki-Deverts D. Who’s stressed? Distributions of psychological stress in the United States in probability sam-
ples from 1983, 2006, and 2009. J Appl Soc Psychol. 2012;42(6): 1320-1334. 35. Institute of Medicine. The future of nursing: leading change, advancing health. http://www.iom.edu/Reports/2010/The-futureof-nursing-leading-change-advancing-health.aspx. Published October 5, 2010. Accessed April 2, 2014. 36. Schmid B, MacWilliams B. Admission criteria for undergraduate nursing programs: a systematic review. Nurse Educ. 2011;36(4):171-174. 37. Seaward BL. Managing Stress: Principles and Strategies for Health and Wellbeing. 8th ed. Burlington, MA: Jones and Bartlett; 2013.
Barcode Training Innovation Barcode medication administration (BCMA) is an integral technological component of patient safety. One of our clinical partners required BCMA training for nursing students prior to using their facility as a clinical site. The facility training module required 4 hours of time as well as staff and resources. An abbreviated module specific to the needs of the beginning student was needed. The nursing school purchased 2 wireless barcode scanners identical to devices used in the facility. One faculty member and 1 laboratory resource nurse were trained in the use of the hardware and software. A library of barcodes for patient identification bands and medication labels was created. In addition, electronic medication administration records (eMAR) were developed using spreadsheet software. These were incorporated into a learning module on medication administration in a beginning laboratory course. The module was then made available for independent student practice. Students are now able to learn to use BCMA in a safe setting in a short amount of time. The eMAR with the BCMA is used in numerous laboratories and simulations throughout the curriculum. Students report satisfaction with the learning module. Our clinical partner is satisfied with the training as preparation for using BCMA at the clinical site. Submitted by: Suzanne E. Cook, MN, RN, CHSE, CNE, Professor of Nursing, Olympic College, Bremerton, Washington. DOI: 10.1097/NNE.0000000000000071
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Nurse Educator Vol. 39, No. 5, pp. 227-231 Copyright * 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Longitudinal Study of Stress, Self-care, and Professional Identity Among Nursing Students Desiree Hensel, PhD, RN, PCNS-BC, CNE & Marcia Laux, MSN, RN, CNE This longitudinal study describes the factors associated with the acquisition of a professional identity over the course of prelicensure education among 45 baccalaureate nursing students. At every time point, personal spiritual growth practices and the students’ perceptions of their caring abilities predicted sense of fit with the profession. Even as there is a growing emphasis of quality and safety education, caring and spirituality remain central to nurses’ professional identities on entry to practice. Keywords: caring; nursing education; professional ethics; professional identity; professional role; QSEN; spirituality
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priority outcome of nursing education is the acquisition of an identity consistent with the profession’s core knowledge, skills, values, and attitudes.1-4 This identity is thought to support optimal practice and be a key factor in job retention.5,6 Still, what exactly comprises a nurse’s professional identity and how it forms is poorly understood.7,8 Cowin9 proposed that a nurse’s professional identity arises from self-perceptions of one’s nursing abilities known as a nurse self-concept. The perceptions include self-confidence with caring, staff relations, communication, leadership, knowledge, and nurse general self-concept. Within this framework, caring refers to responding with empathy and concern, whereas nurse general self-concept is defined as positive feelings about nursing and sense of fit with the profession.5,9 More recently, experts have suggested that a nurse’s professional identity should be grounded in quality and safety knowledge, skills, and attitudes known collectively as the Quality and Safety Education for Nurses (QSEN) competencies.1 That framework includes the 6 general domains of patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, informatics, and safety. Cowin’s factors and the QSEN competencies have many overlapping aspects. For instance, Cowin5,9 defined staff relations in terms of maintaining relationships with coworkers and communication as the ability to share information with patients and the healthcare team. Together, these factors reflect fostering open commuAuthor Affiliations: Assistant Professor (Dr Hensel) and Assistant Clinical Professor (Ms Laux), School of Nursing, Indiana University, Bloomington, Indiana. The authors declare no conflicts of interest. Correspondence: Dr Hensel, Indiana University, 1033 E 3rd Street, SY444, Bloomington, IN 47405 ([email protected]). Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.nurseeducatoronline.com). Accepted for publication: April 17, 2014 Published ahead of print date: May 23, 2014 DOI: 10.1097/NNE.0000000000000057
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nication and functioning effectively within teams and exemplify the QSEN competency of teamwork and collaboration.1 However, the QSEN model does not address a nurse’s sense of fit with the profession, which is highly associated with job retention.5 It has been postulated that the acquisition of a professional identity is a developmental process.8,10,11 Socialization and belonging to a community are thought by some to be mechanisms by which students acquire this identity,12,13 but others have found that students enter prelicensure education with a fairly well-formed sense of the nurse that they aspire to become.14,15 In fact, some research suggests that sense of fit with the profession and the humanistic values found in beginning nursing students tend to be fairly stable.15,16 Several studies have found that stress poses a threat to the optimal development of a professional identity during prelicensure education and as new nurses transition to practice.17-21 Conversely, self-care has been associated with stronger perceptions of professional adequacy and has been deemed prerequisite to the practice of professional nursing.22-25 Self-care includes lifestyle activities geared at optimizing one’s health status and enhancing higher levels of wellness and personal growth.25-27 These activities include taking responsibility for one’s health, eating a healthy diet, participating in regular physical activity, using stress management techniques, maintaining healthy interpersonal relationships, and engaging in spiritual growth practices.26,27 Interpersonal relations refer to communicating with others to achieve closeness, whereas spiritual growth is characterized by developing inner resources, cultivating an awareness of personal values, and connecting with some greater force.26,27 Thus, both concepts involve a sense of connecting to enhance well-being.27 Caring, spirituality, and the transformation of the professional nurse have long been linked in nursing.25,28,29 Touch, presence, and competence are requisite to fulfilling high-quality nursing practice standards and are the basis for competency in the cognitive, affective, and psychomotor learning domains.30 Volume 39 & Number 5 & September/October 2014
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It also has been theorized that caring is at the core of a nurse’s identity and leads the nurse toward self-actualization.28,31 Watson’s Carative Factors and Caritas Processes clearly link spirituality and caring, proposing that care for the self and for the one being cared for defines competency and selfactualization as actions of the professional nurse.28 Evidence suggests that nursing students engage in spiritual growth, discussing spiritual matters regularly and finding it important for guidance and answering life’s questions.32 Still, in the face of modern healthcare systems that emphasize competence in quality and safety, it is unknown what factors most support the development of a nurse’s professional identity during prelicensure education.
Purpose The purpose of our study was to describe how self-care and stress were associated with the acquisition of a professional identity in a sample of students over the course of their prelicensure education. The 2 research questions that guided this study were as follows: (1) How do professional identities, selfcare practices, and perceptions of stress change during prelicensure education? and (2) how are professional identities, self-care practices, and perceptions of stress related?
Methods Approval to conduct this longitudinal study was obtained by the university’s institutional review board. A serial survey design was used to capture changes over time. The convenience sample was drawn from a cohort of 60 BSN students enrolled at a large Midwestern university. Data were collected during the first, second, and last year of nursing major courses during regularly scheduled class time. The final data collection point was during the last week of class just before graduation.
Instruments The Nurse Self-concept Questionnaire (NSCQ) was used to measure professional identity in this study. The NSCQ is a 36-item, 8-point, summative Likert scale. With responses ranging from 1 (definitely disagree) to 8 (definitely agree), the NSCQ is designed to measure the 6 dimensions of nurse self-concept defined by Cowin.9 The scale has evidence of construct validity, and published Cronbach’s ! scores have ranged from .83 to .93.9 For consistency and clarity, we refer to the dimension Cowin called ‘‘nurse general self-concept’’ as ‘‘sense of fit.’’ Self-care practices were measured using the Health Promoting Lifestyle Profile II (HPLPII). Arising from Pender’s Health Promotion Model, the HPLPII is s 52-item, 4-point Likert response scales designed to measure 6 aspects of a healthy lifestyle. Responses range from 1, rarely, to 4, routinely. The tool has been used in more than 200 studies and has evidence of construct and convergence validity and reported Cronbach’s ! scores from .79 to .87.27 Stress levels were measured using the Perceived Stress Scale (PSS). This 10-item, 5-point ordinal scale has responses ranging from 0 (never) to 4 (very often) and measures the degree to which participants perceive their life is stressful by asking how often they have felt certain ways in the past month. Higher scores indicate greater stress.33 The PSS has 228
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construct validity and published internal reliabilities ranging from .78 to .91.34
Data Analysis SPSS Statistics for Windows version 21.0 (IBM Corporation, Armonk, New York) software was used to complete the data analysis. Descriptive statistics, repeated-measures analysis of variance (ANOVA), Pearson product-moment correlations, and linear regression tests were used to answer the research questions. Findings were considered significant at P G .05 (2 tailed).
Results Originally, 57 of the 60 eligible students volunteered to participate in the study. Only data from the 45 students who completed questionnaires at all 3 collection points were used for analysis. The mean (SD) age of the participants at the beginning of the study was 20.4 (1.05) years. All participants who declared their gender reported it as female. Seven students (15%) did not identify a gender. Research question 1 asked how professional identities, self-care practices, and perceptions of stress changed during prelicensure education. A repeated-measures ANOVA test was done to evaluate differences in the study variables at 3 time points (Table 1). All aspects of students’ professional identities became stronger over time with the noted exception of sense of fit with the profession, which remained fairly stable. Students also engaged in more self-care behaviors and experienced decreased stress as they progressed through the program. Polynomial contrasts showed a linear effect in these variables, meaning changes increased from beginning to midpoint and then again from midpoint to program end. Research question 2 examined how professional identity, self-care practices, and perceptions of stress were related. The Table, Supplemental Digital Content 1, shows the Pearson product-moment correlation coefficients for the study variables, http://links.lww.com/NE/A143. At every time point, spiritual growth was positively associated with increased sense of fit (r = 0.396-0.451) and staff relations (r = 0.323-0.445) and decreased perceived stress (r = j0.508 to j0.646). Linear regression was done to determine which factors most predicted sense of fit with the profession. To avoid problems of collinearity, models were tested using only 1 other professional identity and 1 self-care subscale variable at a time. Together, caring and spiritual growth predicted sense of fit with the profession at every time point (See Figure, Supplemental Digital Content 2, http://links.lww.com/NE/A144). At program entry, the model was significant (F2, 42 = 22.61; P = .001) and explained 49% of the variance. At midprogram, the model explained only 38% of variance (F2, 42 = 14.26; P = .001). At both time points, spiritual growth was a stronger predictor of sense of fit than were stress management, interpersonal relations, or perceived stress. At program end, spiritual growth and caring continued to predict sense of fit with the profession (F2, 42 = 22.43; P = .001) and explained 49% of the variance. However, combining interpersonal relations with caring explained slightly more variance (r 2 = 0.50), as did combining knowledge with spiritual growth (r 2 = 0.50). These findings suggest that individuals who entered the program with a compassionate concern for others and strong Nurse Educator
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Table 1. Differences in Professional Identity, Self-care, and Perceived Stress Over Time T1 Professional identity (NSCQ) Sense of fit Caring Communication Knowledge Leadership Staff relations Self-care (HPLPII) Health responsibility Interpersonal relations Nutrition Physical activity Spiritual growth Stress management Perceived stress (PSS)
227.5 43.2 35.6 37.2 38.8 32.7 39.7 2.6 2.3 3.3 2.6 2.3 3.1 2.2 20.3
(23.29) (4.84) (5.24) (5.63) (4.45) (5.08) (5.46) (0.29) (0.51) (0.52) (0.49) (0.50) (0.46) (0.44) (7.48)
T2 233.1 43.6 38.2 38.0 40.1 34.2 38.8 2.8 2.4 3.4 2.8 2.5 3.2 2.4 19.3
T3
(19.14) (4.08) (3.06) (4.24) (3.16) (4.31) (4.95) (0.32) (0.44) (0.42) (0.46) (0.53) (0.43) (0.54) (5.94)
247.9 43.9 41.2 41.1 42.0 36.9 42.5 3.0 2.6 3.5 3.0 2.7 3.3 2.5 16.3
(15.14) (3.94) (3.07) (3.57) (3.34) (3.70) (3.27) (0.36) (0.46) (0.37) (0.66) (0.51) (0.45) (0.53) (6.20)
F
P
20.02 0.566 24.12 16.90 8.77 12.99 20.69 19.66 9.54 7.43 9.30 12.80 7.17 15.37 9.69
.001 .572 .001 .001 .001 .001 .001 .001 .001 .002 .001 .001 .002 .001 .001
Data are presented as mean (SD).
spiritual growth practices also felt well suited for the nursing profession throughout their prelicensure education and as they entered practice.
Discussion Our study used a framework of professional identity that included aspects of caring, staff relations, leadership, communication, knowledge, and nurse general self-concept or sense of fit.9 We found that all components of professional identity, except sense of fit, increased from program entry to end. Questionnaire items to measure sense of fit generally reflected getting enjoyment from being a nurse. Participant responses reflected that sense of fit was the strongest aspect of the student’s identity at every measurement point and was relatively stable over time. On the other hand, the subscale that addressed enjoyment with nursing leadership responsibilities and self-confidence in the leader role received the lowest NSCQ scores at program entry and end. These findings are similar to those from 1 crosssectional study that found the strongest aspect of nursing students’ identity to be sense of fit and the weakest to be leadership across program levels.15 Beyond having implications for exploring more effective ways to build confident nurse leaders, the findings have ramifications for educators who are constantly seeking ways to craft admission criteria aimed at selecting candidates who will be most successful in their programs and who will best support nursing’s preferred future. With national calls for nurses to become stronger leaders, the professional identity acquisition trends found in this study lend support to the recommendation that attention needs to be paid to this personal characteristic and perhaps other nonacademic factors in candidate selection for prelicensure programs.35,36 On the HPLPII, questions designed to measure spiritual growth looked for evidence of transcending, connecting, and developing to achieve inner strengths, peace, and sense of purpose.27 Although multiple studies have discussed the hazards of stress during nursing education, our study illuminated the protective nature from developing inner resources. At every point, we found that stress was inversely related to interperNurse Educator
sonal relations and stress management, but the strongest relationship each time was between increased spiritual growth and decreased perceptions of stress. As educators seek the best methods to help students reduce stress, 1 study concluded that traditional methods for teaching stress management that were strong on theory but with too little practice were of little value.17 Successful stress management involves relaxation techniques that can be practiced to promote homeostasis and growth activities, or coping strategies, to help individuals develop the resources to deal with the underlying sources of stress.37 The findings of our study suggest that exploring approaches to teaching stress management that highly integrate spiritual growth practices and foster interpersonal relationships may be more effective than focusing primarily on relaxation activities. We found that caring and spiritual growth predicted sense of fit with the profession at every time point and, except at program end, explained the most variance of any model. The NSCQ measures caring in terms of self-perceptions of the ability to provide care with a sense of concern and empathy for others.5 Spirituality and caring are characteristics that can be traced back to Florence Nightingale and the inception of modern nursing.25 Watson28 writes that caring is an imperative humanistic value system to be combined with a scientific knowledge foundation as a requisite to effective nursing action and interventions. The combination of humanistic-scientific values and knowledge functions as the underpinnings of the science of caring. Watson’s assumptions include the dimensions of spirituality that lead to the growth and transformation of the professional nurse. Our study found that students still retain these traditional nursing values. There is a growing emphasis on integrating QSEN competencies into nursing curricula.1,10 Analysis of the QSEN framework reveals that several of the knowledge, skills, and attitudes in patient-centered care reflect the ability to provide compassionate care while calling for the nurse to engage in spiritual growth. Specifically, the competencies that reflect caring include valuing situations through the patient’s eyes, being willing to support patients’ values, and relieving pain and suffering. Statements that reflect sense of greater purpose, Volume 39 & Number 5 & September/October 2014
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although limited, include seeking opportunities to learn from diverse patients and recognizing one’s own beliefs about pain and suffering. Although research is just beginning to emerge on how students integrate the QSEN attitudes, 1 study found 3 patterns of identity in new nurse graduates: champions, collaborators, and individualists.2 That study found that champions had no major disagreements with the QSEN attitudes and most valued patient-centered attitudes. Collaborators, on the other hand, had a stronger sense of teamwork, and individualists remained committed to serving the patient but were skeptical about universal solutions to care issues. That study found that all participants valued safety, but quality improvement and informatics (ie, technology) attitudes played a minimal role in defining the new graduates’ identities. Our study supports the findings that on entry to practice, nurses still define themselves in terms of connections and relationships, whether it is with patients or colleagues. What is not known is how quality and safety attitudes change once new graduates are in the workforce.
Limitations This study used data collected on self-report questionnaires, which rely on students’ willingness to give honest answers and must be considered a study limitation. To best protect student privacy, we collected limited demographic data, making it difficult to determine if there were major differences between students who did and students who did not complete the study. Our study also used a convenience sample of all students entering a nursing program at 1 large Midwestern university, and therefore, the data may not be generalizable to other programs. Despite these limitations, this study contributes to the body of literature surrounding professional identity formation and helps set directions for future research. Larger studies are needed to help create models that best explain the professional identity of nurses in the 21st century and help predict what factors will make them most successful during prelicensure education and in practice. Acknowledgments The authors thank Phyllis Dexter for her editorial guidance and the Indiana University Stat Math department for assistance with data analysis.
References 1. Cronenwett L, Sherwood G, Barnsteiner J, et al. Quality and safety education for nurses. Nurs Outlook. 2007;55(3):22-131. 2. Hensel D. Typologies of professional identity among baccalaureate prepared nurses. J Nurs Scholarsh. 2014;46(2):125-133. 3. Iacobucci TA, Daly BJ, Lindell D, Griffin MQ. Professional values, self-esteem, and ethical confidence of baccalaureate nursing students. Nurs Ethics. 2013;20(4):479-490. 4. National League for Nursing. Outcomes for Graduates of Practical/ Vocational, Diploma, Associate Degree, Baccalaureate, Master’s, Practice Doctorate, and Research Doctorate Programs in Nursing. New York, NY: National League for Nursing; 2010. 5. Cowin LS, Johnson M, Craven RG, Marsh HW. Causal modeling of self-concept, job satisfaction, and retention of nurses. Int J Nurs Stud. 2008;45(10):1448-1459. 6. Jahanbin I, Badiyepeyma Z, Ghodsbin F, Sharif F, Keshavarzi S. The impact of teaching professional self-concept on clinical performance perception in nursing students. Life Sci J. 2012;9(4):653-659. 7. Andrew N. Professional identity in nursing: are we there yet? Nurse Educ Today. 2012;32(8):846-849.
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30. Brilowski GA, Wendler MC. An evolutionary concept analysis of caring. J Adv Nurs. 2005;50(6):641-650. 31. Cara C. A pragmatic view of Jean Watson’s Caring Theory. Int J Hum Caring. 2003;7(3):51-51. 32. Shores CI. Spiritual perspectives of nursing students. Nurs Educ Perspect. 2010;31(1):8-11. 33. Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. 1983;24(4):385-396. 34. Cohen S, Janicki-Deverts D. Who’s stressed? Distributions of psychological stress in the United States in probability sam-
ples from 1983, 2006, and 2009. J Appl Soc Psychol. 2012;42(6): 1320-1334. 35. Institute of Medicine. The future of nursing: leading change, advancing health. http://www.iom.edu/Reports/2010/The-futureof-nursing-leading-change-advancing-health.aspx. Published October 5, 2010. Accessed April 2, 2014. 36. Schmid B, MacWilliams B. Admission criteria for undergraduate nursing programs: a systematic review. Nurse Educ. 2011;36(4):171-174. 37. Seaward BL. Managing Stress: Principles and Strategies for Health and Wellbeing. 8th ed. Burlington, MA: Jones and Bartlett; 2013.
Barcode Training Innovation Barcode medication administration (BCMA) is an integral technological component of patient safety. One of our clinical partners required BCMA training for nursing students prior to using their facility as a clinical site. The facility training module required 4 hours of time as well as staff and resources. An abbreviated module specific to the needs of the beginning student was needed. The nursing school purchased 2 wireless barcode scanners identical to devices used in the facility. One faculty member and 1 laboratory resource nurse were trained in the use of the hardware and software. A library of barcodes for patient identification bands and medication labels was created. In addition, electronic medication administration records (eMAR) were developed using spreadsheet software. These were incorporated into a learning module on medication administration in a beginning laboratory course. The module was then made available for independent student practice. Students are now able to learn to use BCMA in a safe setting in a short amount of time. The eMAR with the BCMA is used in numerous laboratories and simulations throughout the curriculum. Students report satisfaction with the learning module. Our clinical partner is satisfied with the training as preparation for using BCMA at the clinical site. Submitted by: Suzanne E. Cook, MN, RN, CHSE, CNE, Professor of Nursing, Olympic College, Bremerton, Washington. DOI: 10.1097/NNE.0000000000000071
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