Joumal of Advanced Nursir^, 1992,17,1166-1170
The young pioneers:firstbaccalaureate nursing students in the People's Republic of China AnneJ Davis RN PhD FAAN Professor of Nursing, Deparimeni of Menial Healih, Commumiy and Admimstrahve Nursmg, University of Califomia, San Franasco, USA
Lan Jun Gan RN BSN Former Dean, Department of Nursing, Ttanjin Medical College, People's Republtc of Chtna
Ju Ying Lin RN BSN Former Prestdeni, Chnese Nurstng Assoaahon, Beijing, People's Republic of Chtna
and Virginia L Olesen PhD Professor of Soaology Deparimeni of Behaviounal Saences, Untverstiy of Califomia, San Francisco, USA
Accepted for publication 2 March 1992
DAVIS A J, GAN L J, LIN J Y & OLESEN V L (1992) journal of Advanced Nurstng 17,1166-1170 Hie young pioneers: first baccalaureate nursmg students in the People's Republic of China Nursing in the People's Republic of China, like elsewhere, has undergone monumental changes dunng the 20th century This paper focuses on one of those changes by examining the professional soaalization process of the first class from the first baccalaureate in nursing (BSN) programme in China since 1952 These data from this first BSN dass are part of a larger study on professional soaalization in which data were collected from four of the recently established 11 BSN programmes m China To put these data mto a histoncal context, some highlights of Chinese nursmg history are noted These will help us to understand the present-day situahon m this the worid's most populous nation
HISTORICAL HIGHLIGHTS
in 1888 The Chinese word for nurse, Kan-Hu, was coined and meant watch and take care or attendant (Yu 1989) In the early 1880s, China had no nurses, no sdiools of In 1907, Cora Sunpsoa also an Amencan, mterested in nursing and no word that would translate as nurse Elizabeth promotmg the truning of mirses in China, was mstrumenMcKedmic from the Umted States went to China m 1884 tal in the early developments of the nursing associahon as the 6rst graduate nurse m the country and estabbshed there In 1914, the first ofl&cers of the Chinese Nursing the first Nightingale system of nursing at Shanghai West Associahon were elected. The president was an Amencan Gate Hospital The first school for Chinese nurses was named Gage Cora Simpson was elected director general estabbshed m Fuchou by another Amencan, Ella Johnson, and Feng Zhen Ma became the vice president Mrs Ma, the first Chinese nurse to study in Er^Iand, also recast Correspondence Profe^orA] Dams, School of Nursmg, Department of Menial Heallh, the Chinese word for nurse into Hu-Shh which means Commumty and Admmtstrttbve Nursing Huveraty of Califorma San franasco, educated nurse or nurse sdtolar She also translated from Cabforma 9*143-0608, USA 1166
Ftrsi Chinese baccalaureaie nursing siudenis
English mto Chinese the first nursmg handbook (Yu 1989) By 1922, a number of Chinese nurses, women and men, had been trained and some of them went abroad for post graduate work A nursing joumal began pubbcahon in 1920 and numerous nursing textbooks in Engbsh were translated mto Chinese The Chinese Nursmg Assoaahon joined the Intemational Council of Nurses m 1922 and retamed membership unhl 1949 when Mao came to power and estabbshed 'the new China' At that hme, China had 32 800 nurses (Yu 1989) Growth of nursing schools The growth of nursir^ schools conhnued in the 1920s and 1930s and among these schools the most notable, the Pekmg Union Medical CoUege (PUMC) estabbshed by the Rockefeller Foundation, accepted students who had a nurumum of 2 years of college and who were fluent in Engbsh In 1922, PUMC became the first bachelor of saence programme in nursing in China, thereby prepanng many future nursmg leaders (Bullock 1980) It is mterestmg to note that the first BSN programme in the United States was opened m 1916 at the University of Minnesota while the first BSN programme in Chma opened m 1922, a mere 6 years later From this early development m nursmg educahon, China benefitted and continues to benefit today Numerous early PUMC graduates have held leadership posihons and have had an immense impact on nursing education and service To a large extent it has been these PUMC graduates who mamtamed the vision of professional nursing through the many soaal changes that Chma has expenenced since the 1940s Because of World War II, PUMC closed m Beijing from I94I to 1947 and moved to Chengdu, a westem a t y 1000 miles away, where it funchoned from 1943 to 1945 Ms Nieh, the first Chinese dean of the PUMC School of Nursing, and the nursing students were known as the class who walked 1000 miles to school (Nieh 1988, personal communication) The PUMC was re-opened m Beijmg m 1945, but it closed again in 1952 due to ideological differences after Chairman Mao came to power For over 30 years Chma had no BSN programmes and durmg many of these years it was cut off from the rest of the nursmg world Addihonally, dunng 10 years from 1967 to 1977, the Cultural Revoluhon dosed all hospital nursmg programmes as well as the nursing associahon Nursmg educahon and professional achvities came to a gnndmg halt Dunng the early 1980s the nahonal govemment, coiKemed about the lack of developn^nt m nursmg
education and nursing service, supported the estabbshment of BSN programmes m the People's Republic of Chma In September 1983, Tianjin, China's third largest aty, estabbshed the first nursing department at Tianjin Medical College to prepare BSN students This first BSN programme in the new China graduated its first class m 1988 Nursing education conference In January 1984, shortly after this first dass of students was enrolled at Tianjin, the Mimstry of Pubbc Health and the Ministry of Education met m Tianjm to hold the First National Nursing Educahon Conference and distnbuted conference proceedings throughout the People's Repubbc of Chma (PRC) These proceedings emphasized the importance of nursing development and the strengthenmg of the educational system to develop more nursmg leaders This conference had important effects on nursmg and nursmg education as well as on the health care system throughout the PRC In a country where the ratio of physiaans to nurses is about two to one, China reports a severe nursing shortage According to the 1990 health personnel stahstics, Chma has a total of 1 725 349 physiaans and secondary doctors This number includes Westem-mediane physiaans (1058 460), tradihonal Chinese physiaans (239 602) and physiaans who prachse both Westem and tradihonal Chmese medicme (4935) The secondary doctors, with less education, total 422 352 and are divided between traditional secondary mediane (91123) and Westem secondary medicme (331 229) (Mimshy of Pubbc Health 1990) In 1949, as mentioned earber, there were approximately 32 000 nurses and, by 1990, the number had grown to approximately 975 000 nurses working in 67 000 hospitals and dmics Of this total number of nurses, Chma has 431 541 semor nurses who have either an assoaate or a BS degree and 542 999 nurses with 3 years of nurses' traming Even with such progress, China still needs approximately 200 000 more nurses for its population of 1 1 bilbon (Mmistry of Pubbc Health 1990) The need for nurses in teaehmg, admimstration and sjjeciality areas is particularly cntical This is the moment m Chma's long history mto which these students step as BSN-prepared nurses
THE SAMPLE The 33 students from this first dass of the first BSN programme located m Tianjm constitute the sample for this paper Data were collected m the summer of 1986 after 1167
AJ Dapisetal these students had completed 2 years of basic and 1 year of the course Fundcunentals m Nursing which mduded theory and scane prachce These students, 30 females and three males, with only two exceptions, grew up in Tianjm or nearby Unbke most nurses m the PRC who complete 9 years of general education and have 3 years of nurses' trammg, these Tianjm students complete 12 years of general education before entenng a 5-year BSN programme These 20-21-year-oId students tended to come from middle-dass families as defined by Chmese categones In the PRC, highschool graduates take a national exammahon and also indicate what or where they want to study According to their score and their choice, they are placed m vanous mstituhons of higher leammg, a high score enables a student to choose medical saences, engmeenng, etc Once a student chooses the larger category of medical saences, there are six categones from which to select medicme, pubbc health, pharmacy, dentistry, nursing and medical mstruments Not all students mdicate a choice from these categones but simply request medical saences Others do not enrol m theirfirstchoice due to their low exammation score These BSN students were placed accordmg to their score but most did not indicate that they wished to study nursing Some left it open, while others said that they wanted to study at Tianjm Medical University They did not know that there was a new BSN programme and had assumed they would study mediane The setting Dunng theirfirst2 years of study, the BSN students at the Medical College of Tianjm took the same dasses as the medicine students, namely the basic sciences The Tianjin faculty carefully observed and evaluated this model Later they discarded this model Tianjin Medical University School of Nursmg is fortunate to have well-prepared and seasoned nurse teachers on its faculty In numerous other BSN programmes m China, female and some male physiaans are the majonty of the faculty The first dean of this school, Lan Jun Gan, graduated from PUMC in 1946 and has been mvolved m teaching and nursmg assoaahon achvihes for many years Dunng thefirst2 years, nurse leadersfromthe immediate area as well as from other ahes spoke to these students about the importance of nursing and their role m nursmg's future A film on Florence Nightmgale was shown and students wrote an essay on their reaction to the film In their third year, they had 5 hours of dasses on nursing history and ethics and read the first chapter m the Fioidamentals texH^ook which focuses cm history of 1168
nursmg m old China and in the new China This history and ethics focuses on the virtues of the nurse such as considerahon, service and responsibibty The instrument Data were gathered by usmg a questionnaire developed in Engbsh by the authors, two Amencans and two Chinese After this instrument was refined it was translated into Chmese by one Chmese author and this translation was checked by the other Chinese author Questions focused on (a) demographics, (b) initial study/work plans, (c) professional socialization in nursmg, and (d) the future Informed consent Informed consent was not obtamed from the students The authors explamed to the University of Cabfomia's lnshtutional Review Board that the Westem philosophical tradihon that underlies bioethics and places great emphasis on the ethical pnnaple of mdividual autonomy is not part of Chinese ethics Therefore, no wntten or oral consent was obtamed Students were promised confidentiality and this promise was kept No one at Tianjm Medical College saw the students' responses to the queshonruure
FINDINGS The questionnaire asked a number of questions related to the students' professional soaalizahon and their response to their programme These mduded quenes about members of their famtbes in the health saences, views on their course work, the relahonship of the danwei (the soaalist work group), whether they saw themselves as nurses To start their analysis, the authors read the entire queshonnaire to gam a sense of the class's thinking and responses After that they mtensively looked at answers to three questions (a) Has bemg in the first class of the first BSN nursmg programme made a difference for you? (b) If so, what difference has it made? (c) What do you see as the fiiture of nursing m China? This analysis did not proceed from hypotheses deduced from theory, which would have been quite inappropnate and unrealishc in this study Hence, the approach was inductive and ejqjloratory The authors therefore focused on finding an organizing theme which would charactenze most students' answers, a master code, as it were They also looked carefully for characteristics or properties of the themes To attempt to assure consistency and eredibibty, or what in quanhtahve work would be termed reli^»lity and
Ftrsi Chinese baccalaureaie nursing sitidents
validity, the authors scrutinized the queshonnaires for both vanahon m answers and answers whidi ran counter to the themes they found (Readers familiar with qualitahve research here will recogruze strategies set out in such analytic approaches as grounded theory (Glaser & Strauss 1967), domain analysis (Spradley 1979) and dimensional analysis (Schatzman 1990))
Sense of responsibility On the very first reading of the queshon, 'What difference has bemg m nursing made for you', the theme of responsibility emerged A majonty menhoned it m a vanety of ways Subsequent re-readmgs of this and the other central queshons affirmed that this was a central theme expressed m vanous ways and with varying degrees of emohon The customary sense of responsible individual professional behaviour, e g good clinical practice, however, was not the sense of responsibibty which emerged over and over again This IS not to say that these young nurses did not have a sense of individual professional behaviour, but our data do not speak to that sense of responsibility It was doubtless implied in that which was dearly expressed, but it was not stated expbatly Rather, what charactenzed their views on and statements of responsibibty, often couched m emotional terms, was a sense of personal responsibibty for the future of the nursmg profession m China I feel the pressure We are the &rst generation of nursmg graduates We carry the responsibibty to develop nursmg in China and bnng it up to world level What were the properties of this strong sense of responsibility? Some felt that the responsibility for Chmese nursmg had been handed to them from the older generation, an expectation, albeit a burdensome one, as the previous comments suggest At the same time this history of nursmg in general had been transnutted to them they bebeved they would have to produce the future for nursing Thus the tradihonal past, noted m the histoncal review above, (1 have a sense of histoncal responsibibty') and the uncertain future CWhether our nursing can be developed speedily depends on our generation') loomed large m their statements More than mere passmg references to responsibility could be detected m their responses Details of their language reflected their concems (To be sure the authors were not readmg westemized views mto the translation, they asked Chmese-speaking colleagues to check both the
Engbsh and Chmese translations of the queshons and the
answers They advised us that the students' responses were as translated) Students' use of verbs was informative they referred to having responsibibty, almost as a possession They also spoke of carrying it, a frame that led understandably to the related verb of burdened wiih These comments related to their womes We worry that the weight of the responsibihty is too heavy for us People look down on nursing Elevating nursing Thus, m the students' eyes responsibility has a weight, a great weight because it is set m a frame of others' invidious views Not only is responsibibty 'heavy', but it is "big', because it mvolves, they believe, elevatmg nursing m the eyes of doctors and the public, as well as bnngmg Chinese nursmg up to world standards An added difficulty was that they were to accompbsh these perceived demands with no examples to guide them, for they saw themselves as the first university nurse graduates in the new era Also being the first class to graduate, what we plan to do in the future are only plans We have no pnor examples to guide us It IS almost impossible to overestimate the sense of history conveyed m these students' comments, a sense of history that creates its own burdens for these new professionals Another provided details of what histoncal responsibility entailed The present Chinese nursmg is below standard Therefore, nursing needs us to study hard, to expand and develop, although our burden is heavy and it is possible that we nught walk many unnecessary miles But as thefirstclass of nursmg, we should not hesitate to reach the high level of nursmg m the world Along with descnptions which aptly pointed to charactenstics of the responsibility, their comments also contamed many emohonal references Although many comments were suffused with depression and concem about the future, the pnde they feel was unmistakable I am very proud to be the &rst class student We have a responsibibty that our elders handed down to us Our country and our fnends all over the world support us and have great expectations of us We are proud to be thus trusted Whether we can fulfil the expectations womes me Fear was also present m some students' statements, fear
that they would not bve up to this received responsibiLty, 1169
AJ fear that the niagnitude of the responsibibty and the demands to carry Chinese nursmg to a new level and a new era could prove personally detnmoital The pressures conung from society, family, school and everywhere could almost destroy us
the profession would charactenze other first dasses can only be answered with comparahve analysts Whether they will enact their visions of responsibility will have to be answered with longitudinal study of their future lives and careers For now, a postscnpt on their current situation perhaps hmts at that future
Great passion
Postscript
Students spoke m detail and with great passion about their perceived responsibility as the first uruversity graduates to improve and carry forward Chmese nursmg m a context of mvidious views and with no exemplars to lead them How then are these findings to be mterpreted? Inculcation of responsible behaviour is, of course, a major hope of all professional educahon m the helping professions Indeed, members of a profession utibze professional responsibibty as a commonly understood and accepted term m evaluatmg their peers Moreover, the lay pubbc easily grasps this when breaches of professional conduct are reported What differentiates these Chmese university trained nurses is the onentation of the responsibility and the intensity with which it is expressed The responsibility so intensely expbcated in their comments is not an mdividualishc responsibtbty, but a broad professional and soaetal onentahon It is bnked not to the mdividual, though individuals dearly feel both proud and afraid, it is responsibibty onented to profession and country
On a visit m December 1991 to Tianjin Medical University, the first author asked the faculty of nursmg what positions these first graduates now have 3 years afrer graduation Of the three male students, one is performing simple surgery in the countryside and is not regarded as a nurse Another has become an X-ray techniaan in a Tianjin Cbmc and therefore has also lefr nursmg The third is teaching m the Tianjm BSN programme Of the 30 female students, two are studying overseas, eight are teaehmg and 15 are working m the Tianjin Medical University affibated teaehmg hospitals Of these 15, one IS a head nurse m an intensive care unit and two are engaged m medical research projects One student fell ill and did not graduate and the remaining four graduates are workmg m dimcal posihons in or around Tianjm
CONCLUSION Soaabzation mto a profession is never solely a personal trajectory, for example, a shift from bemg a layperson to becommg a professional prachhoner Nor is it exclusively a cultural process, for the histoncal moment is of considerable importance Clearly these are blended, as can be seen m these young students' outlooks which, m spite of reluctance to study nursmg, nevertheless reflect communal onentations and a high sensihvity to this penod and the future in Chmese nursmg Whether such an onentahon to
1170
References Bullock M B (1980) An Amencan Transplant University of Cabforma, Berkeley Glaser B & Strauss A (1967) The Discovery of Grounded Theory Aldine, Chicago Ministry of Pubbc Health (1990) National health personnel stahstics (unpubbshed) Ministry of Pubbc Health, Beijing SchatzmanL (1990) Dimensional analysis notes on an altemative approach to the groundmg of theory in quabtative research In Social Orgamzahon and Soaal Process Essays tn Honor ofAnselm Siraus (Mames D ed), Aldme Gniyter, Hawthome, New York State Spradley J (1979) The Eihnographtc Inierview Holt, Rinehart and Wmstoa New York. Yu X (1989) Eighty Years ofHtsiory of Chinese Nursing Associahon Chmese Nursing Association, Beijing
The young pioneers:firstbaccalaureate nursing students in the People's Republic of China AnneJ Davis RN PhD FAAN Professor of Nursing, Deparimeni of Menial Healih, Commumiy and Admimstrahve Nursmg, University of Califomia, San Franasco, USA
Lan Jun Gan RN BSN Former Dean, Department of Nursing, Ttanjin Medical College, People's Republtc of Chtna
Ju Ying Lin RN BSN Former Prestdeni, Chnese Nurstng Assoaahon, Beijing, People's Republic of Chtna
and Virginia L Olesen PhD Professor of Soaology Deparimeni of Behaviounal Saences, Untverstiy of Califomia, San Francisco, USA
Accepted for publication 2 March 1992
DAVIS A J, GAN L J, LIN J Y & OLESEN V L (1992) journal of Advanced Nurstng 17,1166-1170 Hie young pioneers: first baccalaureate nursmg students in the People's Republic of China Nursing in the People's Republic of China, like elsewhere, has undergone monumental changes dunng the 20th century This paper focuses on one of those changes by examining the professional soaalization process of the first class from the first baccalaureate in nursing (BSN) programme in China since 1952 These data from this first BSN dass are part of a larger study on professional soaalization in which data were collected from four of the recently established 11 BSN programmes m China To put these data mto a histoncal context, some highlights of Chinese nursmg history are noted These will help us to understand the present-day situahon m this the worid's most populous nation
HISTORICAL HIGHLIGHTS
in 1888 The Chinese word for nurse, Kan-Hu, was coined and meant watch and take care or attendant (Yu 1989) In the early 1880s, China had no nurses, no sdiools of In 1907, Cora Sunpsoa also an Amencan, mterested in nursing and no word that would translate as nurse Elizabeth promotmg the truning of mirses in China, was mstrumenMcKedmic from the Umted States went to China m 1884 tal in the early developments of the nursing associahon as the 6rst graduate nurse m the country and estabbshed there In 1914, the first ofl&cers of the Chinese Nursing the first Nightingale system of nursing at Shanghai West Associahon were elected. The president was an Amencan Gate Hospital The first school for Chinese nurses was named Gage Cora Simpson was elected director general estabbshed m Fuchou by another Amencan, Ella Johnson, and Feng Zhen Ma became the vice president Mrs Ma, the first Chinese nurse to study in Er^Iand, also recast Correspondence Profe^orA] Dams, School of Nursmg, Department of Menial Heallh, the Chinese word for nurse into Hu-Shh which means Commumty and Admmtstrttbve Nursing Huveraty of Califorma San franasco, educated nurse or nurse sdtolar She also translated from Cabforma 9*143-0608, USA 1166
Ftrsi Chinese baccalaureaie nursing siudenis
English mto Chinese the first nursmg handbook (Yu 1989) By 1922, a number of Chinese nurses, women and men, had been trained and some of them went abroad for post graduate work A nursing joumal began pubbcahon in 1920 and numerous nursing textbooks in Engbsh were translated mto Chinese The Chinese Nursmg Assoaahon joined the Intemational Council of Nurses m 1922 and retamed membership unhl 1949 when Mao came to power and estabbshed 'the new China' At that hme, China had 32 800 nurses (Yu 1989) Growth of nursing schools The growth of nursir^ schools conhnued in the 1920s and 1930s and among these schools the most notable, the Pekmg Union Medical CoUege (PUMC) estabbshed by the Rockefeller Foundation, accepted students who had a nurumum of 2 years of college and who were fluent in Engbsh In 1922, PUMC became the first bachelor of saence programme in nursing in China, thereby prepanng many future nursmg leaders (Bullock 1980) It is mterestmg to note that the first BSN programme in the United States was opened m 1916 at the University of Minnesota while the first BSN programme in Chma opened m 1922, a mere 6 years later From this early development m nursmg educahon, China benefitted and continues to benefit today Numerous early PUMC graduates have held leadership posihons and have had an immense impact on nursing education and service To a large extent it has been these PUMC graduates who mamtamed the vision of professional nursing through the many soaal changes that Chma has expenenced since the 1940s Because of World War II, PUMC closed m Beijing from I94I to 1947 and moved to Chengdu, a westem a t y 1000 miles away, where it funchoned from 1943 to 1945 Ms Nieh, the first Chinese dean of the PUMC School of Nursing, and the nursing students were known as the class who walked 1000 miles to school (Nieh 1988, personal communication) The PUMC was re-opened m Beijmg m 1945, but it closed again in 1952 due to ideological differences after Chairman Mao came to power For over 30 years Chma had no BSN programmes and durmg many of these years it was cut off from the rest of the nursmg world Addihonally, dunng 10 years from 1967 to 1977, the Cultural Revoluhon dosed all hospital nursmg programmes as well as the nursing associahon Nursmg educahon and professional achvities came to a gnndmg halt Dunng the early 1980s the nahonal govemment, coiKemed about the lack of developn^nt m nursmg
education and nursing service, supported the estabbshment of BSN programmes m the People's Republic of Chma In September 1983, Tianjin, China's third largest aty, estabbshed the first nursing department at Tianjin Medical College to prepare BSN students This first BSN programme in the new China graduated its first class m 1988 Nursing education conference In January 1984, shortly after this first dass of students was enrolled at Tianjin, the Mimstry of Pubbc Health and the Ministry of Education met m Tianjm to hold the First National Nursing Educahon Conference and distnbuted conference proceedings throughout the People's Repubbc of Chma (PRC) These proceedings emphasized the importance of nursing development and the strengthenmg of the educational system to develop more nursmg leaders This conference had important effects on nursmg and nursmg education as well as on the health care system throughout the PRC In a country where the ratio of physiaans to nurses is about two to one, China reports a severe nursing shortage According to the 1990 health personnel stahstics, Chma has a total of 1 725 349 physiaans and secondary doctors This number includes Westem-mediane physiaans (1058 460), tradihonal Chinese physiaans (239 602) and physiaans who prachse both Westem and tradihonal Chmese medicme (4935) The secondary doctors, with less education, total 422 352 and are divided between traditional secondary mediane (91123) and Westem secondary medicme (331 229) (Mimshy of Pubbc Health 1990) In 1949, as mentioned earber, there were approximately 32 000 nurses and, by 1990, the number had grown to approximately 975 000 nurses working in 67 000 hospitals and dmics Of this total number of nurses, Chma has 431 541 semor nurses who have either an assoaate or a BS degree and 542 999 nurses with 3 years of nurses' traming Even with such progress, China still needs approximately 200 000 more nurses for its population of 1 1 bilbon (Mmistry of Pubbc Health 1990) The need for nurses in teaehmg, admimstration and sjjeciality areas is particularly cntical This is the moment m Chma's long history mto which these students step as BSN-prepared nurses
THE SAMPLE The 33 students from this first dass of the first BSN programme located m Tianjm constitute the sample for this paper Data were collected m the summer of 1986 after 1167
AJ Dapisetal these students had completed 2 years of basic and 1 year of the course Fundcunentals m Nursing which mduded theory and scane prachce These students, 30 females and three males, with only two exceptions, grew up in Tianjm or nearby Unbke most nurses m the PRC who complete 9 years of general education and have 3 years of nurses' trammg, these Tianjm students complete 12 years of general education before entenng a 5-year BSN programme These 20-21-year-oId students tended to come from middle-dass families as defined by Chmese categones In the PRC, highschool graduates take a national exammahon and also indicate what or where they want to study According to their score and their choice, they are placed m vanous mstituhons of higher leammg, a high score enables a student to choose medical saences, engmeenng, etc Once a student chooses the larger category of medical saences, there are six categones from which to select medicme, pubbc health, pharmacy, dentistry, nursing and medical mstruments Not all students mdicate a choice from these categones but simply request medical saences Others do not enrol m theirfirstchoice due to their low exammation score These BSN students were placed accordmg to their score but most did not indicate that they wished to study nursing Some left it open, while others said that they wanted to study at Tianjm Medical University They did not know that there was a new BSN programme and had assumed they would study mediane The setting Dunng theirfirst2 years of study, the BSN students at the Medical College of Tianjm took the same dasses as the medicine students, namely the basic sciences The Tianjin faculty carefully observed and evaluated this model Later they discarded this model Tianjin Medical University School of Nursmg is fortunate to have well-prepared and seasoned nurse teachers on its faculty In numerous other BSN programmes m China, female and some male physiaans are the majonty of the faculty The first dean of this school, Lan Jun Gan, graduated from PUMC in 1946 and has been mvolved m teaching and nursmg assoaahon achvihes for many years Dunng thefirst2 years, nurse leadersfromthe immediate area as well as from other ahes spoke to these students about the importance of nursing and their role m nursmg's future A film on Florence Nightmgale was shown and students wrote an essay on their reaction to the film In their third year, they had 5 hours of dasses on nursing history and ethics and read the first chapter m the Fioidamentals texH^ook which focuses cm history of 1168
nursmg m old China and in the new China This history and ethics focuses on the virtues of the nurse such as considerahon, service and responsibibty The instrument Data were gathered by usmg a questionnaire developed in Engbsh by the authors, two Amencans and two Chinese After this instrument was refined it was translated into Chmese by one Chmese author and this translation was checked by the other Chinese author Questions focused on (a) demographics, (b) initial study/work plans, (c) professional socialization in nursmg, and (d) the future Informed consent Informed consent was not obtamed from the students The authors explamed to the University of Cabfomia's lnshtutional Review Board that the Westem philosophical tradihon that underlies bioethics and places great emphasis on the ethical pnnaple of mdividual autonomy is not part of Chinese ethics Therefore, no wntten or oral consent was obtamed Students were promised confidentiality and this promise was kept No one at Tianjm Medical College saw the students' responses to the queshonruure
FINDINGS The questionnaire asked a number of questions related to the students' professional soaalizahon and their response to their programme These mduded quenes about members of their famtbes in the health saences, views on their course work, the relahonship of the danwei (the soaalist work group), whether they saw themselves as nurses To start their analysis, the authors read the entire queshonnaire to gam a sense of the class's thinking and responses After that they mtensively looked at answers to three questions (a) Has bemg in the first class of the first BSN nursmg programme made a difference for you? (b) If so, what difference has it made? (c) What do you see as the fiiture of nursing m China? This analysis did not proceed from hypotheses deduced from theory, which would have been quite inappropnate and unrealishc in this study Hence, the approach was inductive and ejqjloratory The authors therefore focused on finding an organizing theme which would charactenze most students' answers, a master code, as it were They also looked carefully for characteristics or properties of the themes To attempt to assure consistency and eredibibty, or what in quanhtahve work would be termed reli^»lity and
Ftrsi Chinese baccalaureaie nursing sitidents
validity, the authors scrutinized the queshonnaires for both vanahon m answers and answers whidi ran counter to the themes they found (Readers familiar with qualitahve research here will recogruze strategies set out in such analytic approaches as grounded theory (Glaser & Strauss 1967), domain analysis (Spradley 1979) and dimensional analysis (Schatzman 1990))
Sense of responsibility On the very first reading of the queshon, 'What difference has bemg m nursing made for you', the theme of responsibility emerged A majonty menhoned it m a vanety of ways Subsequent re-readmgs of this and the other central queshons affirmed that this was a central theme expressed m vanous ways and with varying degrees of emohon The customary sense of responsible individual professional behaviour, e g good clinical practice, however, was not the sense of responsibibty which emerged over and over again This IS not to say that these young nurses did not have a sense of individual professional behaviour, but our data do not speak to that sense of responsibility It was doubtless implied in that which was dearly expressed, but it was not stated expbatly Rather, what charactenzed their views on and statements of responsibibty, often couched m emotional terms, was a sense of personal responsibibty for the future of the nursmg profession m China I feel the pressure We are the &rst generation of nursmg graduates We carry the responsibibty to develop nursmg in China and bnng it up to world level What were the properties of this strong sense of responsibility? Some felt that the responsibility for Chmese nursmg had been handed to them from the older generation, an expectation, albeit a burdensome one, as the previous comments suggest At the same time this history of nursmg in general had been transnutted to them they bebeved they would have to produce the future for nursing Thus the tradihonal past, noted m the histoncal review above, (1 have a sense of histoncal responsibibty') and the uncertain future CWhether our nursing can be developed speedily depends on our generation') loomed large m their statements More than mere passmg references to responsibility could be detected m their responses Details of their language reflected their concems (To be sure the authors were not readmg westemized views mto the translation, they asked Chmese-speaking colleagues to check both the
Engbsh and Chmese translations of the queshons and the
answers They advised us that the students' responses were as translated) Students' use of verbs was informative they referred to having responsibibty, almost as a possession They also spoke of carrying it, a frame that led understandably to the related verb of burdened wiih These comments related to their womes We worry that the weight of the responsibihty is too heavy for us People look down on nursing Elevating nursing Thus, m the students' eyes responsibility has a weight, a great weight because it is set m a frame of others' invidious views Not only is responsibibty 'heavy', but it is "big', because it mvolves, they believe, elevatmg nursing m the eyes of doctors and the public, as well as bnngmg Chinese nursmg up to world standards An added difficulty was that they were to accompbsh these perceived demands with no examples to guide them, for they saw themselves as the first university nurse graduates in the new era Also being the first class to graduate, what we plan to do in the future are only plans We have no pnor examples to guide us It IS almost impossible to overestimate the sense of history conveyed m these students' comments, a sense of history that creates its own burdens for these new professionals Another provided details of what histoncal responsibility entailed The present Chinese nursmg is below standard Therefore, nursing needs us to study hard, to expand and develop, although our burden is heavy and it is possible that we nught walk many unnecessary miles But as thefirstclass of nursmg, we should not hesitate to reach the high level of nursmg m the world Along with descnptions which aptly pointed to charactenstics of the responsibility, their comments also contamed many emohonal references Although many comments were suffused with depression and concem about the future, the pnde they feel was unmistakable I am very proud to be the &rst class student We have a responsibibty that our elders handed down to us Our country and our fnends all over the world support us and have great expectations of us We are proud to be thus trusted Whether we can fulfil the expectations womes me Fear was also present m some students' statements, fear
that they would not bve up to this received responsibiLty, 1169
AJ fear that the niagnitude of the responsibibty and the demands to carry Chinese nursmg to a new level and a new era could prove personally detnmoital The pressures conung from society, family, school and everywhere could almost destroy us
the profession would charactenze other first dasses can only be answered with comparahve analysts Whether they will enact their visions of responsibility will have to be answered with longitudinal study of their future lives and careers For now, a postscnpt on their current situation perhaps hmts at that future
Great passion
Postscript
Students spoke m detail and with great passion about their perceived responsibility as the first uruversity graduates to improve and carry forward Chmese nursmg m a context of mvidious views and with no exemplars to lead them How then are these findings to be mterpreted? Inculcation of responsible behaviour is, of course, a major hope of all professional educahon m the helping professions Indeed, members of a profession utibze professional responsibibty as a commonly understood and accepted term m evaluatmg their peers Moreover, the lay pubbc easily grasps this when breaches of professional conduct are reported What differentiates these Chmese university trained nurses is the onentation of the responsibility and the intensity with which it is expressed The responsibility so intensely expbcated in their comments is not an mdividualishc responsibtbty, but a broad professional and soaetal onentahon It is bnked not to the mdividual, though individuals dearly feel both proud and afraid, it is responsibibty onented to profession and country
On a visit m December 1991 to Tianjin Medical University, the first author asked the faculty of nursmg what positions these first graduates now have 3 years afrer graduation Of the three male students, one is performing simple surgery in the countryside and is not regarded as a nurse Another has become an X-ray techniaan in a Tianjin Cbmc and therefore has also lefr nursmg The third is teaching m the Tianjm BSN programme Of the 30 female students, two are studying overseas, eight are teaehmg and 15 are working m the Tianjin Medical University affibated teaehmg hospitals Of these 15, one IS a head nurse m an intensive care unit and two are engaged m medical research projects One student fell ill and did not graduate and the remaining four graduates are workmg m dimcal posihons in or around Tianjm
CONCLUSION Soaabzation mto a profession is never solely a personal trajectory, for example, a shift from bemg a layperson to becommg a professional prachhoner Nor is it exclusively a cultural process, for the histoncal moment is of considerable importance Clearly these are blended, as can be seen m these young students' outlooks which, m spite of reluctance to study nursmg, nevertheless reflect communal onentations and a high sensihvity to this penod and the future in Chmese nursmg Whether such an onentahon to
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References Bullock M B (1980) An Amencan Transplant University of Cabforma, Berkeley Glaser B & Strauss A (1967) The Discovery of Grounded Theory Aldine, Chicago Ministry of Pubbc Health (1990) National health personnel stahstics (unpubbshed) Ministry of Pubbc Health, Beijing SchatzmanL (1990) Dimensional analysis notes on an altemative approach to the groundmg of theory in quabtative research In Social Orgamzahon and Soaal Process Essays tn Honor ofAnselm Siraus (Mames D ed), Aldme Gniyter, Hawthome, New York State Spradley J (1979) The Eihnographtc Inierview Holt, Rinehart and Wmstoa New York. Yu X (1989) Eighty Years ofHtsiory of Chinese Nursing Associahon Chmese Nursing Association, Beijing
