Cathy Maginnis, Charles Sturt University, Australia
Students entering pre-registration programs to become a Registered Nurse are required to develop a broad range of professional capabilities, including socialisation into the profession and a professional identity (PI) (Brown, Stevens, & Kermode, 2012). A search of the literature highlighted a lack of empirical research in PI development during the pre-registration education program. The aim of this paper is to describe PI development in pre-registration nursing students’ education and the relationship between development of a PI and the tertiary provided education. A range of concepts and practices will be explored that relate to PI, including identity, professional socialisation, a sense of belonging to the profession, clinical placement and the historical context of nursing. Development of a PI is drawn from social identity and self-categorisation theories and it is through professional socialisation during nursing education and clinical placements that a PI is developed (Moreland, Ewoldsen, Albert, Kosicki, & Clayton, 2015). PI is an integral aspect of being a professional and how individuals view and present themselves as professionals (Sabanciogullari & Dogan, 2015). Exploring the development of a PI in nursing students and becoming a professional can assist with identifying drivers of PI formation and identify factors that may inhibit it.
A systematic literature search of health, education, medicine and psychology databases occurred. The parameters of the review were English language and literature between 2001-2017. The search terms included professional identity, nurses, students, undergraduate students, nursing students, journey, professional socialisation, identity, self-identity and combinations of these key terms. Each citation set was scrutinised to decide on relevance to the topic as many focused on discrete aspects of the pre-registration education program such as clinical placement, belonging, identity, socialisation, professionalism and theory-practice gap. There was a lack of literature focused on development of a PI in nursing students and if a PI develops during the pre-registration program.
Identity is a fundamental aspect of being a professional and how an individual presents themselves (Happell, 2014). Identity is who an individual is and relates to their choice of profession aligning with perceptions of themselves, matching their values and beliefs influenced by societal and personal factors (Brennan & Timmins, 2012; Johnson, Cowin, Wilson, & Young, 2012). To understand the importance of self-identity within groups it is useful to draw upon social identity theory (Tajfel & Turner, 1979) and self-categorisation theory (Turner & Oakes, 1989), both of which contribute to the process of professional socialisation and building a PI in nursing students.
Social identity theory encompasses a body of ideas that combine to form an approach to understanding social identity and intergroup relations. This approach builds upon the pioneering work of Tajfel from the 1970s. Tajfel (1979) theorised that social behaviour could be viewed on a continuum from interpersonal behaviour to intergroup behaviour, where interactions are determined by personal relationships between individuals and intergroup interactions determined by individuals’ membership of social groups. The addition of the self-categorisation theory further developed social identity (Turner & Oakes, 1989).
Self-categorisation theory described that behaviour along with the interpersonal and intergroup continuum could be explained by a distinction between two identities: one personal and one social. Personal identity defines what makes a person unique and individual from other people. Social identity defines individuals based on characteristics they share with others in a group such as nursing (Turner & Oakes, 1989). These group characteristics contrast with characteristics of other groups, and identify the group as ‘us’ in contrast to ‘them’. For nursing students, social identity would encompass their membership of the pre-registration nursing program and exposure to nurses on clinical placements. Personal and social identities can be seen to contribute to development of a PI. Development of a PI in nursing students can be assumed to encompass more than just the academic constructs and outcomes, it includes an understanding of identity and professional socialisation that relate to professionalism and belonging (Willetts & Clarke, 2014). The aim of professional socialisation is to develop a PI in nursing students (Arreciado Maranon & Isla Pera, 2015)
Professional socialisation is essential for exposing and immersing nursing students in professional practice (Zarshenas et al., 2014). Professional socialisation is a process of learning skills, attitudes, values, and behaviours necessary to fulfil and understand the professional role whilst also being a process whereby an individual gains an identity that displays the characteristics, knowledge, and skills of the chosen profession (Brown et al., 2012; Del Prato, 2012). Professional socialisation can be viewed as a dynamic and interactive process whereby the individual internalises the values, knowledge, skills and beliefs of the chosen profession, developing a PI as an outcome of this process (Dinmohammadi, Peyrovi, & Mehrdad, 2013). The socialisation process and subsequent development of a PI is often preceded by the students’ preconceived notions of the nursing profession values and attributes thus providing an early dichotomy between the ideal of the profession versus the reality of the profession (Hensel, Middleton, & Engs, 2013). Brennan and Timmins (2012) when examining the student nurses’ education identified that the core identity of an individual prior to entering the nursing program is reshaped through the professional socialisation process, interactions, relationships and experiences during the program. Brown et al. (2012) when investigating student nurse professional socialisation surmised that the mainstay of professional socialisation was the spaces where teaching and learning occurred and the educators who become the socialising agents. It is through socialisation processes during pre-registration education, including exposure to clinical practice, as a nursing student that a PI develops (Arreciado Maranon & Isla Pera, 2015; Moreland et al., 2015).
PI is one component of an individual’s overall identity (Johnson et al., 2012). PI includes professional, educational and social values and is essentially perceived as what makes a person a professional and distinguishes one profession from another. Trede, Macklin, and Bridges (2011, p. 10) refer to PI as “a way of being and a lens to evaluate, learn and make sense of practice”. A nursing PI develops continuously throughout an individual’s lifetime, commencing prior to starting the pre-registration program and constantly evolving throughout their professional career (Johnson et al., 2012). A nursing PI is possessing a common identity through using the title ‘nurse’ and sharing common experiences. This is emphasised through professional socialisation whereby the nursing student internalises a sense of professionalism and belonging (Moreland et al., 2015). Sabanciogullari and Dogan (2015, p. 848) state “The development of professional identity in nursing begins when a student enters nursing education”. Identifying as a nurse is an essential element to becoming a nurse. The construction of a nursing PI evolves during the education of nursing students through socialisation when undertaking clinical placements as part of the course requirements and where students begin to identify as a professional nurse (Walker et al., 2014; Brown, Stevens & Kermode, 2012). By socialising and interacting with practice nurses a PI evolves through applying the knowledge, skills, values, and culture of the nursing profession by active engagement from the student (Dinmohammadi et al., 2013; Trede et al., 2011). To explore the relationship between PI development and the tertiary institution an understanding of the historical context of nursing education is required.
PI is one of a multitude of identities an individual holds and for nurses it is inextricably linked to the historical context of nursing (Shahidi, Vahidi, Mahram, Areshtanab & Zarghi, 2014). The historical context contributes to the understanding of identity, practice boundaries and autonomy required by the nursing profession (Brennan & Timmins, 2012). The changes in nursing education that have occurred over the past thirty years have contributed to the changing focus of a nursing PI. Historically nursing students were employed in an apprenticeship model based within vocational training associated with a single hospital or health service until 1984 when the nursing education model was introduced to the Australian university institutions (Willetts & Clarke, 2014; Brennan & Timmins, 2012; Apesoa-Varano, 2007). The move recognised nursing as a profession and possessing a professional identity with licensing requirements and regulation of the practice of nursing with differing nursing qualifications (Brennan & Timmins, 2012). This brought challenges as nursing had been entrenched as an apprenticeship model and took a further decade to be fully transferred to the tertiary sector. Whilst the tertiary provided education of nursing students does not solely inform the formation of a PI it has significant influence (Levett- Jones, Lathlean, Higgins & McMillan, 2009). The building blocks of a nursing PI develop during the nursing education program and one of the objectives of the program is to create a PI (Shahidi et al, 2014). Shahidi et al (2014) highlight that there are studies in this area but none focus on the nursing curriculum and PI, yet curriculum has a great influence on socialisation and development of a PI in nursing students. Curriculum has been identified as neglecting to identify the importance of the history of the profession and this in turn inhibits the formation of a PI (Shahidi et al, 2014; Madsen, McAllister, Godden, Greenhill & Reed, 2009). Recognising the importance of nursing history contributes to constructing an identity and an understanding of the profession itself (Madsen et al, 2009). A PI enables students to relate to their chosen profession and to behave, think, feel and act like a nurse. Relating to the profession and feeling like a nurse enables nursing students to experience a sense of belonging.
Belonging is part of the professional socialisation process and can be viewed as a precursor to learning and developing through interactions with practising nurses and academics alike, where being part of a defined group enhances the opportunity to engender a sense of belonging (Levett-Jones, et al., 2009; Walker et al., 2014). A sense of belonging to a profession includes acquiring a body of knowledge as well as a sense of the history of the profession and the practices and skills that form the profession (Reid, Dahlgren, Petocz, & Dahlgren, 2008). Belonging has been described as a fundamental, omnipresent human need, offering a sense of security or relatedness, of connection with others, being a valued member of a team and accepted by the profession (Levett-Jones et al., 2009). Maslow’s (1987) hierarchy of human needs includes belonging and acceptance in the middle of the 5 tiers, where these two needs have to be met before the individual is able to meet their needs on the next level which are esteem and self-actualisation and having already met the physiological and safety needs. The need to be accepted is deep-seated, and the fear of rejection or exclusion can be demoralising. Belonging as a nursing student impacts on the student’s ability, capacity, and motivation to learn and to make the most of their educational experiences as well as their ability to socialise on a professional basis and develop a PI (Levett-Jones et al., 2009). It is important to facilitate effective nursing education and develop a sense of belonging to the profession through professional socialisation. A sense of belonging is synonymous with developing a sense of confidence and professionalism (Del Prato, 2012).
Professionalism can be viewed as a complex evolving concept that is integral to developing a PI. Professionalism relates to professional competence, professional codes and standards, autonomy, reflexive practice, communication, accountability, professional development and professional relationships (Grace & Trede, 2013). Professionalism demands that individuals be trustworthy, maintain confidentiality, put clients first, be honest and ethical. These characteristics are expected of nurses (Birks, Chapman, & Francis, 2010). These distinct characteristics enable nursing to be recognised as a profession, nurses as professional and are a positive aspect of PI for nursing students.
Gaining an understanding of how nursing students develop a PI and the relationship with the tertiary institutions that provide the nursing education is important to the nursing profession with many factors linked to developing a PI. Absence of a PI is self-destructive to the individual and the profession (Brown et al., 2012) . Education has been identified as essential in shaping nursing students’ PI (Johnson et al., 2012). Developing a PI is inherently integrated within a socialisation process where one identifies and experiences a sense of belonging. Exposure to academics and practising nurses is essential to provide a balance of knowledge and skills and a provision of authentic experiences (Trede et al., 2011). Research has identified that failing to socialise students for the reality of nursing and develop a PI has a correlation with attrition in the pre-registration program and the initial year or two post graduate related to transition shock and a lack of belonging (Milton-Wildey, Kenny, Parmenter, & Hall, 2014; Sabanciogullari & Dogan, 2015; Worthington, Salamonson, Weaver, & Cleary, 2013). Nursing education research has focused on individual components of the entire journey such as clinical placements, the mentoring role (Brown et al., 2012; Del Prato, 2012; Walker et al., 2014) and a sense of belonging particularly whilst undertaking clinical placements (Levett-Jones et al., 2009). Gaps remain when considering the entire journey and how all the individual concepts interrelate and impact on developing a PI as a nursing student.
Clinical placements undertaken by nursing students throughout their pre-registration program are a major contributing factor to developing a PI. Research into student satisfaction and the need to belong focuses on clinical placement and their influence in belonging and identifying as a nurse. Engaging with the educational experience and learning are referred to as authentic learning. Authentic learning is where students are exposed to learning opportunities where they actively engage and reflect on their learning. Clinical placements have been identified as providing authentic learning but the tertiary setting also provides authentic learning with teaching of skills through a variety of strategies including simulation prior to undertaking clinical placements (Walker, Rossi, Anastasi, Gray-Ganter, & Tennent, 2016; Trede et al.,2011). These factors enhance and assist the professional socialisation process, facilitating development of a PI.
Studies that have focused on clinical placements and undergraduate students (Ford et al., 2016) identify the importance of exposure to clinical practice settings and quality placements to assist in development of a PI. The duration, quality and quantity of these clinical placements are linked to student satisfaction, a sense of belonging to the nursing profession and the development of a PI (Arreciado Marañón & Isla Pera, 2015; Milton-Wildey et al., 2014; Trede et al., 2011). Faculty and practice incivility, specifically abusive or demeaning behaviours, favouritism, rigid expectations and targeting practices impede development of a PI and must be addressed within academia and professional practice (Del Prato, 2012). A positive learning environment and a sense of belonging motivates nursing students to continue in their studies (Levett-Jones et al., 2009). Belonging refers to feeling accepted and included as well as being valued and a part of the clinical placement unit (Levett-Jones et al., 2009). Clinical placements are associated with a feeling of belonging and their ability to integrate (Levett-Jones et al., 2009). The first clinical placement is an important experience for nursing students in reinforcing their career choice and a positive experience and sense of inclusion motivates continuation in the education course (Cooper, Courtney-Pratt, & Fitzgerald, 2015). A sense of place and purpose reinforces a sense of belonging and is part of the professional socialisation process that develops a PI in nursing students (Levett-Jones et al., 2009). Walker et al (2016) identified clinical placements as providing authentic learning that in turn facilitates development of a nursing identity, thus clinical placements are critical in assisting with development of a PI. Milton-Wildey et al. (2014) in their study on educational preparation for nursing identified key factors relevant for nursing student education and their preparation for nursing. These included clinical practice hours as well as facilitation and support during these clinical placements. Though clinical practice is derived from health providers, the tertiary institution has the responsibility to provide appropriate clinical placements and facilitation. Clinical placement incorporates educators, facilitators, and role models all of whom contribute to developing a PI in nursing students.
Role modelling is an important concept for nursing students developing a PI. Students’ perceptions of what a nurse is and how they behave starts within the pre-registration program. Baldwin, Mills, Birks, and Budden (2014) undertook a literature review regarding role modelling in undergraduate nursing education and identified two main themes. These were the importance of nurses in clinical practice as role models during clinical placements and nurse academics as role models in the education setting. Role modelling is an integral aspect of professional socialisation and occurs in all facets of the authentic learning journey (Baldwin et al., 2014). Felstead (2013) also acknowledges the role of the academic and their importance earlier in the program, whereas clinical role models increase in importance as the students progress and identify with the nurses’ role as completion and registration looms closer. Therefore, lacking, or having an inappropriately developed PI may lead to nursing students feeling insecure and dislocated from the profession (Jones, 2010). This highlights the importance of academic educators and clinical practice role models.
The onus of responsibility for socialisation and developing a sense of PI in nursing students is attributed to the educational institution (Johnson et al., 2012; Walker et al., 2014). Trede et al. (2011, p. 15) summed up the responsibility for developing a PI in nursing students whereby “universities need to claim their role in professional identity development to prepare graduates for global citizenship, for leadership qualities and for future practice”. Nursing education is the key factor in developing a PI in nursing students as it is during this period where nursing students gain the knowledge, skills and sense of belonging to the nursing profession (Johnson et al., 2012; Shahidi, 2014). This is achieved through academic learning spaces and exposure to clinical practice through simulation within the tertiary learning spaces and clinical placements at a variety of clinical settings.
Understanding PI and its relation to educating students for ‘real world’ practice would seem to be a priority when there is an ageing nursing work force, a need for future nurses to address the ageing workforce and where attrition is linked to a poorly developed PI (Cowin & Johnson, 2015; Milton-Wildey et al., 2014; Moreland et al., 2015; Worthington et al., 2013). The National League for Nursing in America felt so strongly about the need for nurses to form a PI that it declared that a PI should be a universal outcome for all nursing curricula (Hensel, 2014). Worthington et al. (2013) identified a correlation between PI and retention, the higher the levels of PI the more these students remained in the course. These students had chosen nursing as their first choice, had positive attitudes and were often in nursing related paid employment. These nursing students’ pre-conceptions about nursing, experience in a nursing environment and a positive attitude led to higher levels of PI.
Reality/transition shock has been identified as a continuing problem for new graduates in their first year of practice (Cowin & Johnson, 2015; Hensel, 2014). Transition shock occurs as the new graduate is expected to ‘hit the ground running’, with limited support or exposure to clinical experiences thus leading to questioning of career choice, transition shock and attrition (Cowin & Johnson, 2015). Identifying patterns of PI development will assist with evaluation of nursing curricula and its effectiveness in preparing nursing students to transition to graduate, with a focus on values requiring further development (Hensel, 2014). The relationship between theoretical education, clinical practice and development of a PI is not fully understood, many studies cite clinical placements and belonging as essential in shaping identity for nursing students (Arreciado Marañón & Isla Pera, 2015; Levett-Jones et al., 2009). Theory and practice are essential to developing a PI and work continues with curricula construction to integrate these components of nursing education (Arreciado Marañón & Isla Pera, 2015; Walker et al., 2016). Hensel and Laux (2014, p. 1) longitudinal study described factors associated with forming a PI where emphasis was on the outcome of nursing education as “acquisition of an identity consistent with the profession’s core knowledge, skills, values and attitudes”. This in turn is recognised as a key factor in retention in the workplace.
A study of students and staff at an Iranian University identified that “…creating a more realistic education, making an exclusive body of knowledge, and following successful role models are helpful in students’ professional identity development” (Shahidi et al., 2014, p. 37). These authors reiterate that curricula is the driving factor in embedding socialisation and developing a PI in nursing students. Reviewing nursing curricula to incorporate the history of nursing and informing students of PI more explicitly is thought to be important to assist new graduates to develop realistic expectations and self-responsibility (Shahidi, 2014). The tertiary educators are the key figures in providing the knowledge, skills, culture and values engendered by the nursing profession, they become role models as do the clinical partners where students undertake clinical placements (Johnson et al., 2012). However, before curriculum redesign occurs, further research is required to explore the links between PI, nursing student education and educational experiences. Research continues to identify a theory-practice gap with the nursing education provided.
A theory-practice gap exists between what students learn in their pre-registration program and what they do once registered in the practice setting (Cowin & Johnson, 2015). Nursing students experience confusion as they grapple with the discrepancies between what they learn in the tertiary institution and what they are asked to do (Shahidi, 2014). Nursing students come into the program with an expectation of what it will be like as a nurse (Hensel et al., 2013; Shahidi, 2014; Worthington et al., 2013). Nursing students may have an idealistic self-image of nursing that makes them vulnerable during the transition from nursing student to new graduate nurse, relating to the changing professional socialisation and ongoing evolvement of a PI (Cowin & Johnson, 2015). Review of curriculum to facilitate the transition from nursing student to new graduate is required. Support for the new graduate in the clinical setting and ongoing education is urgently required to address the theory-practice gap and to reduce transition shock and increasing attrition in the first year post graduate (Cowin & Johnson, 2015).
An expected outcome of the pre-registration program is that nursing students will have formed a PI and this predominantly occurs during the pre-registration period through interactions and role modelling with academic and clinical staff (Walker et al., 2016; Hensel & Laux, 2014; Del Prato, 2012; Trede et al., 2011). Nursing students search for their identity in the nursing education program and interactions with others are a major influence on developing a PI (Shahidi, 2014; Zarshenas et al., 2014). For nursing students’ professional socialisation begins in the pre-registration nursing program where they learn the knowledge, skills, qualities, and values expected by the nursing profession and which develop through socialisation and internalisation thus forming a PI (Hensel & Laux, 2014; Zarshenas et al., 2014). For students to develop a PI they must be guided during their pre-registration program to ensure their journey is inclusive, engaging, authentic and supports the individual needs of each student (Walker et al., 2016). Belonging and identifying with a chosen field of study is important in preparing nursing students for the realities of practice (Levett-Jones et al., 2009). A lack of developing a PI can impede transition into the ‘real world’ thus the need to review curriculum and how developing a PI is facilitated in both the academic setting and in the professional practice settings. Educators need to rethink and redesign curricula to facilitate nursing students developing a PI. This would include identifying and developing new teaching strategies, inclusion of nursing history and addressing identity and socialisation into the profession through curriculum content.
In conclusion, the overriding goal of the pre-registration program is to teach nursing students to think and act as nurses, through developing a PI, and to view the world through a lens that embodies the nursing profession’s values, ethics, standards, attitudes and characteristics. More emphasis is required on the socialisation process in forming a PI during the program and in identifying the components of a PI. Nurse academics have an integral role as positive role models, not just in providing theoretical knowledge and teaching skills. Nurse academics support, facilitate and nurture the development of a PI through socialisation and conveying professional behaviours. Review of curricula and teaching strategies are vital to ensure PI development is explicitly embedded throughout the curriculum. Whilst the tertiary institution does not have the sole responsibility for developing the PI of pre-registration nursing students, it provides and facilitates the portals to develop a PI with both knowledge and skill development and exposure to the clinical practice environment. Nursing students need to feel a sense of belonging to the profession and identify as a nurse. Transitions programs are essential to providing support to new graduates and revision to include more than a skills focus is recommended. The nursing profession has a duty of care to ensure new graduates transition to practice in a supportive environment with positive role models where they continue to receive education and socialisation to further develop their PI. There may not be one simple explanation for what PI is, or how it is developed, but further research and a greater depth of understanding of PI by both the tertiary sector and the nursing profession and an understanding of the attributes and conceptions attributed to a nursing PI is important in designing the education of future nursing students.
Cathy Maginnis is a Lecturer at Charles Sturt University for the past 20 years. She has a passion for nursing and midwifery and providing education for rural students. She has an interest in how nursing students develop a professional identity.
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