THE RELATIONSHIP BETWEEN ROLE

CONCEPTION AND ETHICAL

BEHAVIOUR OF STUDENT NURSES IN
HONG KONG
Hilary Ha-ping Yung

Key words: decision-making, ethical behaviour; role conception; student nurses

This paper was designed to explore the relationships of three role conception types (the
professional, bureaucratic and service role conceptions) to the ethical behaviour of stu-
dent nurses from the apprenticeship and degree nursing programmes in Hong Kong. The
effect of role discrepancy on ethical behaviour will also be explored. A nonprobability
convenience sampling of 140 certificate students from a hospital-based training course
and 81 degree nursing students from a tertiary programme were selected. Role concep-
tion and role discrepancy were measured by the modified Nursing Role Conception scale
originally developed by Corwin. For ethical behaviour, the Judgement About Nursing
Decisions scale developed by Ketefian was used. Multiple regression analyses showed
that the ideal professional role conception was a significant predictor, accounting for 17%
of the variance in the ideal ethical score of the degree students. Actual service role con-
ception was a better predictor of the actual ethical score, explaining 10% and 14% of its
variance for the certificate and degree students respectively. Professional and bureaucratic
role discrepancies together were found to have a negative effect on the actual ethical
behaviour of the degree students. These results suggest that professional values that have
been developed through socialization in nurse education programmes could benefit
patients only when degree students, in particular, could adapt successfully to the
demands of bureaucratic organization.

Introduction
Nurses are constantly faced with making front line decisions that are ethical in
nature and critical to the outcome of patient care. However, studies have shown
that nurses have little authority and power to make free ethical choices. Instead
of exercising what is described as ideal moral behaviour, they are very often
caught in the middle of ethical conflicts under a bureaucratic hierarchy. Their
role as nurses has often been the cause of these conflicts. The same phenomenon

Address for correspondence: Professor Hilary Ha-ping Yung, Department of Nursing, The
Chinese University of Hong Kong, Shatin, New Territories, Hong Kong.

Nursing Ethics 1997 4 (2) 0969-7330(97)NE112OA © 1997 Arnold

100 H Ha-ping Yung

is also applicable to student nurses who are undertaking clinical practice.

It is argued that the education sector is concerned with producing a competent
and caring nurse, capable of making professional judgements and adhering to the
professional code of practice, whilst the service sector is interested in having a
student who is hard working and compliant to the authority. Therefore, once stu-
dents enter into the practice setting, they find themselves struggling with choices
between serving the patient’s needs or getting through the work-load efficiently;
and performing nursing tasks according to ward routines or to the ethical stan-
dards taught by the nursing school. This discrepancy, according to Kramer,1 may
affect the manner in which students function in their clinical practice and the deci-
sions they make on patient care. The purpose of this paper is to examine the rela-
tionship between role conceptions and the ethical behaviour of student nurses in
Hong Kong. The implications of the findings in relation to nurse education and
clinical practice will be discussed.

Literature review
Role socialization and education
Education is a socializing process by which individuals acquire the role behav-
iour attached to various positions and status within an interactional context.2 In
this process, values and attitudes are internalized and an individual’s role con-
ception is shaped. Several studies on students’ attitude towards their professional
role demonstrated that undergraduates scored significantly higher on professional
autonomy when compared with associate and hospital-based students.3,4 It was
also indicated that baccalaureate degree prepared nurses had significantly higher
mean scores in critical thinking ability than the associate and diploma nurses.5,6
A more recent research study by Langston7 further supported the assertion that
degree students were socialized to function in an autonomous and independent
role, while associate degree students were socialized to provide the traditional
pattern of nursing care.
A number of studies have found differences in the role conceptions of nurses
from different socialization patterns.1,8–13 According to Corwin, 8 nursing role con-
ception has three components: professional, bureaucratic and service, which can
be held simultaneously and to varying degrees by one individual. Nurses with
baccalaureate degrees frequently scored higher on the professional role concep-
tions than diploma or certificate-trained nurses. They also experienced greater
conflicts between their ideal role conceptions and the perceived opportunities to
practice them. Davis10 found that community college students were more orien-
tated towards bureaucratic role conception than degree students. Ketefian14 sug-
gested that while students were engaged in study, they experienced changes in
their role conceptions and underwent professional socialization. Yet, these
changes were not enduring but subject to change within the context of the bureau-
cratic work setting.
Kramer1,15,16 examined the role conception of nursing students and graduates
in the transition from school to the working world. She found that the bureau-
cratic role conception sharply increased upon entry to the bureaucratic setting,

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 Role conception and ethical behaviour of student nurses in Hong Kong 101
while the professional and service role conceptions showed a gradual decline.
Kramer1 postulated that the drop in professionalism was the result of ‘reality
shock’, which was related to the desperate need to adjust to a new environment
that was highly bureaucratic in its orientation.
A more recent study by Yung13 indicated that the ideal professional role con-
ception of degree nursing students decreased significantly in the third year and
dropped even further in the fourth year of the education programme. This result
is different to Davis’10 and Kramer’s1 studies, in which professional role concep-
tion dropped significantly only within the first six months after graduation. The
decreasing professional orientation of the degree students indicated that Hong
Kong degree nursing students experienced the reality shock earlier than their
American counterparts. The ‘shocking’ effect occurred early in their exposure to
ward reality and persisted through their clinical placements. Compared with the
degree students, the certificate students from the hospital-based programme
showed no significant change in the ideal professional role conception as they
progressed through the training programme. This result might be due to the
earlier and consistent exposure to ward reality, which not only allowed the
certificate students more gradual adaptation to the ward but also led to a more
realistic comprehension of the role of the nurse.

Role conception and ethical behaviour

Professionals are socialized to make independent judgements and committed to
upholding the ethical code of conduct of their profession. Yet, working under a
bureaucratic setting, they are obligated to adhere to the rules and policies of the
organization. Holly17 and Swider et al.18 suggested that perceived constraints on
their role as a nurse might be a factor influencing nurses’ ethical decision-mak-
ing. The majority of nurses in these studies exhibited a bureaucratic rather than
a patient or a physician orientation to ethical decision-making. Moreover, when
nurses were uncertain and confused about the appropriate role of the nurse, they
perceived themselves to be powerless in making effective ethical decisions.
The findings of Ketefian’s14 study on role conception and moral behaviour
demonstrated that the higher the actual professional role score, the higher the
moral behaviour. It was evident that professional role discrepancy had a negative
effect on moral behaviour. Ketefian’s study also indicated that professional
(actual) role conception was positively correlated while professional (ideal) role
conception was negatively correlated to ethical behaviour. The bureaucratic role
conception demonstrated no relationship with ethical behaviour. Much of the
research on role conception has been focused on bureaucratic and professional
roles; studies related to the service role conception are limited. In a study of
degree-prepared nurses’ participation in continuing education, Bevis19 found that
the professional role and the service role conceptions jointly influenced nurses’
participation in continuing education activities. Without the professional role con-
ception, the service role discrepancy was negatively related to participation in the
activity. These findings indicated that the service role conception was an impor-
tant component in influencing nurses’ attitudes and behaviour.

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102 H Ha-ping Yung

Conceptual framework
The literature reveals that the socializing effect of education has a considerable
impact on the development of role conception. Values and attitudes acquired
through the socialization process of education shape individuals’ role conception
and choice of action in ethical decision-making.
Corwin’s8 model of nursing role conception, which measures the value orien-
tation of nurses, was adopted for this study. It consisted of three role conception
scales: professional, bureaucratic and service. Professional role conception measures
characteristics such as commitment to knowledge as the basis of a profession, to
judgement ability in nursing care, to the upholding of professional standards and
active involvement within the professional association. Bureaucratic role conception
items measure characteristics indicating loyalty to hospital bureaucracy, such as
punctuality, strict adherence to rules, the importance of tenure, and loyalty to the
authorities in control of the hospital. Service role conception emphasizes such ideals
as service to humanity, a willingness to be patient-centred, and a desire to do
‘bedside’ nursing.8 Corwin8 used the term ‘role discrepancy’ to measure the extent
of role conflict occurring within an individual. It refers to the extent to which an
ideal role conception is perceived as unrealistic and nonfunctional in the work
situation. The greater the perceived inconsistency among the roles, the greater the
frustration experienced.
It is theorized that the professional–bureaucratic role conceptions of nurses, and
their perceived discrepancies between the ideal and actual values, influence the
way in which they practise their professional values, including ethical behaviour.1
Therefore, role conception and role discrepancy are selected as predictors, while
ethical practice, which is considered as an important professional value, is
chosen as the criterion variable for this study.
With the increasing demand on nurses to nurture a patient-centred culture
within the hospital service in Hong Kong, it is anticipated that they will have
more active involvement in ethical decision-making related to individualized
patient care. As the trend of nursing education in Hong Kong is towards prepar-
ing nurses at degree level, it is important to ensure that it is a viable programme
which can successfully prepare students to be moral agents who are able to
uphold the value of professional conduct, and able to survive in a bureaucratic
hospital setting.

Purpose
The purpose of this study was to determine the relationships between nursing
role conceptions and the ethical behaviour of student nurses in Hong Kong. The
study set out to answer the following research questions:
1) What are the three nursing role conceptions and role discrepancies of the
degree and certificate nursing students?
2) Are there significant differences between the degree and certificate nursing stu-
dents in the three nursing role conceptions and role discrepancies?
3) What is the relationship between the three nursing role conceptions and the
ethical behaviour of degree and certificate nursing students?

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 Role conception and ethical behaviour of student nurses in Hong Kong 103

4) What is the relationship between the role discrepancies and ethical behaviour
of degree and certificate nursing students?

Methods
Subjects
The sample consisted of 140 students from one of the regional hospitals offering
a certificate nursing training programme (certificate) and 81 students from one
institution offering a degree nursing programme (degree). The certificate students
were part of the work-force for the hospital service and they had only 38–42 weeks
of theory taught within the five study blocks of the programme. Due to the lack
of a hospital as a home base for clinical attachment, the degree students had to
rotate to various wards of different hospitals for short periods of time (2–4 weeks)
throughout the programme of clinical practice.

Procedure
After receiving approval from the ethics committee of the hospital and the ter-
tiary institution, the author administered the questionnaire in person to the stu-
dents. A verbal explanation and a letter of information were given to all students
at the time of the meeting. Participation was voluntary and all respondents were
assured of anonymity.

Instruments
Nursing role conception instrument
The Nursing Role Conception instrument (Appendix 1) is a modification of the
original scale developed by Pieta,11 whose questionnaire was originally based on
Corwin’s scale. 20 The three role conception scales consisted of eight professional,
eight bureaucratic and seven service items. The items in each scale were com-
posed of a hypothetical situation in which nurses might find themselves. For each
situation, there were two questions: question A asked the extent to which the
respondent thought the situation should be practised in nursing (the ideal), and
question B the extent to which the respondent perceived the situation was actu-
ally happening at the hospital (actual). Scoring was by the Likert-type of response
alternative from 1 to 5 with, ‘strongly disagree’ as 1 and ‘strongly agree’ as 5.
The arithmetic sum of question A constituted the total score of ideal role con-
ception, and question B the score of actual role conception. By subtracting the
actual score from the ideal score, a difference score yielded the role discrepancy
score. Positive role discrepancy scores indicated that the situation was perceived
as not existing to the extent that the respondent thought that it should. Negative
scores indicated that the perceived situation existed to a greater extent than the
respondent thought that it should.
Pieta11 established the reliability of the three subscales by test-retest and
computation of Cronbach’s alpha. The content validity was determined by a panel
of nurse experts with experience in teaching nursing and administration. Only

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104 H Ha-ping Yung

situations that were selected at least 75% of the time were retained.
Since some of the hypothetical situations related to the professional and bureau-
cratic scales mentioned in Pieta’s instrument are not applicable in Hong Kong,
the instrument used for this study was modified by the author, based on her expe-
rience. Only those situations relevant to Hong Kong were selected and additional
situations were developed resulting in a total of 23 situations. The validity of the
instrument was tested again, based on Kramer’s15 ‘known group’ method. As pre-
dicted, the results showed a significant difference between the members of the
nursing faculty and the administrators, with the former scoring highest on the
professional scale and the latter highest on the bureaucratic. The Cronbach relia-
bility coefficient for each role conception scale of the revised instrument for the
present study was also computed.

Ethical behaviour measure

Ethical behaviour was measured by the Judgement About Nursing Decisions
(JAND) instrument developed by Ketefian.21 The instrument measured two
dimensions of ethical decision-making: professionally ideal ethical decision-mak-
ing and realistically likely decision-making. The ANA code for nurses22 was used
as the standard for assessing the extent to which nursing actions were ethical or
not (Appendix 2).21
The JAND scale consisted of six stories depicting nurses in ethical dilemmas;
each story was followed by a list of six or seven nursing actions. Respondents
were asked to respond ‘yes’ or ‘no’ twice to each action: first, whether they
thought the nurse experiencing the dilemma in the story should or should not
engage in that action (column A); and secondly, what they thought the nurse expe-
riencing the dilemma was likely to do (column B). The correct answer to each
nursing action was determined by a panel of professionally recognized nursing
experts in ethics, who rated each action according the ANA code of ethics. A score
of 1 was assigned to an ‘appropriate’ nursing action and 0 for an ‘inappropriate’
nursing action. The scores in each column were summated; this reflected the sub-
ject’s score on the ideal and actual ethical decisions. The higher score indicated a
more ethical nursing action. It was noted that the score in column B (actual eth-
ical score) only reflected the respondent’s beliefs of what the nurse in the situa-
tion would do rather than the respondent’s own action.
The content validity of the JAND scale was established and a representative
sampling of the ethical dilemmas that nurses commonly faced was included. All
items in the tool were assessed and evaluated by nursing experts in terms of the
extent to which each nursing action embodied the tenets of the code. The tool
was also significantly correlated with a known measure of moral reasoning, the
Defining Issues Test (DIT) developed by Rest.23 According to Oddi and Cassidy,
a low coefficient obtained between the JAND and the DIT signals a need for pru-
dence in interpeting JAND scores.24 Given the lack of a strong interrelationship
among the items (internal consistency) in the column for ideal ethical decision-
making, Ketefian25 also cautioned that it should not be used as a separate scale
for hypothesis testing. For internal consistency, the Cronbach’s coefficient alpha
was also computed.

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 Role conception and ethical behaviour of student nurses in Hong Kong 105

Results
Differences in role conception types
To evaluate the differences between the certificate and degree students’ role con-
ception types, independent t-tests were used. The mean scores of ideal and actual
role conception for the certificate and degree students are presented in Table 1.
The results revealed that both groups perceived that the ideal professional role
should be practised to the greatest extent in nursing, the service role was next
and the bureaucratic role was the one that was considered should be practised to
the least extent. The degree students scored significantly higher on ideal profes-
sional role conception than did the certificate students (t = 2.87; p < 0.01).
In terms of scores reflecting the actual situation, both groups of students per-
ceived that the extent of the actual practice of the service role was lowest, the
actual practice of the professional role came next, and the actual bureaucratic role
was practised to the greatest extent. Of the three role conceptions, the certificate
students scored significantly higher on actual professional role conception than
the degree students (t = 3.44; p < 0.05). In contrast to the ideal bureaucratic role
conception, the degree students scored higher on the actual bureaucratic role
conception than the certificate students (t = 2.74; p < 0.05). The two groups were
similar on the actual service role conception scores.

Differences in discrepancy role conception

The mean scores and standard deviations of the three role discrepancy concep-
tion types are shown in Table 2. The greatest discrepancy for the certificate stu-
dents was the service role discrepancy score followed by the professional role
discrepancy. For the degree students, the service role discrepancy score was sim-
ilar to the professional score. The bureaucratic role had the lowest discrepancy
score for both groups of students, although the degree students had a higher dis-
crepancy score than the certificate students. The results of the independent t-tests
indicated that the degree students had a significantly greater discrepancy score
than the certificate students across all three role conceptions: discrepancy profes-
sional (t = 4.94; p < 0.001); discrepancy bureaucratic (t = 3.30; p < 0.001); discrep-
ancy service (t = 2.30; p < 0.05).

Relationship between role conception and ethical behaviour

To evaluate the effect of role conception on ethical score, multiple stepwise regres-
sion analyses were performed, with ideal and actual ethical scores as the criteria
variables and the three role conception types as predictors. The results shown in
Table 3 indicate that the ideal professional role conception was a significant pre-
dictor for the ideal ethical score in the degree students, accounting for 17% of the
variance. This showed that degree students with a stronger ideal professional role
conception were higher in their ideal ethical decision-making. For the actual
ethical score, actual service role conception was found to be a significant predic-
tor among the three role conception types for both the certificate and degree stu-
dents, accounting for 10% and 14% of the variance respectively. For the certificate

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106 H Ha-ping Yung

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 Role conception and ethical behaviour of student nurses in Hong Kong 107

Table 2 Means (M) and standard deviations (SD) of discrepancy role

conception between certificate and degree students

Group n Role conception

Professional Bureaucratic Service

discrepancy discrepancy discrepancy

M SD M SD M SD
Certificate 140 5.50 3.95 –2.23 4.57 6.78 4.44
Degree 81 8.58 5.01 –4.49 4.62 8.45 5.73

Table 3 Multiple stepwise regression with ethical score as criterion variable

and role conceptions as predictors

Criterion Predictors R R2 Change in R2 β

Certificate
Ideal ethical score Ideal bureaucratic 0.18 0.03 –0.15 *
Ideal service 0.25 0.07 0.03 0.18 *
Actual ethical score Actual service 0.31 0.10 0.36 ***
Degree
Ideal ethical score Ideal professional 0.42 0.17 0.42 ***
Actual ethical score Actual service 0.37 0.14 0.37 **

*p < 0.05; **p < 0.01; ***p < 0.001.

students, the ideal bureaucratic role conception alone explained only 3% of the
variance in the ideal ethical scores. When the ideal service role conception was
entered into the regression equation, it contributed an additional 4% and
accounted for a total of 7% of the variance in the ideal ethical score. This showed
that the magnitude of the relationship between the role conceptions and the ideal
ethical scores was quite small.
To investigate the effects of discrepancy role conception on the ethical score,
multiple stepwise regression analyses were computed with the ethical score as
the criterion variable and the three role discrepancy scores as predictors.
Professional role conception discrepancy was a significant predictor for ideal eth-
ical score and actual ethical score accounting for 8% and 7% of variance in the
degree students (Table 4). When bureaucratic discrepancy was entered into the
regression analysis, it yielded an additional 7% and contributed a total of 14%
variance in the actual ethical score. For the certificate students, the bureaucratic
role conception discrepancy was found to be a better predictor for the ideal eth-
ical scores, accounting for 8% of the variance. The negative β-weight suggested
that the role discrepancy scores were negatively related to ethical behaviour. The

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108 H Ha-ping Yung
Table 4 Multiple stepwise regression with ethical score as criterion variable
and discrepancy role conceptions as predictors

Criterion Predictors R R2 Change in R2 β

(discrepancy)

Certificate
Ideal ethical score Bureaucratic 0.27 0.08 –0.17 **
Actual ethical score Service 0.22 0.05 –0.22 **
Degree
Ideal ethical score Professional 0.28 0.08 –0.18 **
Actual ethical score Professional 0.25 0.07 –0.25 **
Bureaucratic 0.37 0.14 0.07 –0.33 **

**p < 0.01.

results showed that, for the certificate students, higher discrepancies in bureau-
cratic and service role conceptions led to lower ideal and actual ethical decision-
making. For the degree students, higher discrepancy in professional role
conception was related to lower actual ethical decision-making.
In summary, a relationship between ethical scores and role conception types
was observed. Among the three role conception types, the ideal professional role
conception was found to be the best predictor for the ideal ethical score, and actual
service role conception for the actual ethical score. A total of 14% of the variance
in students’ ethical decision-making was accounted for by the actual service role
conception. The discrepancy in bureaucratic and professional role conceptions
was found to have a negative effect on ethical decision-making. However, given
the low predictive strength of the role relationship on ethical decision-making
ability, the findings of this study need to be viewed as suggestive rather than
definitive.

Discussion
For the three role conception types, only ideal professional and actual bureau-
cratic role conceptions were found to be significantly higher in the degree stu-
dents. This was consistent with that of other studies on role conception.9–11 In
Corwin and Taves’ study, the degree graduates had significantly higher profes-
sional role conceptions than diploma nurses. Compared with the hospital-based
students, the degree students in the present study seemed to be more pressurized
to adhere to the bureaucratic system, owing to their position as outsiders to the
ward and the lack of familiarity with the ward. Any breaking of rules might be
perceived as not being respectful to the hospital being visited, and thus students
were reminded to do things the ‘local way’.
In fact, the analysis of students’ responses to items comprising the bureaucratic
role further confirmed the above interpretation. Item 18 (belief about following
all hospital rules even though they were not fully agreed with) and item 22 (belief

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 Role conception and ethical behaviour of student nurses in Hong Kong 109

about the need to accomplish all routine work in order to be considered useful)
had the highest agreed scores (75%). Item 4B (the need to carry out hospital rou-
tine for promotion) and item 14 (the need to finish routine work within a set time)
had the second highest score (65%). These responses seem to confirm the asser-
tion that the hospital routine was given prime importance by the degree students
in the actual setting.
The degree students had significantly higher discrepancy scores in all the three
role conception types when compared with their certificate counterparts. The pos-
itive discrepancy scores revealed that the actual practice did not meet the nurses’
expectations whereas the negative discrepancy scores indicated that the role was
practiced to a greater extent than they expected it should be. This result was con-
sistent with that of Corwin and Taves’9 and Pieta’s11 studies on role conception.
The significantly lower discrepancy role score in the certificate students could be
accounted for by the early organizational socialization experienced by these stu-
dents. As the certificate students were left to work independently much of the
time, adhering to the organization rules and regulations and expecting them to
work according to known norms were considered the most efficient and safest
ways for them to practise. In fact, they had been socialized to submit to service
needs and accepted it as a necessary part of their early training. Moreover, by
being affiliated to the same hospital throughout their training and being part of
the hospital work-force, certificate students were more likely to be involved in
decisions about patient care than their degree counterparts. This might lead to
less conflict in their perception of the actual practice. For the degree students, the
frequent rotations to various clinical sites at different hospitals throughout the
programme may prevent them from becoming acquainted with dissimilar ward
practices in patient care, resulting in greater variance in their perceptions of the
actual practice of patient care.

Relationship between role conception and ethical decision-making

The service role conception was a significant predictor for certificate students for
both the ideal and the actual ethical decision-making. However, for the degree
students, the ideal professional role conception was a better predictor for ideal
ethical decision-making, while the actual service role conception was a better
predictor for actual ethical decision-making.
The finding of a positive relationship between the ideal professional role con-
ception and ideal ethical decision-making in this study supported the previous
research by Ketefian.14 Moreover, the results further confirmed that the social-
ization process occurs differently according to the type of educational programme.
As discussed previously, the certificate students are socialized to hold a more tra-
ditional view of nursing with more emphasis on direct patient care, whereas the
degree students are socialized to value independent judgement, function
autonomously and be committed to uphold the ethical standards of their profes-
sion. However, the results of the present study show that this ideal conception of
the professional role only contributed to nurses’ ideal ethical behaviour. Once it
came to a realistic situation, it was the service role orientation that gave a better
prediction of an individual’s ethical behaviour. Such a relationship was consistent
with Corwin’s20 concept of service role orientation, which emphasizes primary

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110 H Ha-ping Yung

loyalty to patients and humanitarian nursing care. Therefore, it is desirable to

encourage both the degree and certificate students to maintain the service role
conception to which they aspire.
The stepwise regression analysis showed that the actual decision-making was
found to be negatively related to service role discrepancy in certificate students
and to professional role discrepancy in the degree students. In other words, the
greater the service role discrepancy experienced by the certificate students, the
lower the ethical score. For the degree students, the greater the professional role
discrepancy, the more adverse the effect on the ethical decision-making. The find-
ing of a negative relationship between role discrepancy and ethical behaviour con-
curred with Ketefian’s study.14 This might suggest the need for nursing students
to cultivate loyalty to both professional and bureaucratic values in order to reduce
such conflict. The present practice of frequent rotation to different hospital set-
tings for degree students, in particular, may not be conducive to ethical behav-
iour; a more stable practice environment would help students to integrate
professional values into a bureaucratic hospital organization.

Conclusions
The results of the present study suggest that, in the degree students, the higher
the ideal professional role conception, the higher the ideal ethical behaviour.
However, when it came to the actual world of practice, it was the service role ori-
entation that gave a better prediction of the ethical behaviour in both degree and
certificate students. Therefore, it is desirable to encourage students to maintain
their primary loyalty to humanitarian patient care. Nursing education should cul-
tivate this traditional focus of nursing and emphasize the importance of direct
nursing care to patients.
The results further demonstrated that the professional and bureaucratic role dis-
crepancies together had a more negative effect on actual ethical behaviour in the
degree students. The professional value that had been developed through the edu-
cational process could successfully be put into practice and benefit patients only
when these students could master the practicalities of bureaucratic organizations.
In order to achieve a better integration of both value systems, they should be
exposed to mild reality shock earlier in their educational careers. It is also rec-
ommended that the degree nursing education programme should provide stu-
dents with realistic ward experience, structured in ways that will allow students
more active participation in decision-making that is related to patient care.
The findings of this study have limited generalizability, as it was only con-
ducted in one hospital training programme and one tertiary institution in Hong
Kong. The hypothetical situations with predetermined, closed questions adopted
in this study might not represent the complex nature of the decisions. A qualita-
tive approach, which includes interviews to explore why nurses felt they were
not engaging in what they believed to be ideal nursing practice, may provide a
better understanding of the cause of this discrepancy.

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 Role conception and ethical behaviour of student nurses in Hong Kong 111

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112 H Ha-ping Yung

Appendix 1
Sample question from the Nursing Role Conception instrument
For the situation listed below, indicate both:
A. The extent to which you think the situation should be the ideal for nursing;
B. The extent to which you think the situation actually exists in the hospital.

Strongly Agree Undecided Disagree Strongly

agree disagree

1. A registered nurse tries

to put into practice his
or her standards and
ideals about good
nursing, even if they
are in conflict with the
hospital rules and
procedures.

A. Do you think this is

what registered nurses
should do?
B. Do you think this is
what registered nurses
actually do when the
occasion arises?

Appendix 2
Sample question from the Judgement About Nursing Decisions
instrument*
Nurse X was taking care of Mr Y in a community geriatric facility, where he was
on medication for his arthritis. In the course of taking a nursing history, Nurse X
discovered that the patient had a history of an old ulcer and had had occasional
bleeding from it. The nurse subsequently found this also documented in the chart.
Mr Y was on medications for his arthritis that were contra-indicated for ulcer con-
ditions. She brought this to the attention of the head nurse who said she would
take care of it. Later in the day, the head nurse talked to the physician, who was
semiretired and part-owner of the faculty. The physician responded by saying that
he knew what he was doing. It soon became apparent that the head nurse would
not pursue the matter any further. Nurse X then talked to her supervisor who
refused to become involved.
We are interested in Nurse X’s actions.

Nursing Ethics 1997 4 (2)

 Role conception and ethical behaviour of student nurses in Hong Kong 113

For each of the actions below, check yes or no: for column A (whether she should
take this action or not); and for column B (whether she is realistically likely to take
this action or not).

Nursing actions A. Nurse X B. Nurse X is realistically

should do: likely to do:

Yes No Yes No

1. Ask for an additional prescription

for antacid to cover the gastro-
intestinal distress.
2. Forget the whole matter; this battle
is not as important as some others
with which Nurse X is involved.
3. Talk to the Director of Nursing
and ask her to intervene; Nurse
X tells her director that, if the
medicine problem is not corrected,
she will report the physician to the
Medical Society.

*Developed by and copyright of Shake Ketefian, University of Michigan (used

with permission).

Nursing Ethics 1997 4 (2)