THE DEGREE OF PROFESSIONALISM AMONG

ACTIVELY PRACTICING REGISTERED NURSES

IN SOUTH TEXAS

A Dissertation

Presented to the Faculty of the College of Health Sciences

of TUI University

in Partial Fulfillment of the Requirements for the Degree of

Doctor of Philosophy

by
Kai Aziza N. Makeda
July 2009

©2010 Kai Aziza N. Makeda

 UMI Number: 3406530

All rights reserved

INFORMATION TO ALL USERS

The quality of this reproduction is dependent upon the quality of the copy submitted.

In the unlikely event that the author did not send a complete manuscript
and there are missing pages, these will be noted. Also, if material had to be removed,
a note will indicate the deletion.

UMI 3406530
Copyright 2010 by ProQuest LLC.
All rights reserved. This edition of the work is protected against
unauthorized copying under Title 17, United States Code.

ProQuest LLC
789 East Eisenhower Parkway
P.O. Box 1346
Ann Arbor, MI 48106-1346
 BIOGRAPHICAL SKETCH

Kai Aziza Netfa Makeda, Ph.D, RN, was born in Montgomery, Alabama, and was

raised in the Bronx, New York. Kai graduated from Theodore Roosevelt High School,

Bronx, New York. She received her Bachelor of Science in Nursing from Bloomfield

College, Bloomfield, New Jersey. Kai received her Masters of Science in Management

with a concentration in Health Care Management from Florida Institute of Technology,

Melbourne, Florida. Kai is a former Army Nurse Corp Officer.

In support of her husband Alfarata Griffin, Jr. and his military career, Kai and her

daughters Nijeri Mariama and Tiye Afiya moved to San Antonio, Texas in 1998. Kai is

currently employed at the Audie L. Murphy Division of the South Texas Veterans

Healthcare System as a Bed Flow Coordinator. Kai has worked in various clinical and

administrative roles while serving on active duty in the United States Army Nurse Corp,

as a civilian employed by the Department of the Defense, and at multiple sites by the

Veterans Healthcare Administration.

Kai is a Distinguished Toastmaster (DTM), club officer and active member of

Toastmasters International; an organization that advocates the enhancement of

communication and leadership skills. She has served in the roles of: Division Governor,

Assistant Chief Judge, Assistant Area Governor, President and Vice President of

Education, Club 8461 (Schertz, Texas). Kai is an active member at the Resurrection

Baptist Church, Schertz, Texas and serves in several ministries. She enjoys volunteering,

reading, traveling, and the company of family and friends.

iii
This study is dedicated to my esteemed parents, Mary Louise and James Miggins

(Alabama), whom have gone on to glory. I am the very best of both of you.

iv
 ACKNOWLEDGEMENTS

To whom much is given, much is certainly required. All thanks to my

omnipotent, omniscient, and omnipresent Father God. My sincerest thanks, gratitude,

and appreciation to many who came along beside me at different stages during this

extremely challenging yet gratifying dissertation journey.

To my loving family to whom I am eternally committed for their sacrifice,

unconditional love and support over the past seven years. To my husband, Alfarata

Griffin, Jr., who also pursued and achieved his educational goals while supporting mine.

We did it! To my daughters Nijeri Mariama Makeda Griffin and Tiye Afiya Makeda

Griffin, you bring me great joy and know that you can achieve greatness. To my dearest

sister, coworker, and friend, Cynthia DeVeaux, RN, as this is a topic we both irrefutably

embrace; I am so proud of you and my nieces Fatima and Dara. To my loving Miggins,

Ashe, Rumph, Williams, and Griffin family ties for all of your demonstrations of faith

and encouragement.

From inception, thanks to my dear friend Yvonne Paraway, Ph.D, RN, whose

valued insight kept me reminded of our shared vision for personal/professional growth

and accomplishment. To LTC (Ret) Angela Ross, MSN, RN, who reminded me often of

the tremendous blessing upon our lives. To my church family at the Resurrection Baptist

Church, Schertz, Texas, who prayed for and with me. To the Toastmasters International

Communication & Leadership Program for captivating my passion to speak up, share,

and make my difference in the world; specifically the members of Club #8461. To

Jennifer L. Mitchell, DTM, for your listening ear, words of encouragement, and sharing

your gifts of literary and oratory excellence. You graciously shared in my public and

v
private victories.

Thanks to my many co-workers and professional colleagues at Audie L. Murphy

Memorial Hospital, San Antonio, Texas, who prompted me to see further. To Jackie

Reeves, MSN, RN, my CS, for your friendship, honesty, professional and technical

expertise . To Shuko Lee, MS, Statistician, for your time, spirit of service, expert insight,

enlightenment, and keen ability to make discovery exciting. You share a major role in

the success of this work.

To my dearest and lifelong friends in New York, New Jersey, Virginia, Maryland,

Georgia, and San Antonio whom through prayer, consultation, shopping, vacations, lunch

and dinner dates have helped strengthen me more than words can convey. My sincere

thanks to every registered nurse who participated in the survey as well as those who were

unable to participate.

My absolute respect and gratitude is graciously extended to my Committee Chair,

R. Steven. Konkel, Ph.D, MCP, BCs, AICP, FRIPH, Eastern Kentucky University, U.S.

Fulbright Scholar 2007/08; for your scholarly advice. Your enthusiasm for the learning

process guided and challenged me toward fulfillment of this professional goal. To my

eminent committee member Sarah Williams, Ph.D, RN, The University of the Incarnate

Word, School of Nursing and Health Professions, San Antonio; for your knowledgeable

and professional viewpoints. Lastly, Frank Gomez, Ph.D, Director, PhD Program Health

Sciences, TUI University, California; for your relentless support and expertise as you

have enriched and influenced my professional growth through a shared passion for this

topic. You all have become a source of great inspiration to me.

vi
 TABLE OF CONTENTS

BIOGRAPHICAL SKETCH..............................................................................................iii

DEDICATION....................................................................................................................iv

ACKNOWLEDGEMENTS.................................................................................................v

LIST OF TABLES...............................................................................................................x

LIST OF FIQURES...........................................................................................................xii

CHAPTER I INTRODUCTION.....................................................................................1
Problem Statement.............................................................................................4
Purpose Statement..............................................................................................5
Aim of study.......................................................................................................5
Research Questions............................................................................................6
Theoretical Considerations and Conceptual Framework...................................7
Conceptual Flow Diagram................................................................................11
Professional Socialization................................................................................15
Professionalism................................................................................................15
Attitude.............................................................................................................18
Study Significance to Nursing..........................................................................21
Definition of Terms..........................................................................................24
What is Your Nursing Philosophy?..................................................................26

CHAPTER II REVIEW OF THE LITERATURE.........................................................28

Nursing Historical Perspective.........................................................................29
Preparation for Professional Practice...............................................................50
Nursing Background.........................................................................................51
The Socialization Perspective..........................................................................58
Professional Development................................................................................67
Professional Socialization................................................................................73
Entry Level Into Professional Practice.............................................................75
Competency......................................................................................................78
Attitude Development Perspective...................................................................80
Theoretical Basis for Behavior and Behavioral Change..................................86
Professionalization...........................................................................................89
Profession albeit Professionalism Varies.........................................................91
Professionalism and Use of Foreign Born and Agency Nurses.....................112
Other Variables Which May Influence Degree of Professionalism...............115
Age.................................................................................................................115
Gender............................................................................................................118
Shift Work and Employment Status...............................................................120
Membership in Professional Organizations and Professional Certification...121
Role in Organization......................................................................................122
Practice Years.................................................................................................123

vii
 Practice Setting...............................................................................................124
Practice Environment.....................................................................................125
Continuing Education and Competence.........................................................127
Salary..............................................................................................................128
Job/Career Satisfaction...................................................................................129
Retention and Intent to Stay...........................................................................133
Mentorship......................................................................................................136
Study Hypotheses...........................................................................................138

CHAPTER III RESEARCH METHODOLOGY........................................................141

Data Collection...............................................................................................141
Design.............................................................................................................143
Sample............................................................................................................144
Research Instrument.......................................................................................145
Independent and Dependent Variables...........................................................150
Pilot Study......................................................................................................150
Procedure / Data Analysis..............................................................................152
Research Questions........................................................................................154
Conceptualization of Attitudes Toward Professionalism...............................154
Measurement Levels of Other Demographic Variables.................................156

CHAPTER IV DATA ANALYSIS AND RESULTS.................................................160

Construct Validity..........................................................................................162
Relationship Between Respondents to Attitudes Toward Professionalism....169
First Hypothesis..............................................................................................178
Second Hypothesis.........................................................................................184
Third Hypothesis............................................................................................189
Variables and the Attitudes That Follow........................................................231
Logistic Regression Analysis.........................................................................236

CHAPTER V DISCUSSION AND IMPLICATIONS................................................240

Discussion......................................................................................................240
Influence of Variables on Attitudes Toward Professionalism........................241
Research Question 1.......................................................................................244
Education................................................................................................244
Research Question 2.......................................................................................247
Age.........................................................................................................247
Research Question 3.......................................................................................249
Gender....................................................................................................250
Employment Status.................................................................................251
Role in the Organization.........................................................................254
Salary......................................................................................................255
Professional Certification.......................................................................257
Professional Organization Membership.................................................258
Expressed Degree of Satisfaction...........................................................260
Mentor Relationship...............................................................................262

viii
 Continuing Education Hours..................................................................264
Limitations of Study.......................................................................................265
Recommendations..........................................................................................267
Conclusions....................................................................................................269

REFERENCES................................................................................................................275

APPENDICES.................................................................................................................298
A Nursing Education Programs..........................................................................299
B First Survey Postcard 302
C Follow-up Survey Postcard.............................................................................304
D Survey Tool 306
E Invitation Letters to Respondent‟s.................................................................310
F Sample Size and Power Analysis...................................................................313
G IRB Considerations and Approval..................................................................316
H Permission from Thomas Underwood............................................................319
I Token Book Mark 321
J List of Respondents Professional Organization Memberships......................323
K List of Respondents Subscriptions to Professional Journals..........................325
L List of Respondents Professional Certifications (ANA/ANCC)...................327

ix
 LIST OF TABLES

Table Page

1 Board of Nurse Examiners Currently Licensed Texas Registered Nurses

Residing in Texas by Age, Ethnicity and Sex (09/01/2006)...........................54

2 Comparison of Erickson‟s Stages of the Life Cycle and the Leddy

Professional Development Cycle....................................................................72

3 Comparison of Structural and Attitudinal Elements of Professionalism

from the Professional Model..........................................................................111

4 Comparison of Surveys of Nurse Work Settings...........................................125

5 Comparison of Hall‟s Professionalism Attributes to the ANA Code of

Ethics Statements...........................................................................................140

6 Research Questions Related to the Dependent and Independent

Variables.........................................................................................................151

7 Initial Factor Method: Principal Components Analysis With

Factor Loading...............................................................................................164

8 Standard Cronbach Alpha Coefficient and Attitudes of

Professionalism (Mean, SD)..........................................................................168

9 Demographic Characteristics and Frequencies by

Basic Nursing Degree....................................................................................172

13 Overall Mean Professionalism Scores by Basic Nursing Degree..................179

14 Mean Professionalism Scores to Item Statements in each

Dimension by Basic Nursing Degree.............................................................183

15 Overall Mean Professionalism Scores to Age...............................................185

16 Overall Mean Professionalism Scores to Gender..........................................190

17 Overall Mean Professionalism Scores to Shift Worked................................192

18 Overall Mean Professionalism Scores to Employment Status.......................194

x
 LIST OF TABLES (continued)

Table Page

19 Overall Mean Professionalism Scores to Professional Organization

Membership...................................................................................................196

20 Overall Mean Professionalism Scores to Professional Certification.............199

21 Overall Mean Professionalism Scores to Organizational Role......................202

22 Overall Mean Professionalism Scores to Practice Setting.............................207

23 Overall Mean Professionalism Scores to Practice Years...............................213

24 Overall Mean Professionalism Scores to Continuing....................................216

Education Hours

25 Overall Mean Professionalism Scores to Annual Salary...............................220

26 Overall Mean Professionalism Scores to Expressed Degree of.....................223

Satisfaction with Current Role

27 Overall Mean Professionalism Scores to Mentorship…................................227

28 Professionalism Dimensions with Initial and Final

Variables of Significance...............................................................................234

29 Professionalism Dimensions and the Related Values for the Predictor

Variables of Significance...............................................................................235

30 Logistic Regression Analysis of the Professionalism Dimensions and

the Values for the Predictor Variables of Significance..................................239

xi
 LIST OF FIQURES

Figure Page

1 Conceptual Flow Diagram…..........................................................................14

2 Average Mean Scores for Attitudes Toward Professionalism

Dimensions....................................................................................................178

xii
 THE DEGREE OF PROFESSIONALISM AMONG ACTIVELY PRACTICING

REGISTERED NURSES IN SOUTH TEXAS

Kai Aziza N. Makeda, Ph.D, RN

TUI University 2009

Crucial to the plight of nursing as a profession is the prospect of enhancing

members‟ status by increasing professionalism. This study examines the degree of

professionalism among practicing Registered Nurses in South Texas, specifically their

attitudes toward conformance with professional behaviors based upon Hall‟s

Professionalism Scale. Additionally, an assessment of other factors which may impact

attitudes toward professionalism is explored, focusing on preparation for practice from

three nursing educational degree programs. Limited research is available which focuses

on the attitudinal dimension of professionalism among nurses who are educated within

three educational programs. A key question is “Does basic educational attainment drive

the degree of professionalism demonstrated through practice”, and if so, “how does

educational attainment foster or drive professionalism?”

This exploratory study analyzes (N= 244) mailed and electronic responses from

randomly selected, actively practicing Registered Nurses targeted from 64 counties in

South Texas. Hall‟s Professionalism Scale served as the data collection instrument

designed to determine professional attitudes toward behaviorally worded statements (1-

strongly agree to 5 - strongly disagree). The six attitudinal dimensions (Hall, 1968,

Schack & Hepler, 1979) were:

Use of the Professional Organization as a Major Referent (serves as the major

resource of ideas and judgments for the work of the individual professional)
Belief in Continuing Competence (accept personal commitment to continually
extend professional knowledge)
 Belief in Self-Regulation (work of the profession should only be judged by
members of the profession due to their inherent qualifications)
Sense of Calling to the Field (dedicated to the work of the profession)
Autonomy (should be knowledgeable and skillful in making decisions and
judgments about their work)
Belief in Service to the Public (profession is regarded as being indispensible to
society)

Inferential statistics were utilized to establish whether there were statistically

significant differences between the degree of professionalism manifested in practice by

nurses educated within associate, diploma, and baccalaureate nursing programs.

Descriptive statistics were used to report the nature of any existing effects. Attitudinal

items were examined utilizing univariate and multivariate linear regression models.

Logistic regression analysis was utilized to determine more about the relationship

between several independent or predictor variables (basic nursing program, age, gender,

shift worked, employment status, professional organization membership, professional

journal subscription, professional certification, role in the organization, years of nursing

practice, practice setting, continuing education hours, salary, expressed degree of

satisfaction, and mentor relationship toward the dependent variable ( Hall‟s

Professionalism Scale – 6 attitudinal dimensions).

This study is grounded in the concepts of applicable social and behavioral theories

which provided the framework for the data analysis. Specifically, the concepts of

attitudinal change and professionalism as they relate to the understanding and prediction

of behavior as well as adaptation of behavior.

Nurse respondents reported a moderate level of professionalism (p<0.05)

however, baccalaureate degree nurses demonstrated higher mean professionalism scores

in all six attitudinal dimensions. The results also suggest that basic nursing education, as
measured by the degree of educational attainment is not a strong predictor of

professionalism of nurses. Other variables were found to contribute in a synergistic

fashion to the degree of professionalism of nurses who had attained a baccalaureate

level of education. These other variables are also important to attitudes toward

professionalism demonstrated by those nurses who had attained associate or diploma

levels of education.

The nature of these other factors and whether they operate in a fashion to increase

or detract from professionalism is a major focus of this dissertation. Targeting

measurable professional behaviors can be used to improve the professionalism of the

profession among nurse‟s at all educational levels and ages.

 CHAPTER I
INTRODUCTION

It is relevant and timely to explore how nurses perceive their attitudes toward

professionalism as well as factors that influence these attitudes as a means to enhance

professional behaviors. Members of a profession have an obligation to contribute to the

advancement of the profession and to the development of its members at all levels

(Waters, 1996). Nursing is one of the world‟s most diverse occupations (Sherrod,

Sherrod, & Rasch, 2005), and historically, nurses have struggled to determine whether

professionalism is present or absent from nursing (Tanaka, 2008). The relationship

between personal and professional values, attitudes, and behaviors is a topic of great

interest to those who believe that nursing continues to struggle toward full professional

status. Rutty (1998) proposes that for nursing to emerge as a proper profession, only

nurses can execute and achieve the transformations required. Professionalism is

important in nursing, however consensus has not been reached about what it contains

(Adams & Miller, 1994). Professionalism is both an attitudinal and behavioral

orientation that individuals possess toward their occupation (Lusch & O‟Brien, 1997),

therefore, attitudes held by practitioners determine the degree of professionalism

characterized in an occupation (Snizek, 1972).

The baccalaureate degree has long been the accepted entry educational level into

any given profession. That being said, there are still three types of professional nursing

programs in which practicing registered nurses are educated or competently trained still

in existence today. Educational preparation for the registered nurse licensure

examination can be obtained through diploma, associate degree, and baccalaureate

degree

1
 2

programs.

Nursing Degree Time Frame (usual) Educational Setting

Associate 2-year program Community College

Diploma 3-year program Hospital
Baccalaureate 4-year program University/School of Nursing

Appendix A provides an in-depth description of the three types of nursing

programs still in existence today. In summary, the two-year degree, attained from a

college is known as the associate degree (ADN), the three-year degree, attained from a

hospital or sometimes in conjunction with a community college, is known as the diploma

degree (Diploma), whereas the 4-year degree attained from a university or college school

of nursing is known as the baccalaureate or Bachelor of Science in Nursing (BSN)

degree. The curricula for each of the nursing programs differ and this results in

differentiated entry level competencies of the graduates. Despite predictions over the

past several decades that professional nursing would support the BSN as the entry-level

degree, significant progress has not been made toward this requirement (Halter, 2002).

Weiss & Schank (1997) assert that professional values are standards for action that are

accepted by the practitioner and the professional group which provide a framework

for evaluating beliefs and attitudes that influence behavior.

In addition, in Texas, there are 14 key core competencies which are organized by

three major roles for the nurse: provider of care, coordinator of care and member of a

profession. The competency characteristic “member of a profession” is fostered

differently by educational settings for associate and diploma programs versus

baccalaureate programs. Differentiation of nursing roles encompasses the matching of

values, knowledge, and skills of individual nurses to health/illness needs of the public for
whom they serve. It serves little if any purpose, however, to either the public or the

profession, if various roles are not built upon a common core of values, knowledge, and

practice. Interestingly, professional socialization into the profession for the

baccalaureate-trained registered nurse is to act as a leader in promoting nursing as a

profession and for the associate and diploma-trained registered nurse is to participate in

activities that promote the development and practice of professional nursing. The

American Heritage dictionary defines “act” as „the process of doing or performing‟, and

defines „participate‟ as „to join or share with others‟. Equally important in the realm of

educational preparation for practicing registered nurses and crucial to the professional

socialization process is the subsequent attitudinal and behavioral attributes held by all

nurses and ultimately demonstrated in practice. It becomes critical for the professional

group to determine professional values and behaviors guided by personally held

principles, beliefs and values (Martin, 2003) specifically that nurses at every level share

in the performance and promotion of professionalism within the profession.

While nurses are of the male and female gender and have experiences directly

related to their cultural backgrounds, the predominant reason each enters the field is a

desire to help people (Sherrod, B. D., & Rasch, 2005), thereby each other. Individual

nurses are the referenced people of the nursing professional group. While striving for full

professional status, important consideration should be given to determining the values

and behaviors that are consistent with that status no matter what the basic educational

preparation achieved. It appears that basic education may influence registered nurses

attitudes toward professionalism while ultimately impacting:

Nursing as a career
Retention of practicing nurses
 Status of nursing as a profession

Problem Statement

Competency, knowledge, attitudes, behaviors and professionalism have emerged

as moving targets of concern for nurse leaders burdened with devising effective methods

for recruitment, retention, and management of a diverse nursing profession. The Texas

Board of Nursing recognizes 2-diploma nursing programs, 56 associate-degree nursing

programs, 25 baccalaureate-degree nursing programs, and 4 baccalaureate-degree

programs for registered nurses. The problem addressed in this study is whether the basic

nursing educational level of practicing registered nurses in South Texas can be utilized as

a yardstick to infer the degree of professionalism manifested in practice. Of greater

importance is whether these registered nurses who are trained within different basic

nursing programs exhibit similar attitudes toward professionalism through their reported

professional behaviors. It can then be stated that with regard to the differentiation of

professionalism of the occupational group and the professionalism of individual

members, that professionalism of nursing can only be attained through members‟

professionalism (Styles, 1982).

Active learning is a continual necessity within professional arenas and the

outcome being a change in an individual‟s attitudes and behaviors. While the

baccalaureate educational level is the ideal standard for professional nursing; can a

nurse‟s entry-level education serve as the predictor for the level of professionalism

evident in a nurses‟ professional practice? Relevant to this study is the importance of

describing professional nursing behaviors among a sample of practicing registered nurses

in South Texas by their reported attitudinal attributes toward professionalism.

Purpose Statement

The literature is limited in its current examination of the attitudinal attributes toward

professionalism among practicing registered nurses specifically addressing the behavioral

component as it relates to the competency level of associate, diploma, and baccalaureate-

prepared practicing registered nurses. The purpose of this study is to assess registered

nurses attitudes and factors associated with practice behaviors. This study is designed to

extend existing research findings relevant to professionalism in nursing and suggest

methods to improve professional attitudes by understanding the current level of

professionalism of a representative sample of practicing registered nurses in South Texas.

No recent studies have sought the input from this population of registered nurses. While

the knowledge of a person‟s attitude can tell us little as to whether they will perform

some particular behavior, it can tell us something about their overall pattern of behavior

(Ajzen, 1980).

Aim of study

The aim of this study is to identify the attitudinal attributes toward

professionalism among practicing registered nurses educated in associate, diploma, and

baccalaureate basic nursing programs. By sharing this data with nurses, nursing

organizations, nurse managers/administrators, and nursing leaders, it enables them to

explore the interrelationships and design methods to enhance the number of professional

attributes to target toward the novice to the experienced nurse prepared at all education

levels. The further development of professional attitudes can contribute to elevating

nurse‟s practice and professional status, and improve the image of nursing, as well as its

attractiveness as a career choice. More research is needed to: (a) understand whether the
development of professional attitudes is related solely to basic educational level, (b) to

become more informed about other variables within the practice environment that

demonstrates influence upon professional attitudes, and (c) how best to purposefully

target the level of professionalism among member nurses at all practice levels. If the

desire is an increase in professional attitudes, then attention must be directed in the

provision of methods to quantify professional attributes, and alter behavior. To that end,

assessment of an individual nurse‟s perception of their attitude toward professionalism

cannot be determined without surveying registered nurses.

Gross (1999) described the following attitudinal attributes: a high level of

personal involvement in the profession, a sense of obligation to the work being done, and

the identification with other members through professional associations. Hall (1968)

asserted that the strength of the attitude is based on the kind of socialization (which stems

from formal education) and in the work itself. Values are difficult to assess, yet behavior

is characteristic of both values and attitudes. Schack and Helper (1979) contend that the

attitudinal dimension is logically and empirically more valid than the structural approach

for the assessment of an individuals position on the professionalization continuum.

Therefore, the attitudinal component of professionalism will be the major area of

exploration within this study.

Research Questions

There is such diversity in the nursing practice environments leading one to expect

that differences might exist in the perception of individual nurse professionalism based

on levels of educational attainment. Particularly, how can this information be used to

promote or enhance professionalism through targeted interventions with nurses. As with

other professions, one can expect to observe different levels or degrees of

professionalism among its members. Researchers interested in professionalism of nurses

have suggested numerous other variables that may contribute to the diversity in attitudes

of practicing nurses; this dissertation research seeks to identify the most important

variables and test the hypotheses related to the level of educational attainment. The

following research questions are addressed in this dissertation:

1. Will baccalaureate-prepared practicing registered nurses report a higher degree of

professionalism within all dimensions as compared to associate and diploma-prepared

practicing registered nurses in South Texas?

2. Will baccalaureate-prepared practicing registered nurses in South Texas report

a higher degree of professionalism within all dimensions regardless of age?

3. Is there a positive correlation with degree of professionalism of actively practicing

registered nurses prepared at the baccalaureate level to: age, gender, shift worked,

employment status, professional organization membership, professional journal

subscription, professional certification, role in the organization, practice years, practice

setting, continuing education hours, salary, expressed degree of satisfaction, and

mentorship? Which of these variables has the greater effect or are more strongly

associated with professionalism?

Theoretical Considerations and Conceptual Framework

The conceptual framework for this study is grounded in the exploration of

applicable social, behavioral theories and models in the literature as it relates to

professionalism, understanding and predicting behavior, adaptation to and internalization

of behavioral characteristics. A vast number of studies relating to attitude have shown a

high correspondence between the attitude measured and the behavior exhibited in

respondents (Jacox, 1978). Considerable attention is being raised in research about the

nature of professionalism; within which values and ethics are seen as a means to

understanding attitudes and behaviors, relationships with patients and professional peers,

and the acquisition and application of knowledge and skills (Last, 1992). Adaptation of

professional attitudes must be evident in practice as a mechanism to study, implement,

influence, and contribute to the enhancement of professional practice behaviors. One

cannot exist outside of the other, and all are dynamic, showing change over time.

Roy‟s Adaptation Model (1990) serves as a theoretical backdrop to this study.

Roy (1990) conceptualized that behaviors can be observed, measured, or subjectively

reported. People are viewed as adaptive systems. The ability to respond positively to

changes is a function of a person‟s adaptive level; a changing point influenced by the

demands of the situation and the person‟s internal resources. This structural compound

includes capabilities, hopes, dreams, aspirations, motivations, and all that makes the

person constantly move toward mastery (Roy, 1991), which is an expected outcome of

professional socialization toward greater professional attributes. Roy (1991) posits that

the recipient of nursing care may be an individual, a family, a group, a community, or

society as a whole. Additionally, Leddy (1998) adds that the purpose of the nurse within

this theory is to promote adaptation by manipulation of stimuli which foster successful

coping and change while Eagly & Chaiken (1998) are brilliant in their assertion that

attitudes facilitate adaptation to the environment.

Two key dimensions of professionalism is a nurse‟s sense of calling and service

to others. Nurses are individuals as well as change agents. Within personal and
professional relationships, it stands to reason that individual nurses can advance the

profession by becoming aware of and facilitating change (change agents) to embrace and

increase professional attitudes (adaptation) that are commensurate with professional

status.

The assumptions, which are made concerning the application of the adaptation

process in this study, are:

(1) Change is an opportunity for further development

(2) Attitudes are manifested in behavior

(3) Nurses interact within professional environments

(4) Nurses are professionals

When considering today‟s varied practice environments and whether they are conducive

to the fostering of professionalism, consider that not all nurses will obtain baccalaureate

degrees, not all nurses will work full time within healthcare industries, nor will all nurses

exhibit the same degree of professionalism. It is well known that the common core of

values, knowledge, and practice are the essence of nursing and should not change by

nursing role or practice site, but serve as the foundation of RN roles and nursing

education at all levels (AACN, 1998). This theoretical framework is applicable to further

assess the degree to which professional behaviors (professionalism) of nurses being the

primary adaptive system within practice environments differ with regard to basic

educational preparation. Lusch (1997) makes the distinction between „professionalism‟

and „being in a profession‟ by highlighting that they do not go hand in hand. As

members who are licensed professionals in the same profession, and educated within

different educational programs, can the assumption be made that professional attitudes
and behaviors will be the same within and among groups? With regard to the adaptation

of professional behaviors, can it be stated hat the more attitudinal attributes possessed,

the greater the degree, promotion or propensity toward professionalism?

To further explore behavior, the Theory of Reasoned Action (TRA) by Ajzen &

Fishbein (1975) is a highly researched and utilized general theory of human behavior in

support of the use of attitudes in the determination of behavior. The TRA explains the

relationship between one‟s beliefs, attitudes, intentions, and behaviors in an attempt to

predict and understand that intention will provide the best predictor of behavior (Ajzen &

Fishbein, 1975). According to TRA, attitudes are the result of a person‟s belief that a

certain outcome will occur in the performance of certain behaviors. Although attitudes

and subjective norms are not related directly to actual behaviors, the TRA postulates a

strong link between attitudes and behavior through the development and functioning of

behavioral intentions. Fishbein and Ajzen (1975) conceptual framework consists of four

categories:

(1) Affect (feelings or evaluations), and this is referred to as “attitude”

(2) Cognition (opinions, beliefs)

(3) Conation (behavioral intentions)

(4) Behavior (observed overt acts)

A clear distinction is made between “behavioral intentions” and “actual behavior”

since attitude deals with a predisposition to behave rather than with behavior itself.

Behavioral intentions are the direct cause of a person‟s behavior (Hemsley-Robinson,

1995). The intention is viewed as a function of two primary determinants – the

individual‟s positive or negative attitude toward the evaluation of performance or non-

performance of the behavior, and their perception of the normative (or social norm)

pressure exerted on them to perform or not perform the behavior (Azjen, 1980, Fishbein,

2001). The assessment of intentions in this study are found within the thirty items used

to assess six attitudinal dimensions which attest to the respondent‟s performance or non-

performance of behaviors deemed to demonstrate their expressed degree of

professionalism.

Overall, attitudes toward professional nursing behaviors or professionalism are a

manifestation of the practicing nurse‟s socialization into their professional role,

experiences, and values. Professionalism is indeed measurable in the work environment.

Basic educational level influences the formation of professional beliefs, behaviors, and

intentions which in turn influences attitudes toward professionalism initially and

throughout practice. The educational process can be most successful not only when

knowledge is exchanged, but also when enhancement and awareness of one‟s

responsibility to effect change and professional performance are emphasized (Witt,

1992).

Conceptual Flow Diagram

This conceptual basis for nursing practice supports the exploration of the

association between nursing basic educational level and professional practice behaviors

(professionalism) within the social and behavioral theoretical/conceptual frameworks

presented. The conceptual flow diagram (Figure 1) displays the relationship between

educational level (structural attributes of professionalism), practice level (socialization

into practice), competency level (member of the profession) and attitudinal attributes of

professionalism which are manifested in reported and measureable behavior.

The diagram begins with the nurse population of who have matriculated through any of

the three basic nursing programs and has gained current licensure through state boards of

nursing as a professional nurse. Basic nursing education, whether in a baccalaureate

degree, associate degree, or hospital-based (diploma) program, prepares the novice nurse

to take a national licensure examination that validates his or her entry level knowledge

whereas workplace opportunities provide for continuing professional development

(Lannon 2007). After licensure into the professional practice within the profession,

members are bestowed the title of “Professional Registered Nurse” from their respective

state board of nursing based upon any of the three basic educational levels attained.

Another transition occurs as the nurse takes on the role and associated competencies as

“member of profession”. Nurses who are educated in the state of Texas are within two

competency levels under “Member of Profession”. The expectation for the associate and

diploma licensed registered nurse is to „participate in activities that promote the

development and practice of nursing‟, while for the baccalaureate licensed registered

nurse it is to „act as a leader in promoting nursing as a profession‟. In the quest for nurses

to become more professional, Landreneau (2002) urges nursing in its process of

professionalization to forge onward utilizing philosophy, theory, and knowledge in

refining their professional base. The competency level for the baccalaureate-prepared

licensed registered nurse contrasted to both the associate and diploma-prepared licensed

registered nurse casts a different standard for nurses whose responsibilities within their

respective roles often times does not differ in the practice environment. Nurses are

expected to be positioned in a continuous state of readiness for change that leads to

professional improvement whether it is in the support of policy and procedural change,

organizational change, or changes in evidenced based practice. By being actively

engaged in self development and participating in activities that promote the development

and practice of professional nursing, whether one is considered a leader or not, nursing as

a profession will be promoted. Individual and corporate change is the expected by

product available to all those who participate. The overall conceptual framework guiding

this study seeks to evaluate the attitudinal attributes toward professionalism for nurses

held to the same dimensions. The overall greater the competence and intention for all

nurses to “act” can promote leadership opportunities and greater professionalism as

measured by Halls Professionalism Model (1968) as modified by Schack & Hepler

(1979):

(1) Use of the professional organization as a major referent (nurses seek professional

community affiliation),

(2) Belief in service (nurses social obligation to the welfare of society),

(3) Belief in Self-Regulation (nurses professional standards should be judged by

professional peers),

(4) Sense of calling (nurses dedication to the profession),

(5) Autonomy (nurses should make decisions about nursing policies),

(6) Continuing competence (nurses should be life long learners).

Socialization is a continuous process within professions today. The targeted

professional development of the members in the profession and the processes set forth to

maintain behavioral standards set by the profession is a core goal of nursing.

 14

Figure 1
Conceptual Flow Diagram: Attitudinal Attributes Toward Professionalism For Nurses

Basic Educational Level Entry/Practice Level Competency Level

‘Structural Attribute’ ‘Socialization into the Profession’ ‘Member of a Profession’

Associate Associate Degree (*RN) Participates in activities

Program Licensure: All states that promote the
* 2 years Professional Registered Nurse (*RN) development and practice
of
Diploma Diploma Degree (*RN) professional nursing.
Program
* 3 years
Acts as a leader in
Baccalaureate Baccalaureate Degree (*RN) promoting nursing as
Program a profession.
* 4 years

PROFESSIONAL DEVELOPMENT
(participates) AND
BEHAVIORAL CHANGE IN THE PRACTICE ENVIRONMENT (acts)

ATTITUDINAL ATTRIBUTES OF PROFESSIONALISM

(Hall, 1968, Schack & Hepler, 1979)
~ Use of a professional organization as a major referent
~ Belief in service to the public
~ Belief in Self-Regulation
~ Sense of calling to the profession
~ Autonomy
~ Belief in continuing competence
 15

According to the Healthcare Leadership Alliance, the competency of professionalism is

addressed by the ability to align personal and organizational conduct with ethical

standards, service orientation, and commitment to lifelong learning and improvement (p.

219).

Professional Socialization

Professional socialization is not completed upon graduation from an institution of

higher learning or upon licensure as a registered nurse. All three levels of nurses must

pass the same licensure examination within their respective state and then practice side

by side while actively engaging in the competent delivery of healthcare. Fetzer (2003)

refers to professionalism as an inductive process during professional education and thus

the requisite professional knowledge, skills, values, attitudes, and behaviors are formally

taught to students of nursing. Mortimer and Simmons (1978) asserts that: (a)

socialization is a process of learning to participate in social life, (b) any structure of social

interaction requires minimally stable and predictable behaviors on the part of all

participants that must be learned initially or be developed over time, and (c) the process

does not include all changes in personality and behavior … but only to learning that is

relevant to social behavior or role enactment.

Professionalism

The two attributes of professionalism encompassed in the professional model are

structural and attitudinal as they distinguish professions from other occupations (Hall,

1968; Schack & Helper, 1979). A clear distinction is made between a professional,

which suggests a more personal, subjective characteristic, while a profession indicates

membership in a defined occupation and is often quite objectively determined.

Professionalism among nurses as in other professions is exhibited by both structural

attributes with respect to the profession and attitudinal attributes with respect to the

individual professional. Wilensky (1964) is well known for his report of the structural

components of professionalism which he reports to occur in the sequential process of

professionalization: creation of a full-time occupation, establishment of training and

education with the development of standards, academic degrees, research programs,

formation of a professional association, support of law to protect job territory, and

sustaining a code of ethics with rules to eliminate the unqualified and the unscrupulous.

There is no doubt that nursing has met the structural attributes of the professional model.

Hall (1968) proposes that if he or his occupation has met the structural

prerequisites of professionalism, the attitudinal attributes become the important

consideration highlighting that variations in the members degree of conformity to

attitudinal attributes will also exist. Hall (1968) uniquely examines the attitudes of

individuals in a profession as a measure of this concept being studied. Snizek (1972)

suggests that the attitudes and ideology held by practitioners denotes the degree of

professionalism characteristic of the occupation. The question regarding this relationship

remains unanswered.

Although researchers that have focused extensively on the degree of

professionalism among nursing students trained within different educational programs,

cannot fully agree upon the degree of uptake during their professional socialization

process (Brooks, 1992; Hodges, 2005; Halter, 2002, Fetzer, 2003). This socialization

process continues to evolve within the practicing registered nurses‟ work environment.

For this reason, student nurses do make a great impetus to better understand gained and
existing professional attitudes in the work environment, as they are influenced by nurse

instructors as well as by practicing nurses.

Truesdell (1984) addressed the perception of professionalism held by actively

practicing registered nurses in Kansas. Truesdell (1984) randomly surveyed full-time

registered nurses (N=202) concerning their views on the state of nursing. The research

questions assessed whether the nursing profession is “what it ought to be”, whether the

nursing profession is “what it should be now”, and “what is the current level of

professionalism among practicing registered nurses in Kansas”. Questions were further

analyzed grouping age, sex, basic training program, state of original license, educational

background, present position, years of practice as a registered nurse, annual salary, and

status of membership in the American Nurses Association. Significant differences

existed in the professional scale responses revealing a positive level of professionalism

within the different practice levels of registered nurses in Kansas. Even though 25 years

have passed since Truesdell did her work in Kansas, the significant differences in

responses of registered nurses and the positive level of professionalism provide a

relevant foundation for surveying registered nurses in South Texas today to either

replicate or reject her findings?

Fetzer (2003) proposes that the BSN prepared nurse has gained a greater degree

of professionalism inherent in their nursing program and while working alongside the

ADN prepared nurse, exposing them to professional attitudes, behaviors, and values.

Fetzer explored the relationship of practice exposure and intensity of professionalism of

ADN nurses. Through an ex post facto approach, four ADN programs in the Northwest

were surveyed. Data was gathered from (N=304) currently practicing registered nurses
through the use of a demographic questionnaire, Hall‟s Professionalism Scale, and the

Short Index of Self-Actualization. The findings of the study support the idea that an

internal variable, self-actualization is related to professionalism, and the greater the self-

actualization, the more likely the AD N nurse will assimilate and integrate behaviors,

attitudes, and values of the professional culture (p. 142).

Martin (2003) also determined that differences existed in the professional values

of graduating students who attended BSN and ADN programs in Texas. The Nurse

Professional Values Scale represented 11 value statements found in the 1985 American

Nurses Association Codes of Nursing. Findings demonstrated that ADN graduating

students scored higher than BSN graduating students on the subscales of: right to privacy,

assumes responsibility and accountability, exercises informed judgment, implements and

improves standards of nursing, and collaboration with others.

Attitude

Attitudinal attributes toward professionalism reflect the manner in which

members view themselves and their work and must be addressed throughout the

professional continuum (Hall, 1968). We are likely to see that greater attitudes toward

professionalism will advance nursing as a profession for all nurses, and influence the path

for the retention of nurses with higher levels of satisfaction and career success.

Consequently the inverse would hold true if lower attitudes toward professionalism were

to prevail.

Schumann (1990) reported on the factors that contributed to the formation of

attitudes among nursing students as: quality instructors, attitudes of other hospital nurses,

and, attitudes of senior nursing students. Schumann (1990) surveyed (N=381) nurses by
a mail survey representing 156 schools in 35 states in the United States and 6 other

nations (Canada, USA, New Zealand, Philippines, Denmark, and England). Graduates

represented members of diploma, associate, and baccalaureate degree nursing programs.

The purpose of the study was to determine what attitudes nurses had toward their basic

nursing program, and what variables were related to the formation of these attitudes.

Nurses from the three types of nursing programs utilized the semantic differential scales

to rate four attitude concepts: basic nursing program, faculty attitude toward students,

faculty attributes in the basic program, and a concept of the ideal nursing program (p. 75).

In general, the diploma graduates had the most positive attitude toward their nursing

program preparation, and the associate graduates had the least positive attitudes toward

their basic program. This supports the assertion that the existing workforces of practicing

registered nurses throughout the world are the communities which ultimately hold the

pulse for professional ideals.

The literature supports the assertions that attitudes are manifested in behavior. Experts

define nursing professionalism as “participation in specific behaviors that illustrate the

beliefs of the profession” (Griffith, 2002, p. 22). Practicing registered nurses as

professionals would then be expected to demonstrate professional behaviors congruent

with their educational and competency level. Understanding that professional

socialization is an ongoing process, it is imperative to assess the factors influencing

professional attitudes and behaviors for all levels of nurses in the professional practice

environment where significant professional growth occurs. Emphasis can then be placed

on methods to optimize and enhance individual and collective professional growth

toward development of the profession. Secondarily, documented associated variables

acting as formal or informal „professionalizing agents‟ may influence attitudes toward

professionalism regardless of a nurse‟s practice level. The variables found to influence

the development or enhancement of professional attitudes are: age, gender , shift worked,

employment status, professional organization membership, professional journal

subscription, professional certification, role in organization, practice years, practice

setting, continuing education hours, salary, expressed degree of satisfaction, and

mentorship.

The attitudinal approach operates on the individual level and is more valid for the

assessment of an individual‟s position on the professionalization continuum (Schack &

Hepler, 1979). Jackson (1970) suggests that the use of attitude implies the movement

towards a definition where attitude takes on the meaning of values. Values are important

in the preparation of nurses capable of managing patients in an ethical and professional

manner (Martin, 2003).

Nurses as other professionals practice together effectively despite their different

practice levels within organizations, political arenas, professional associations, and across

disciplines. The degree of professionalism will continue to greatly vary among members

of the profession, and in turn will directly impact retention, satisfaction, and attainment of

full professional status. In other words, the status of a profession is both a social and an

individual phenomenon (Underwood 2001). Resultant knowledge enables the profession

to positively mediate the contributing effects of the nursing shortage. Additionally, men

are the largest untapped resource for potential nurses, and nurse leaders must identify

strategies to make nursing more appealing to them (Sherrod, B. L., & Rasch, 2005).
Study Significance to Nursing

Professional attitudes and behaviors may be a determining factor in the decisions

of nurses to commit to the job, remain in nursing, promote nursing as an attractive and

rewarding career choice, and prompt nurses to pursue advanced educational degrees in

nursing. Currently, the nursing profession faces a labor shortage of a different magnitude

than in years past. Surprisingly, it is an overwhelming shortage of practicing nurses

within the profession. Kimball & O‟Neil (2001) report that one factor which contributes

to the nursing shortage is a general dissatisfaction of nurses with the professional image

of nursing. For that reason, professionalism can be the mechanism in work environments

which correlates to increased job satisfaction, decreased turnover, and lessening of the

resultant nursing shortage. A serious shortage of professional nurses provides the

impetus for the examination of relationships between values and positive outcomes for

nurses (McNeese-Smith, 2003).

The nursing shortage, second careers due to economic hardship, and the rising use

of nursing agencies contributes to the increase in the employment of foreign nurses,

temporary nursing staff, as well as nurses who are trained within associate degree

programs. The challenge then becomes how to continuously assess the transformation of

nurses into the core professional standards set by educational programs and the work

environment. The question posed is: Do practicing registered nurses in South Texas

exhibit similar levels of professionalism? The study of professionalism among practicing

registered nurses in South Texas is designed to supplement the current knowledge base

related to professionalization as this study population comprises 42% of the total

population of practicing registered nurses in Texas. The American Nurses Foundation

Nursing Summit (2001), “Nursing Agenda for the Future”, identified the scope of the

work required to attain goals in charting the future for nursing. The issues addressed

were: the need to improve how nurses were recognized, the perceived value of nurses,

and the image of the profession. The emphasis was placed upon the preparation of nurses

for adaptation to the myriad of professional challenges of the 21st century.

Many researchers agree with Sheehan (1974) who noted that the registered nurse

with true baccalaureate education is described as a nurse who will have internalized

professional values, norms, and beliefs, and will practice with greater knowledge,

confidence, and autonomy.

Goode (1957) asserted that an important characteristic of established professions is

the „community of profession‟. Goode suggests that each profession is called community

by virtue of these characteristics:

(1) Its members are bound by a sense of identity.

(2) Once in, few leave, so that it is a terminal or continuous status for the

most part.

(3) Its members share values in common.

Its role definitions, vis-a vis both members and non-members are agreed upon

and are the same for all members.

(4) Within the areas of communal action, there is a common language.

(5) The community has power over its members.

(6) Its limits are reasonably clear, though they are not physical and

geographical, but social.

(7) Though it does not produce the next generation biologically, it does so
 socially through its control over the selection of professional trainees, and

through its training process it sends these recruits through an adult

socialization process and maintains procedures for continuing social controls

over the practicing professional.

(8) To the extent that any community exists, it evaluates the behavior of

its members (p. 196).

Goode offers us a great depiction of those qualities which appear to be the core attributes

of the professional in modern day research and application.

There are few definitive studies validating whether nursing has reached full

professional status. In general, nursing has long been regarded as a profession based

upon the professional model utilized as a reference for other professions (Setterstein,

1991, Chaska, 1978, Wilensky, 1964, Greenwood, 1957, Goode, 1957). For example,

nursing meets the criteria of a profession that Wilensky (1964) refers to as a sequence of

stages that occupations pass through upon becoming a profession: emergence as an

occupation, establishment of has a training school, formation of professional associations,

licensure requirements, political activity to establish recognition and protection of

professional work by a sustained code of ethics (pp. 142-145). In addition, Latherer

(1999) and Secrest (2003) points out that a profession consists of three essential

characteristics: expert knowledge (as distinguished from a practical skill); self-regulation,

and fiduciary responsibility to place the needs of the client ahead of the self-interest of

the practitioner. Greenwood (1957) honed in on the concept of the existinence of a

continuum in distinguishing professions from non-professions and the presence or

absence of attributes which are not exclusive to the profession. He states that all
professions possess (a) systematic theory, (b) authority, (c) community sanction, (d)

ethical codes, and (e) a culture (pp. 45-46). Nursing displays all the fundamental

characteristics of a profession including standards of education and practice, and

professional associations (Pellegrino, 2000).

Definition of Terms

The following definitions are used within this study:

(1) Nursing

The provision at various levels of preparation of services that are essential to or

helpful in the promotion, maintenance, and restoration of health and well being or in

the prevention of illness, as of infants, of the sick and injured, or of others for any

reason unable to provide such services for themselves (Dorland, 1998).

(2) Nursing Practice

Refers to a phenomenon that nurses as agents of nursing work do and experience

other than that which nurses traditionally do with clients (Hesook, 1983). Refers to

cognitive aspects of professional actions, along with behavioral and social aspects

(Bourdieu, 1990).

(3) Profession

An occupation that requires extensive formal education and often formal

requirements such as state licensing and professional certification (Lusch, 1997).

(4) Professionalism

An attitudinal and behavioral orientation that individuals possess toward their

occupation, such as thinking of it as a calling and using colleagues in the profession

as major referents for work-related behaviors (Lusch, 1997).

(5) Professionalization

The dynamic process an occupation engages in and can be evaluated by according

to the manifestation of characteristics set by that profession.

(6) Attitude

People‟s biases, inclinations, or tendencies that influence their response to

situations, activities, people, or program goals

(www.cdc.gov/tobacco/evaluation_manual/glossary.html). Some psychic unit, which

corresponds exactly with the category of behavior. Given opportunity, the absence of

counter-veiling attitudes, and an appropriate situation, one predicts behavior from

attitude on the basis that behavior is a direct reproduction of attitude (Warner, 1969).

An attitude is a disposition to respond favorably or unfavorably, evaluative nature

(Ajzen, 1988). Statements that reflect values either favorable or unfavorable

concerning people, objects, or events (DeCenzo, 1997).

(7) Attitudinal Change

To bring about a change in someone‟s attitude about (i.e. patient groups,

physician, nurse, administration), (Kramer, 1974).

(8) Behavior

Internal and external actions and reactions under specified circumstances (Roy,

1991).

(9) Adaptation

The human system has the capacity to adjust effectively to changes in the

environment and, in turn, affects the environment (Roy, 1991). The processes of

change to better conform to environmental conditions or other external stimuli

 (Goggle, 2005).

(10) Values

Things (beliefs, objects, ideas, etc), which a person considers important and

affects his or her actions. Strongly held beliefs an individual has that guides his or her

behavior (Goggle, 2005, DeCenzo, 1997).

(11) Competency

Specific behaviors upon graduation and the associated knowledge based upon the

knowledge, judgment, skills, and professional values, which were, derived from the

nursing and general education content (Board of Nurses, 2002).

What is Your Nursing Philosophy?

Smalley (2005) asks the question, “What is your nursing philosophy”? She

highlights that nurses who continue their education, are active in professional

organizations, are life-long learners, autonomous, and are competent, also, enjoy career

satisfaction, provide better healthcare, are exposed to research, ethics, theory, and

evidenced based practice, and think critically. To embrace the perspective of profession

is to agree that: this group shares a special body of knowledge, standards of education

and practice, professional associations, an ethical framework, a social contract to the

public, and self-regulation. Critical to the understanding of how professionalism can be

enhanced is the expansion of the knowledge base through exploration of variables which

influence a nurse‟s degree of professionalism after licensure. Nursing educational

programs do not produce a homogeneous group of nurses with respect to attitudes, skills,

or behavior. Nursing educational programs need to assure that knowledge, skills,

methods, and training provide a level of competency for preparation of nurses who can
successfully fulfill the expectations of the entry-level professional into the profession.

Although there is no guarantee, it is expected that socialization will be fostered in the

workplace leading to greater professional attributes or higher levels of competency for

nurses after entrance into the profession resultant from continuing education and learning.

If that is not found to be the case, Brown (2008) suggests that recognition of a persistent

problem cannot be fixed if it cannot be measured. The goal to increase the degree of

professionalism among nurses cannot be attained if it is not first measured. This

exploration into the degree of professionalism among actively practicing registered

nurses in South Texas provides a snapshot of this endeavor.

This chapter provided a statement of the research problem, formulated the

relevant research questions, explained the theoretical considerations and conceptual

framework, stated the significance of the study and provided the definitions for terms

utilized. Chapter II outlines the relevant review of the related literature findings and

research hypotheses. Chapter III details the procedure and methodology chosen for this

study. Chapter IV presents the analysis and results of the research findings. The

dissertation concludes with Chapter V which presents the discussion of the results along

with study limitations, implications of the research, conclusions, and recommendations

for further research.

 CHAPTER II

REVIEW OF THE LITERATURE

If the nursing profession is to be recognized as respected and valued, assessment

of individual characteristics of professionalism and opportunities for growth is necessary

(Heath, Andrews, Andrews, & Graham-Garcia, 2001). It is imperative that nurses, who

care for others, care for themselves (Marrelli, 2006). All nurses are responsible to

function as leaders and model professional behaviors regardless of their current role

(Eagelson, 2003). Although nursing has a shorter history than that of some traditional

professions and is still dealing with autonomy, preparation, and commitment issues, great

progress has been made in moving nursing toward full professional status. This chapter

presents key aspects of professional socialization, professionalization, and explores the

attitudinal dimension of professionalism. Leddy (1998) concludes that; (a) the process of

becoming a professional nurse involves change and growth at various stages throughout

their career; and, (b) through educational and occupational experiences, nurses gain

attitudes, beliefs, knowledge, and (c) skills, when integrated with moral and legal

standards, characterize competency and commitment to professional service (p. 20).

This study attempts to make a concise assessment about the current degree of

professionalism among a sample of practicing registered nurses prepared at the diploma,

associate (technical), and those prepared at the baccalaureate (professional) level at one

point in time. In the research, professionalism is viewed as a continuous process which

spans over the course of the nurses career. Nursing education addresses those issues that

affect the profession, educational preparation, and the practice of nursing (Hodges, 2005),

therefore, do differences in the professionalism of nurses related to type

28
 29

of educational program exist today? The exploration which follows examines the

historical background of nursing, educational standards/competency, professional

socialization specifically how attitudes and values about the profession are formed,

nursing as a profession, professional development, professionalism, and concludes with

factors which may influence professionalism or act as professionalizing agents.

Nursing Historical Perspective

Nursing practice roles have evolved from the bedside to the boardroom. Over the

years, as well as being seen as an occupation requiring something approaching a

„calling‟, nursing has been an activity performed almost exclusively by women (Taylor &

Field, 1997, p. 237). The American Nurses Association depicted the state of nursing in a

most accurate manner with these annual nursing themes: “Nurses: Your Voice, Your

Health, Your Life” (2004), “Many Roles, One Profession” (2005) , “Nurses: Strength,

Commitment, Compassion” (2006), "Nursing: A Profession and a Passion" (2007),

“Nurses Make A Difference Everyday” (2008)

Until the mid-to-late 1800‟s the roles of men and women in nursing were similar

(O‟Lynn, 2004). As early as 1873, nursing schools were opening and could be

considered as the starting point of the movement toward professionalization. With only a

few hundred hospitals operating in the United States, the shift from the home care of

patients to that of hospital based care had begun. The beginning of diploma based

programs was essentially rendered under the control of administrators and physicians. In

an overall effort to move the profession of nursing away from simply an apprenticeship

model toward a professional model, the educational and practice guidelines were the

topic of the well known Brown Report of 1948. In the report, the first recommendation
was that the baccalaureate degree becomes the standard for professional nursing and the

diploma degree be subordinately recognized (Brown, 1948, p. 153). Interestingly, during

the 1950‟s, hospitals faced staffing shortages and began the recruitment involving

women of lower economic status and minority groups while also increasing the

availability of two-year nursing programs amidst this shortage. Prior shortages were also

evident during periods surrounding 1961, 1967, and 1980‟s. Early on, the characteristic

portrait of the nursing profession was that of a female dominated occupation, wrought

with the perceptions of low status, domesticated, and purely vocational when compared

to medicine. Professional behaviors were initially viewed predominantly as the woman‟s

duty of servitude within a male dominated medical society. Soon the opportunity existed

for middle class women who did not normally work outside of the home to become part

of a growing social status or become professional. Nurses during the Florence

Nightingale era were depicted as “attendants of the sick” and “teachers of hygiene”,

while today, nurses must assume diverse roles in a complex healthcare system in

response to changes in social and demographic trends, medical and technological

advancements, and perceptions of nurses themselves (Yam, 2004). Nightingale believed

very strongly that good nurses were the product of moral rectitude, maturity, and a deep

understanding of the character traits needed to care for sick and vulnerable people and

further acknowledging that scientific training alone would not produce good nurses

(Kitson, 1996). Nightingale‟s emphasis on hygiene and environment, careful data

collection and analysis, and her standards for character and performance expectations

increased the value of nurses and nursing‟s contribution in society‟s perception

(Anthony, 2004). The question to be answered is: Where are we today? Nightingale

advocated for
improved education and status for nurses and was considered an early advocate for

broadening the career options for women (Donahue, 1996). Evans (2004) reports that

ironically, men‟s association with nursing ended in the mid-nineteenth century after the

establishment of nursing by Nightingale as a women‟s occupation whereby in 1971, men

nurses were forced to form the American Assembly for Men in Nursing due to their

inability to play an active role in professional nursing organizations (p. 324). However,

despite the limited recognition given to their role, historically, males have participated in

care giving and described as nurses (Anthony, 2004). The role of women in society was

changing and the rising proportion of female medical graduates, along with other

professions such as physiotherapy and occupational therapy are having some success in

progressing away from male dominance. Today, nursing is one of the world‟s most

diverse occupations (Sherrod, Sherrod, & Rasch, 2005).

Kelly (1981) embellished the original work of Abraham Flexner who was

instrumental in defining the now benchmark criteria accepted as characteristics of any

professional as well as the profession. Kelly (1981) redefined those characteristics for

the nursing profession:

(a) The services provided are vital to humanity and the welfare of society.

(b) A special body of knowledge exists that is continually enlarged through

research.

(c) The services involve intellectual activities; individual responsibility/accounta-

bility is strong feature.

(d) Practitioners are educated in institutions of higher learning.

(e) Practitioners are relatively independent and control their own policies and
 activities.

(f) Practitioners are motivated by service (altruism) and consider their work an

important component of their lives.

(g) A code of ethics guides the decisions and conduct of practitioners.

(h) An organization (association) exists that encourages and supports

high standards of practice. (p.18)

Weber (2003) affirms Florence Nightingale to be the founder of modern nursing

in its pursuit as a profession describing her basic tenets believed to be the principles upon

which nursing rests:

(a) Nurses must define the content of nursing education.

(b) Nurse educators are responsible for the care provided by students and

graduates of the nursing program.

(c) Educators should all be trained nurses themselves.

(d) Nursing schools should be separate entities, not connected with physicians or

hospitals.

(e) Nurses should be prepared with advanced education and should engage in

continuing education throughout their careers.

(f) Nursing involves both sick nursing and health nursing and includes the

environment as well as the patient (holism).

(g) Nursing must include theory (p. 44)

Elzinga (1990) sketches the course for the development of nursing within four

stages:

(1) A calling followed by middle-class women who built up a fund of

 practical knowledge permeated with specific values peculiar to their

background

(2) Semi-professionalization; or the organization of nurses into a semi-profession

with its own traditions, formalized qualification criteria and career patterns, as

well as associated values on the part of some to seek status and strive for

professional acknowledgement. During this stage, expansion of the field

brought in women from working-class homes, which then made up the

majority along with the centralization of hospital care, the expansion of tasks,

and the required additional skills and knowledge.

(3) An emerging discipline based on a scientific knowledge base along with the

integration of nurse training programs into academic systems.

(4) Professionalization, which is characterized by independent research,

associated with nursing, PhD programs, and new career patterns (pp. 155-

156).

The image of nursing is viewed as moving from a craft to a science.

Hunt and Wainwright (1994) report professionalization can be seen as a process

of evolutionary change, as occupation changes with respect to a range of characteristics

where each characteristic is represented on a continuum. In their attempt to expound

upon whether nursing is a profession, they reference Cleland (1975) who suggests that in

the USA, nursing as defined in law as a profession points out that the National Labor

Relations Act Section 2(12) defines „professional employee‟ as:

(a) any employee engaged in work (i) predominantly intellectual and varied in
character as opposed to routine mental, manual, mechanical, or physical work;
(ii) involving the consistent exercise of discretion an judgment in its
performance; (iii) of such character that the output produced or result
 accomplished cannot be standardized in relation to a given period of time; (iv)
requiring knowledge of an advanced type in a field of science or learning
customarily acquired by a prolonged course of specialized intellectual
instruction and study in an institution of higher learning or a hospital, as
distinguished from a general academic education or from an apprenticeship or
from training in the performance of routine mental, or physical processes (p.
7).

Hunt & Wainwright (1994) suggest the following features of a profession to be:

(a) Possession of a body of knowledge

(b) Service to clients

(c) Standard of practice

(d) Ethical code

(e) Accountability

(f) Status (p.141).

Zerwich and Claborn (1997) agree that a profession should consist of the

following criteria:

(a) Provide an important service

(b) Possess a distinct body of knowledge as the basis for practice

(c) Self-regulation

(d) Code of ethics

(e) Commitment to lifelong learning process

(f) Possess a subculture

Heath (2001) profoundly asserts that the criterion addressed by Flexner and Kelly

is only as good as the person who takes responsibility for committing to a professional

role. Pinkerton (2001) agrees stating that some of the same characteristics are utilized to

assess why the job of nursing is recognized as a profession. These characteristics are:
 (a) Education of the practitioner

(b) Code of ethics

(c) Compensation commensurate with the work

(d) Organized to promote a needed service

(e) Autonomy in practice

(f) Recognized by the government with licensure (p. 130)

Miller, Abbot, and Bell (1993) identified similar characteristics and state that

nurses must maintain these characteristics whether they are new graduates or graduated

thirty years ago in order to be considered professional. They challenge nurses to evaluate

how they measure up to: higher education, autonomy, code of ethics, continuing

education/competency, communication/publication, professional organizations,

community service, and research involvement. Although medicine and nursing do not

occupy positions of equality, the continued path to professionalization is daunted by its

own hierarchies, career paths, educational and training systems (Taylor & Field, 1997).

The historical development of nursing depicts a process of professionalization

from a subservient role to one that is independent and guided by a theoretical basis in

practice. Florence Nightingale envisioned nursing to be a profession wrought with nurses

who possess the knowledge, skills and abilities not only for the expressed benefit of

patients, but also for the practice and promotion of nursing as a profession. The early

view of nursing was perpetuated because nurses functioned in a purely vocational status

and their knowledge base was purely technical and gleaned from apprenticeship with

physicians. The outcome of this practice relationship later laid the foundation for formal

training programs affiliated with hospitals.

 Today, the major cause of the prior nursing shortage was attributed to the

increased demand for nurses as opposed to the supply in previous shortages. The primary

factors surround wages, work preferences, career opportunities for women, changing

demographics, nursing school enrollments, and retirements. The length of the current

shortage has been more problematic. Enrollments and graduations from all types of

nursing programs declined in the 1980‟s. These and other factors will continue to

influence the writing of the historical events yet facing nurses, and nursing as a

profession.

Leddy (1998) asserts that four concepts have been commonly accepted as central

to the discipline of nursing:

(a) The human being (who may be a nurse or client or client individual, a

family, group, or community)

(b) The environment (which may be alive or inanimate)

(c) Health (which may include well-being and illness)

(d) Nursing actions (which include all the interactions among nurse, client, and

the environment in the pursuit of health), (p. 139)

Leddy (1998) defines the views of several nursing theorists who have developed

models as the basis for the science of nursing since there is no one model to encompass

all that nursing is. Nursing theorists over the years have depicted the image of nursing

through many characteristics. She also states that nurses‟ role conceptions also include

that of change agent, client advocate, and contributor to their profession.

The following nursing theorists‟ models further define the intended purpose of

nursing as it relates to nursing practice and suggests that the common nursing action is to
be that of a change agent and the provider of physical, psychological, and emotional care

in the support of persons in need:

(a) Imogene King Systems Interaction Model proposes that the purpose of

nursing is to help people attain, maintain, or restore health (p. 172).

(b) Betty Neuman‟s Health Care Systems Model proposes that the purpose of

nursing is the reduction of stressors through preventive measures, and for the

facilitation of optimal system stability (p.172).

(c) Sister Callista Roy‟s Adaptation Model proposes that the purpose of nursing

is to promote a person‟s adaptation by manipulation of stimuli to foster

successful coping (pp. 176-178).

(d) Orem‟s Theory of Self-Care proposes that the purpose of nursing is to help

people meet their self-care needs through actions which overcome or prevent

the development of self-care limitations or provide therapeutic self-care for a

person who is unable to do so (pp.179-181).

(e) Jean Watson‟s Human Science and Human Care Model proposes that the

purpose of nursing is to help people gain greater harmony within the mind,

body, and soul by promoting restoration of a sense of inner harmony (p. 181)

(f) Hildegard Peplau‟s Interpersonal Relations Model proposes that the purpose

of nursing is to foster personality development in the direction of maturity (p.

184)

(g) Martha Roger‟s Human Science of Unitary Human Beings proposes that the

purpose of nursing is to foster health potential through physical, biologic,

psychological, social, cultural, and spiritual attributes, which are merged

into
 behavior that reflects the total person as an indivisible whole. Nursing‟s

primary concern is with human beings (p.187).

(h) Rose Marie Parse‟s Human Becoming Model proposes that the purpose of

nursing is to improve the quality of life of both client and the nurse (p. 188).

(i) Margaret Neuman‟s Model of Health as Expanding Consciousness

proposes that the purpose of nursing is to promote higher levels of

consciousness in both the client and the nurse (p. 190).

I agree with Meleis (1997) who suggests that multiple theories are often required

to address the complexity of nursing (Hagerty & Patuskky, 2003, p. 145) especially when

exploring factors which influence professional behavior.

Kramer (1974) categorizes the nature of change as defined by the goal or

objective of the intended change as:

(a) Attitudinal change: to bring about a change in someone‟s attitude

(patient, groups, physician, nurse, administration).

(b) Technical change: to introduce in some technical aspect of work

(c) Informational change: to bring about a knowledge increase or correction of

erroneous knowledge to a patient, physician, or other staff

(d) Procedural change: to bring about a change in routine or policy

(e) Environmental change: to bring about some alteration or improvement in the

environment of patients or staff

Basically, nursing has become a discipline, which demonstrates the effectiveness

for the health of a society, a practice that achieves outcomes of personal growth for

individuals and groups, promotion and evaluation of change, self-knowing, and personal
and social transformation (Roy, 1990). As a person, the nurse is continually interacting

with the personal environment; as a professional, the nurse is continually interacting

within the professional environment, and because the personal self is developed first,

those behaviors form the basis of the self brought into the profession (Leddy, 1998).

Hunt & Wainwright (1994) agree that nursing is a human service with expressed concern

for individuals based on the values and norms concerning the nature of the relationships

(p. 90). Building upon the foundations which are developed in nursing schools, and

cultivating professional behaviors in practicing registered nurses is an expectation of the

profession. There is indeed an academic nursing discipline as developed through history,

scientific knowledge, and definition within research, practice, and education arenas

(Smith, 2000, p. 27). Nursing is so much more as purported by Perry (2008). It is:

(a) getting inside someone‟s mind, and knowing what will make them whole

(b) taking a risk and helping someone do something they need to, but can‟t

do alone

(c) campaigning for something you know someone needs even when they are

unaware

(d) jeopardizing the certain to attain the essential (p. 19).

Meleis (1992) attests to six characteristics in describing nursing as a discipline:

(1) Adherence to a code of ethics

The values of the profession are found in professional code of ethics (Martin,

2003, p. 291). Eraut (1994) offers insight into the evaluation of professional

accountability for which individual professionals should possess. They are:

(a) a moral commitment to serve the interests of clients

 (b) a professional obligation to self-monitor and to periodically review the

effectiveness of one‟s practice

(c) a professional obligation to expand one‟s repertoire, to reflect on

one‟s experience and to develop one‟s expertise

(d) an obligation that is professional as well as contractual to contribute to the

quality of one‟s organization

(e) an obligation to reflect upon and contribute to discussions about the changing

role of one‟s profession in wider society.

These views are not limited by: education, age, gender, role in the organization,

employment status, membership in professional organizations, professional journal

subscription, professional certification, practice years, practice setting, continuing

education, salary, organization type, expressed degree of satisfaction, and mentorship

with respect to professional accountability.

Positive feedback reinforces a particular sense of self as a professional person that

incorporates desirable behavior and fitting in with social practices identified by the

profession (Clouder, 2003)

(2) Publication and Communication

In relation to non-clinical skills, this is an aspect of professional nursing

development that doesn‟t receive as much emphasis. Lannon (2007) urges nurses to

remember that as nurses look to advance their careers, behaviors which they will be

expected to demonstrate will include: the ability to demonstrate oral presentation or

poster presentation skills, to produce written materials (including publications), and to

maintain professional portfolios (p. 18).

 A bachelor‟s degree may provide a base from which individuals can move

toward other avenues of higher education within nursing, such as teaching, management,

or research (Domino, 2005). National and institutional standards, professional

organizations, laws, regulations, and judicial rulings, as well as federal and state

accreditation organizations all contribute to the skills and competencies required of

professional nurses (Neuhauser, 2002).

(3) Community Service

Hampton and Hampton (2000) examined the level of professionalism among

(N=685) certified-nurse midwives (CNM). They explored the relationship between level

of education, organizational reward structures, and professionalism. Utilizing Hall‟s

Professionalization Scale, the results showed that CNMs exhibited a high degree of

professionalism; especially in the “belief in public service, and “sense of calling” in the

practice of midwifery. Specifically, the findings supported a causal relationship between

education levels, reward structure, and CNM professionalism. The four educational

levels were non-bachelor degree CNM, bachelor degree CNM, CNM with master‟s

degree, and CNM with Ph.D. A within groups ANOVA was conducted for each of the

dimensions of professionalism displaying statistically significant differences in sense of

calling, autonomy, and professional association as a major referent.

(4) Mentoring

Within nursing the term mentor carries a multiplicity of meaning (Andrews,

Wallis & Wrexhem, 1999, p. 201). Mentoring is widely recognized as a valuable process

to aid professional and personal development (Garvy & Alfred, 2000), and is a

professional responsibility, as well as an opportunity for growth (Thompson, 2000).

Mentoring and coaching are key components in the retention and recruitment of nurses

into the profession (Hom, 2003). As typical in most professions, mentors are typically

experienced, confident, and competent professionals who are virtually interested in

facilitating the personal and professional development of one or more junior

professionals (Johnson, 2002), while Bernice &Teixeira (2002) report that mentorships

can help expand the abilities of experienced technologists and afford opportunities for

advancement to enhance job satisfaction and retention (p. 386).

Fawcett (2002) asserts that a mentor does not have to be someone the mentee

works with but can be someone the mentee sees, connects with as a nurse or an

individual, facilitate the career development of others, and believe that the mentee is

capable of growing and sharing (p. 950)

Myers (1990) outlines the Dalton-Thompson Career Development Model which

identifies four stages within the mentoring process as an integral part of a professional

development model for new or trained nurses. In the first stage, dependence, the nurse

takes a subordinate role where the mentor offers the necessary supervision for as long as

needed as part of the relationship. In the second stage, independence, less supervision is

needed and the mentor and nurse enter into a more shared relationship. In the third stage,

of independence, the nurse demonstrates the personal and professional characteristics to

become a mentor but may or may not choose to do so. In the fourth stage, supervision,

the nurse may be held responsible for the performance of others in a manager or

supervisory role.

Literature from psychology and other fields consistently demonstrates that

mentoring is beneficial both personally and professionally. Andrews (1999) performed a

meta-analysis on mentorship in nursing. The author found that much of the literature

review surrounding mentorship was with supervision of students and the more recent

work surrounded the supervision of qualified nurses. Although the main focus was on

the examination of mentorship in relation to students in the practice setting, within

nursing the term mentor carries a multiplicity of meaning (p. 203).

Johnson (2002) encourages a deliberate transition in the psychology profession‟s

conceptualization of mentoring from secondary or collateral duty to intentional,

professional activity requiring intentional preparation and careful application as the

benefits will accrue to mentors, protégés, and the broader profession of psychology (p.

203). Intentional mentors lend themselves to the modeling or direct demonstration of

those behaviors specific to the profession while producing faster learning than direct

experience (p. 92).

As noted by Clark et al., Johnson, Koch, Fallow, & Howe (as cited in Johnson,

2002) the definition of mentorship in the field of psychology was offered as: personal

relationship in which a more experienced faculty member or professional acts as a guide,

role model, teacher, and sponsor of an experienced graduate student or junior

professional providing knowledge, advice, challenge, counsel, and support in the pursuit

of becoming a full member of a particular profession.

Ragins & Cotton (2000) support the assertion that informal mentoring (those that

develop spontaneously, without formal assignment) is thought to be more effective and

meaningful than formal (assigned) mentorships. Roemer (2002) suggests reconsideration

of the concept of mentoring in that the traditional view of mentoring with one mentor and

one protégé in a long-term relationship within the same organization needs to be revised
(p. 58).

Ragins, Cotton, & Miller (2000) compared career and job attitudes among

individuals with formal mentors, informal mentors, and no mentor while controlling for

and investigating the degree of satisfaction obtained from the mentoring relationships (p.

1178). Many of the hypotheses were beyond the scope of this study and were centered

around: relationship between the level of satisfaction and work attitudes, relationship

between level of reported satisfaction and mentoring type, relationship between the

characteristics and design of a formal mentoring program and career and job attitude,

relationship between program type (formal or informal) effectiveness and career and job

attitude, and relationship between formal programs that offer (do not offer) guidelines for

frequency of meetings and career and job attitude. Hypothesis 2 compared the type and

presence of a mentor while the degree of satisfaction with the relationship was controlled

for and examined. Their research questions addressed: (1) Does the type or the presence

of a mentoring relationship account for more of the incremental variance in job and

career attitudes than the level of satisfaction with the mentoring relationship?, and (2)

Does the rank or department of a formal mentor affect a protégé‟s report of program

effectiveness or the protégé‟s career and job attitudes? Equal numbers of males and

females were randomly selected from lists of social workers, engineers, and journalist‟s

professional associations. The results of the survey were: The presence of a mentor was

significantly related to job satisfaction, career commitment (p. 1187), and protégé‟s in

programs that used mentors who were in the same departments as them expressed

marginally more negative career and job attitudes than those in programs that used

mentors from different departments (p. 1189). In sum, the results indicate that the
presence of a mentor alone does not automatically lead to positive work outcomes: the

outcomes may depend on the quality of the mentoring relationship (p. 1190).

It will be more effective when mentoring becomes a natural process and is viewed

as normal behavior within organizations (Garvey, 1995). The current nursing shortage is

consistent with the teacher shortage described by Gagen & Bowie (2005) in the

statement:

Too much time and money are being spent on training new teachers(nurses) who
leave the profession before they have an opportunity to develop into the experienced
professionals that schools(healthcare institutions) need. Teacher (Nurse) shortages are a
direct result of these retention problems as the educational (healthcare) system attempts
to replace the large number of retiring teachers (nurses) from a smaller pool of available
candidates (p. 41).

(5) Professionalism

Professionalism is not concerned with high incomes and increased status, but with

controlling nursing practice and possessing autonomy (Moloney 1986). Members of the

Medical Professionalism Project (2002) responsive to a calling for a renewed sense of

professionalism from many countries developed a set of principles for which all medical

professionals should aspire. Professionalism was viewed in this manner as the basis of

medicine‟s contract with society:

(a) placing the interests of patients above those of the physician

(b) setting and maintaining standards of competence and integrity

(c) providing expert advice to society on matters of health (p. 170).

From these standards, one of the more common responsibilities highlighted was the

“commitment to professional responsibilities”. It describes certain expectations: which

could be likened to nurses:

 As members of a profession, physicians (nurses) are expected to work
collaboratively to maximize patient care, be respectful of one another, and
participate in the processes of self-regulation, including remediation and
discipline of members who have failed to meet professional standards. The
profession should also define and organize the educational and standard-setting
process for current and future members. These obligations include engaging in
internal assessment and accepting external scrutiny of all aspects of their
professional performance (p. 172).

Hall‟s Professionalism Model explored the basis of the professional model. The

professional model consists of two distinct attributes which are viewed to distinguish

professions from other occupations. Per Hall (1968), professionalization occurs when

occupations conform to the professional model as they move along a continuum. Hall

initially measured bureaucracy concluding that seemingly established professions

exhibited weakly developed professional attitudes and conversely less professionalized

groups had strong professional attitudes (p. 103). The question is whether there is a

correlation to the socialization process which occurs during the training period and

particularly in the workplace. The structural attributes of professionalism are the

characteristics of a profession and pertain to licensing, formation of a code of ethics, and

educational requirements. The attitudinal attributes of professionalism are characteristics

by the members and how they view their work and pertain to membership in professional

organizations as a major referent, sense of calling to the field, belief in public service,

sense of autonomy, and belief in self-regulation. Schack and Helper (1979) revised

Hall‟s initial scale and added a sixth attribute; Belief in continuing competence. Hall‟s

(1968) landmark study asserts that both attributes are present to a greater degree in highly

professionalized occupations, and conversely in less professionalized occupations.

Monnig (1978) examined the difference in the degree of professionalism between

(N=300) nurses and (N=300) physicians using Hall‟s Professionalism Scale. Nurses

expressed a higher degree of professionalism within the dimension of Belief in Public

Service whereas physicians expressed a higher degree of professionalism within the

dimensions of use of professional organizations, Belief in Self-Regulation, Sense of

Calling to the Field, and Autonomy (p. 48). Her interpretation of these results rest upon

the notion that nurses feel stronger about their profession is one that is vital to society,

and physicians feel strongly that their profession is one that is essential to society (p. 48).

Key to this study was her suggestion to repeat this study in one decade from speculating

that nursing would be more professionalized with a greater sense of professionalism for

most nurses.

Throughout the years, considerable antagonism has existed between physicians

who want dependable, subservient nurses and nurses themselves who want professional

status and autonomy highlighting the fact that it is not only the nurse/doctor relationship

which affects innovation and change, but the nurse/nurse relationship (Oughtibridge,

1998, pp. 22-23). Therefore the degree or level of professionalism reflects practitioners‟

behaviors and perceptions of their work as defined by the profession (Hampton &

Hampton, 2000, p. 218)

(6) Empowerment

Men and women are attracted to professions where they will be empowered, and

where they can expect to enjoy financial rewards and favorable working conditions for

their efforts (Boughn, 2001). Individuals who are empowered feel positive about their

jobs and may in turn be able to influence the work environment (Kramer &

Schmallenberg, 1993), have a sense of self determination, have a sense of meaning, have
a sense of competence, and have a sense of impact making empowerment a mind-set that

individuals have about their role in the organization (Quinn & Spreitzer, 1997).. Feelings

of empowerment also strengthen the professional nurse‟s commitment to the profession

and ultimately to the professionalization of nursing (Styles, 1982). The concept of

empowerment is described as being intuitively attractive to nurses, to the nursing

profession, and to nursing practice (Ryles, 1998, Gilbert, 1995). Both authors agree that

central to the concept of empowerment is the relationship to power itself. Gilbert (1995)

proposes that there are personal and socio-political attributes to empowerment. He refers

to power as a personal attribute which can be expanded upon whereas personal growth

leads to personal power. From the socio-political perspective, the political view arises

and through synergistic efforts, people and communities working together produce a

greater effect than would be realized by any one individual (p. 866). Similarly,

individuals, professionals, and organizations can actively empower their clients and

colleagues by first empowering themselves (Ryles, 1998).

Hausner (2002) in her doctoral dissertation examined the relationships between

psychological empowerment and professionalism in nursing. Psychological

empowerment was defined as task motivation attained through an increase in personal

sense of meaning and control. The four dimensions of meaning, competence, self-

determination, and impact formed the gestalt of empowerment. She surveyed (N = 584)

registered nurses from the Midwest utilizing a mail in questionnaire. The instruments

utilized to collect the data were the Spreitzer‟s Empowerment Scale, and Hall‟s

Professionalism Scale. Respondent‟s reported a moderate level of empowerment and

professionalism at a .05 confidence level. The results suggest a positive relationship

between empowerment gestalt and professionalism gestalt along with the five attitudinal

attributes of professionalism: use of the professional organization as a major referent,

belief in service to the public, belief in self-regulation, sense of calling to the field, and

autonomy.

Yuke (2006) reports that the beneficial consequences of empowerment are:

(1) stronger task commitment

(2) greater initiative in carrying out role responsibilities

(3) greater persistence in the face of obstacles and temporary setbacks

(4) more innovation and learning, and stronger optimism about the eventual

success of the work

(5) higher job satisfaction

(6) stronger organizational commitment

(7) less turnover (p. 108)

Basically, empowerment can come from within one‟s self; it can come from others; and it

can also have a joint locus of origin (Dempster, 1994). Nurse empowerment will be the

key to the future success of the nursing profession and to the overall health care delivery

system (Klakovich, 1995) if nurses see themselves as having freedom and discretion, feel

personally connected to the organization, confident in their abilities, and capable of

having an impact on the system in which they are embedded (Quinn & Spreitzer, 1997,

p.41). Martin (2002) offer that nurses must exercise „personal power‟ which is the ability

to control their actions, in their personal as well as professional life (p. 4).
Preparation for Professional Practice

Quite the debate continues at every level with respect to the minimum preparation

for professional nursing practice. Nelson (2002) asserts that while the publication of the

1965 ANA position paper calling for the baccalaureate degree as the minimum

requirement for entry into professional nursing practice initiated an impassioned debate

which continues to frustrate and divide nursing today and agreement reached on the

importance of developing a better educated profession for the future. The future of

nursing depends on moving nursing education into institutions of higher education while

phasing out hospital based programs in hopes that those programs would merge with

baccalaureate or associate degree programs (Nelson 2002). The associate degree

programs represented an opportunity for nursing to break away from the apprenticeship

model of education and exert greater control over the educational experiences of nursing

students (Nelson 2002). Mahaffey (2002) asserts that associate degree nursing education

remains a relevant choice for students entering the nursing profession and has had a

significant impact on the registered nurse population in the United States.

The American Association of Colleges of Nursing recognizes the Bachelor of

Science Degree in Nursing as the minimum educational requirement for professional

nursing practice (p. 267). As such, Registered Nurses at the entry level of professional

practice should possess, at a minimum, the educational preparation provided by a 4-year

Bachelor of Science Degree Program in Nursing (BSN) (p. 268). To meet the more

complex demands for today‟s healthcare environment, a federal advisory panel has

recommended that at least two thirds of the basic nurse workforce hold baccalaureate or

higher degrees in nursing by 2010 (Department of Health and Human Services, 2004).
 Another perspective relevant to this topic offered is that:

Differentiated nursing practice is another concept that has been interpreted differently.
Points of difference usually involve the importance formal education holds on the ability
of the nurse to assume different roles. Some differentiated nursing practice models
include formal education, lifelong experiences, work experience, and specialty
certification as mechanisms for maintaining or assuming new roles. Many state and
national models have been identified, but none of them have been implemented at the
national level (Mahaffey, 2002)

While nursing education in other countries has begun to move to the

baccalaureate level, nurses remain the least educated among professional health care

providers (Nelson, 2002). Additionally, as an employee of the Veteran‟s Administration,

who employs a vast number of registered nurses throughout the country, has recently

established that the baccalaureate degree is the minimum preparation for promotion to the

next grade level and can only be waived in defined instances by meeting additional

criteria. Appendix A outlines the basic nursing degree entry level and the respective

educational requirements.

Nursing Background

Nursing shortages have occurred in the past, but the factors involved in the

current nursing shortage are different, because of the increased demand for nurses;

diverse population demographics; increased growth in the population; broadening career

opportunities for women; and an ageing nursing workforce (Coffey-Love, 2001, p. 30).

The U.S. Department of Health and Human Services (HHS) estimated that the United

States was weathering a shortfall of 111,000 full-time equivalent (FTE) RNs in 2000 and

that figure is projected to grow to 275,000 by 2010 (NCHWA, 2004, Auerbach,

Buerhaus, & Staiger, 2000).

According to the Bureau of Labor Statistics (2005), the country will need more
than one million additional nurses within that same timeframe and through 2014; the

United States health care system will need more than 1.2 million new nurses. Currently,

118,000 registered nurses are needed to fill vacancies in U.S. hospitals, according to a

report released by the American Hospital Association in April 2006. In the 2005

American Hospital Association Workforce Survey, the data reveals that recruitment for

new nurses was more difficult in 2004 than in the previous year by forty percent of

hospitals.

There are three major educational paths to registered nursing: A bachelor‟s of

science degree in nursing (BSN), an associate degree in nursing (ADN), and a diploma

degree. BSN programs, offered by colleges and universities, generally take about 4 years

to complete. In 2004, 674 nursing programs offered degrees at the bachelor‟s level. ADN

programs, offered by community and junior colleges, generally take about 2 to 3 years to

complete. In 2004, 846 RN programs granted associate degrees. Diploma programs,

administered in hospitals, generally take about 3 years to complete. In 2004, only 69

programs granted diploma degrees. Licensed graduates of any of these three types of

educational programs qualify for entry-level positions as staff nurses (AACN, 2004)

Employers in some parts of the country and in certain employment settings are

reporting difficulty in attracting and retaining an adequate number of registered nurses,

primarily because of an aging workforce and a lack of younger workers to fill positions.

Enrollments in nursing programs at all levels have increased more rapidly in the past

couple of years as students seek jobs with stable employment. However, many qualified

applicants are being turned away because of a shortage of nursing faculty to teach classes

within these programs. The need for nursing faculty will likely increase as a large number
of instructors near retirement. Many employers are relying on foreign-educated nurses to

fill open positions (AACN 2004).

Allen (2008) reports that the main reasons for the lack of faculty to meet the

demand for more nurses include the increased age of the current faculty and the declining

number of years left to teach, expected increases in faculty retirements, less

compensation for academic teaching than positions in clinical areas for master‟s-

prepared nurses, and finally, not enough master‟s and doctoral-prepared nurses to fill the

needed nurse educator positions (p. 35)

The Board of Nurse Examiners (BNE) for the State of Texas has a

disproportionate number of approved professional nursing education programs in which

to gain entry into professional nursing: 2 Diploma Nursing Programs, 50 Associate

Degree Programs, 26 Baccalaureate Degree Programs, and 5 Baccalaureate Degree to RN

Programs (BNE, 2007).

The Texas BNE most recent demographic report of registered nurses by their

highest degree attainment as of September 2006 is displayed in Table 1. Paramount to

this study is the large population of registered nurses within the age group of 25 to 64.

The age group of 25-34 (18.2%) and 55-64 (18.5%) are relatively equal compared to the

age groups 35-44 (25.4%) and 45-54 (31.6%) combined making up 57% of the total

population. Female registered nurses out number male registered nurses as in most

states, and although not a part of this study, the ethnicity break down reflects the

following: 73.6% Caucasian, 7.8% African American, .34% American Indian, 7.6%

Oriental/Asian, 9.1% Hispanic, and 1.6% Other category. Future studies of this topic are

warranted with respect to this variable.

 The employment status as reported by the BNE for September 1, 2006 reflects

129,170 registered nurses are employed within nursing full time, and 20,512 registered

nurses are employed within nursing part time. Likewise, 4,291 registered nurses are

employed outside of nursing full time, and 1,488 registered nurses are employed outside

of nursing part time. Per this data, there are 24,676 registered nurses that are unemployed

in the state of Texas. The total number of registered nurses reported for this same period

by clinical practice area, position type, and primary place of employment is 149,682. For

this study, this number constitutes the total population of registered nurses within the

state of Texas.

Table 1
Board of Nurse Examiners Currently Licensed Texas Registered Nurses Residing in
Texas by Age, Ethnicity and Sex (09/01/2006)
Board of Nurse Examiners
Currently Licensed Texas RNs Residing In Texas By Ethnicity, Age, Sex
09/01/2006
Ethnicity < 25 25 - 34 35 - 44 45 - 54 55 - 64 > 65 Totals
F M F M F M F M F M F M

Caucasian 2236 141 18411 1962 27934 3365 41149 3654 24435 1988 7081 236 132592
African 195 6 2653 182 3564 330 3651 332 2334 111 668 25 14051
American
American 8 1 90 17 147 27 128 30 109 14 37 2 610
Indian
Oriental/Asian 166 28 2811 524 3487 673 3273 276 2047 117 287 13 13702
Hispanic 489 48 4290 843 3692 949 3123 567 1662 216 402 27 16308
Other 62 5 814 114 827 120 530 61 255 23 61 2 2874

180137

Gender Total 3156 229 29069 3642 39651 5464 51854 4920 30842 2469 8536 305
by Age
3385 32711 45115 56774 33311 8841

Total Females 163108

Total Males 17029
This data is produced by the Texas Board of Nurse Examiners from information provided by the registered nurse on
biannual licensure renewal application.
 The Texas BNE 2006 distribution of registered nurse graduates within all

program types were reported as follows: 2.5% Diploma graduates, 60.0% ADN

graduates, and 37.1% BSN graduates (p. 2). The most current date available from the

Texas BNE reveals an alarmingly low rate of graduation as compared to the enrollment

into nursing programs in 2005. In the Fall 2005, graduates from Diploma Programs

comprised 51.3% of those enrolled, graduates of ADN programs comprised 40% of those

enrolled, and graduates of BSN programs comprised 31.8% of those enrolled.

Bauerhaus (2004) studied 7,600 randomly selected direct care registered nurses

within the United States utilizing forced responses in answering questions related to the

main reasons for the nursing shortage in hospitals. The responses were:

(a) Lack of qualified students pursing nursing as a career (12%)

(b) Fever applicants admitted to nursing schools (8%)

(c) Negative perception of the health care work environment (15%)

(d) More careers for women (32%)

(e) Salary and benefits (41%)

(f) Undesirable hours (27%)

(g) Nurses do not have as much help to support their household (1%)

(h) Nursing not a respected profession (17%)

(i) Faculty shortages in nursing schools (11%)

(j) Nursing not seen as a rewarding career (26%) (p. 65)

To counter those responses, common strategies most often agreed upon by nurses which

they felt would help solve the shortage were:

(a) Programs to encourage people to enter the field of nursing

 (b) Higher status of nurses in the hospital

(c) Improved working environment,

(d) Increased capacity to educate and train nurses (p. 68).

Conclusions were that the effect of the national shortage and perceived outcome upon the

future of nursing would lead to:

(a) Increased stress for nurses

(b) Nurses leaving nursing for other jobs

(c) More respect for nurses (p. 69).

Knox, Irving, Annalee, & Gharrity (2001) reported several factors affecting the

supply of professional nurses in their research:

(a) Changing trends and desires of those seeking nursing as a career

(b) Economics and social trends related to women‟s career and work desires

(c) Changing nature of work/professional nurse choices

(d) Enrollments and completions in nursing education programs

(e) Optional choices within and outside of nursing

(f) Aging nursing workforce relative to the nature of the work

(g) Family patterns and generational expectations and norms (p. 116)

The researchers also offer that the supply of professional nurses available is

influenced by both short and long-term factors. Long-term factors relate to the supply of

professional nurses available in relation to changes in social preferences for nursing as a

career, the size of age cohorts from which prospective nursing students are drawn, the

capacity of nursing education programs, the length of time required to earn a nursing

degree, the supply of faculty, the changes in nursing wages, RN deaths, and requirements.
The specific skills and competencies along with areas of practice become important

variables in determining if the supply of nurses is adequate to meet the actual need.

Short-term factors related to the supply of professional nurses are related to decisions

based upon RNs practice, hours, shifts, types of settings, household factors, more

attractive employment options, and current stressors and difficulties related to work

situations. One strategy stressed is that higher professional competencies are necessary

to promote higher levels of professional practice (p.118).

The Health Resources and Services Administration Bureau of Health Professions

released the report “Projected Supply, Demand, and Shortages of Registered Nurses:

2000 – 2020 in 2002. It demonstrates that the shortage of full-time registered nurses

predicted to begin in 2007 was already manifesting itself in 2000. As predicted, in 2010

the nursing shortage would double from 6% to 12%, or 275,000 per the U.S Department

of Health and Human Services (Brush, Sochalski, & Berger, 2004, p. 78). If strategies

are not put into place to alter this growth, by 2015, it is expected that the shortage can

rise to 20% and to 25% by 2020 or 800,000 per the U.S Department of Health and

Human Services (Brush, Sochalski, & Berger, 2004, p. 78). Reiterating what has already

been noted is that the supply of nurses is diminishing because of decreases in the number

of nursing school graduates, decline in relative earnings, and the expanding menu of

alternative job opportunities (p. 19)

During 2004 and 2005, the reported top four reasons for the nursing shortage were

salary and benefits, more career options afforded to women, undesirable work hours, and

negative work environments (Baerhaus et al., 2006). Ironically, nurses who left the field

years ago are returning to the workplace because of financial, personal, and/or
professional needs (Hom, 2003).

The Socialization Perspective

Socialization is a process used to gain knowledge, skills, and behaviors in order to

participate as a member of a particular group (Hinshaw, 1977); one learns to perform his

various roles adequately, and is a process which continues throughout life (Kramer,

1974). Simpson (1979) reports that by accepting one definition of socialization which is

usually an official one often ignores unofficial socialization agents (p. 47). Socialization

agents can be found to be both formal and informal.

Kramer (1975) profoundly reports that any socialization may be totally congruent

or partially congruent. Congruent socialization is the ability and motivation to act on the

basis of value or belief system that matches one‟s behavior; specifically the internal

changes (beliefs and values) are congruent with the external changes which are specific

behaviors through which beliefs are translated into action. Incongruent socialization is

nay omissions of either value or behavior. The possibilities of manifesting this behavior

are: (a) an individual can subscribe to the values of a particular culture or subculture but

not to the behavior, (b) an individual can subscribe to the behavior but not to the values,

or (c) the individual can adopt neither the values nor the behavior (p. 38). She

summarizes that in congruent socialization, the attitudes and values will match the

behaviors taught, practiced, contending that in professional socialization, the goal is

toward both normative and behavioral changes. (p. 40).

Professional socialization in nursing involves initial socialization in the

educational setting, followed by a resocialization process in the work setting (Leddy,

1998). Furthermore, socialization is referred to as the continuing interactive life-long

process characterizing human development as well as professional growth (Ohlen, 1998),

and it is circular in nature, with many opportunities to exit and reentry (Kramer, p. 155).

The socialization process in nursing education involves both the modification of personal

values and internalization of professional nursing values (Martin, 2003), complimented

by induction of change in those being socialized, role transformation, and synthesis of

what is known into a more coherent and consistent behavioral pattern (Olmstead 1969).

Kramer (1974) stresses that although we usually think of community as an economic,

political, or physical aggregate; it is just as valid to think of the environment into which a

new graduate is immersed as a socialization community (p. 139).

Saarman, Frettas, Rapps, & Riegel (1992) agree that the outcomes pertinent to the

socialization into professional nursing by the AACN include:

(a)A linkage between the individual‟s motivation for entering nursing and the

development of professional behavior;

(b) A nursing perspective and related critical-thinking and problem-solving skills;

(c) Mastery of the knowledge and skills of the profession; identification with and

commitment to the profession (p. 27)

They also point out that internalizing the values, traditions, and obligations of the

profession is perhaps the most difficult outcome to achieve amidst the multitude of

factors which affect socialization including educational institutions, faculty, classmates,

friends, professional colleagues, and other health care professionals (pp. 27-28).

Olmsted (1969) wrote about the professional socialization of medical students.

He proclaimed that medical school socialization is preparatory. It serves to provide the

student with additional attitudes, norms, and values. He also highlight that professional
socialization elaborates or embellishes those attitudes, norms, and values which preexist

(p. 665). Kramer (1974) points out that the physician (just as the nurse), is likely

socialized by patients; learning appropriate performance behaviors in the practice arena

on their own, within interactions with patients, and within day to day practice (p. 667).

He asserts that while childhood socialization is directed to the learning of values, adult

socialization focuses on the learning of behaviors (p. 664).

Eruat (1994) reports that to be a profession, several modes of training and

preparation makes a distinctive contribution to the students‟ knowledge base and to his or

her socialization into the occupation. They include:

(a) A period of pupilage or internship

(b) Enrollment in a professional college outside the higher education system

(c) A qualifying examination, normally set by a qualifying association for

the occupation

(d) A period of relevant study at a college or university leading to a recognized

academic qualification

(e) The collection of evidence of practical competence (p. 6).

Clouder (2003) argues that professional socialization is a process through which

individuals are socially constructed and largely shaped into conformity (p. 220). He

suggests that “the game” is prescribed by the profession, and those who wish to join that

profession need to adapt accordingly to gain membership (p. 220). He goes on to say that

as the newcomer internalizes the values and beliefs of the profession, they actually

become subject to social control at an unconscious level. Also a profession exists as a

powerful structural reality in which newcomers are subjected to a process of being

molded into “good” professionals, which is fundamentally disempowering (p. 215). He

enlisted a convenience sample of 12 occupational therapy students in a 3-year

longitudinal study to explore changes in personal and professional identities utilizing

taped interviews. Insisting that by exploring professional socialization in terms of its

capacity for structural determinacy and for individual agency provides a better

understanding of how individuals construct their profession, which, in turn, constructs

individual professionals (p. 220). Interestingly, he draws upon the notion of education as

an intentional socializing agent, while the profession can be both a constraining and

enabling force for the newcomer to professional life (p. 216).

Simpson (1967) asserts that socialization of an adult into an occupational role

occurs in three sequential phases. She reports that as a person is socialized into a role he

learns it‟s cultural (skills, knowledge, and ways of behaving) content and also acquires

self-identification (internalization of values and goals) with the role. In phase one,

socialization into the profession occurs with transformation toward proficiency of

technical tasks of the profession. In phase two, socialization into the profession occurs

with the acceptance by colleagues of the main referent group. In phase three,

socialization occurs when there is internalization of the values and behaviors of the

occupational group (p. 47). That is when the profession becomes the dominant reference

group (p. 54). Aligned with the concept of autonomy, with internalization, the opinions

of outsiders become unimportant. It is important to recognize also that professional

socialization does not necessarily begin with entry into a professional school, but has its

roots in the earlier experiences of the person which result in the decision to join a

particular occupational group (Jacox, 1973).

 Simpson (1979) further explores that cognitive occupational orientation may be

consistent with professional school, or may take another direction consistent with

other influences. She reports that the school prepares students to:

(a) See service as the performance of tasks that apply specialized knowledge

(b) Uphold the professional group as the definer of its service and the

developer and/or specifier of appropriate knowledge

(c) Uphold a conception of the professional role that gives the practitioner

authority to make and execute decisions consistent with the

occupation‟s knowledge

(d) Uphold the profession as the regulator and judge of professional conduct (p.

30).

She also makes the point that the first and third (a & c) direct attention to how students

are expected to behave. Additionally, this orientation is unique with regard to nursing

because nursing is differentiated horizontally by work setting and function, and vertically

by type of educational certification, degree and scope of authority vested in work

positions, routes of access to work positions, and prestige and other rewards of work (p.

31).

Larsen, McGill, and Palmer (2003) surveyed 11 nursing programs in the Southern

Piedmont Area Health Education Center region of North Carolina. The 11 programs

were inclusive of 2 baccalaureate programs, 7 associate programs, and 2 diploma

programs for a total of 495 participants. The questions addressed were: 1) factors about

the nursing profession that influenced the student‟s decision to become a nurse and, 2)

general factors that influenced the student’s decision to become a nurse. In this study,
the researchers did not attempt to correlate the students‟ choice of enrollment in a

particular type of nursing program. The characteristics about the profession that attracted

the students demonstrated little variability by program type and were: care and concern,

job security, variety of work settings, autonomy, and prestige of the profession. The top

three influencing factors as to why students decided to become nurses were practice

related. Students from all programs identified the reasons as: past experience with a

loved one or self being ill/or hospitalized, past work experience, and having a family

member or friend who was a nurse. Other comments that were conveyed were: helping,

religious, variety/flexibility, security, money, and childhood dream. These students had

some pre-conceived perspectives about nursing from their individual experiences. It is

evident in this survey that practicing nurses make the difference in the attraction and

retention of the nurse pool for the profession. The socialization process becomes a

crucial factor for building upon the experiential base as well as the educational base of

nursing students and practicing nurses. To address the resocialization process,

knowledge of what attracted one to a profession oftentimes is the key to retention

strategies.

Cook (2003) asserted that professional identity is a developmental process, which

evolves throughout a professional nurses‟ career, and identity is foundational to

professional nursing practice (p. 311). His interest was in understanding how students

perceive and define professional identity. Data was collected from (N=109) beginning

nursing students on the first day of school utilizing an open-ended question: What is your

definition of nursing? Statements were formulated which described their understanding

of professional nursing. Three major themes were compiled from their definitions of
nursing and reflected nursing as a verb, noun, and transaction (reciprocal process). The

findings reflected 45% of the definitions for nursing as a verb (teaching, advocating,

collaborating, referring, caring, educating). Nursing defined as a noun (nursing is a

profession, a career, nursing is a helping profession based on holistic and scientific

theories related to health and illness) accounted for 33% of the definitions. Nursing

defined as a transaction (helps clients achieve as healthy a life as possible, helping the

patient meet his or her health care goals) accounted for 22% of the definitions. The

author concluded that nurses who have developed a firm professional identity are more

flexible when faced with role changes (p. 315). This study supports the importance of

understanding why students choose nursing as a career, and displays their beginning

attitudes toward the nursing profession. More importantly, attention to professional

socialization in the early stages is a key factor to professional development regardless of

program type.

Secrest (2003) infers that an important process in any profession is the

development of professional identity (p. 77). From a sampling of baccalaureate-prepared

students, a written descriptive response was elicited to the statement: Think of a time in a

clinical setting when you felt professional as a nurse. Three themes emerged that were

grounded in the experiences from the view of self and others. The theme of “belonging”

was grounded in being a valued part of the nursing team. The theme of “knowing” was

grounded in having the ability to be informative. The theme of “affirmation” was an

experience grounded in professionalism during interactions with others and in terms of

the external validation received from others. Interestingly, the author drove home that

the process of socialization says little about what it is like to be professional. The
development of a sense of professionalism within educational programs is as equally

important as the knowledge and skills (p. 81).

Ohlen (1998) through interviews and related literature review conceptualized the

professional identity of the nurse within personal and interpersonal dimensions. He

conducted semi-structured interviews with (N=8) nurses concerned with the development

or lack thereof in the professional identity of nurses in Sweden. He offered that the

personal dimension of professional identity refers to the individual nurses‟ professional

identity and encompasses the commonality of the nursing profession and to the special

way the nurse utilizes this commonality within the profession. The interpersonal

dimension of professional nurse identity is developed through sources such as: interaction

with other nurses, internalization of knowledge, skills, values, culture of the nursing

profession, and socialization (p. 721). The nurse exists on a maturity continuum

exhibiting professionalism or professional self-image development between strong and

weak professional identity. Thus, indirect knowledge of a nurse‟s professional identity

may be gained by studying their professional self-image (p. 725).

French (1994) searched for the answer to the question: Why did you choose

nursing as a career? One hundred and fourteen Pakistan nurses participated in a survey

designed to determine the reasons they chose their occupational path. These were urban,

highly educated women that were not representative of the average women in the

population. Their top response was “professionalism” followed by “control own

destiny”. The reasons given that followed were altruism, self-interest, and family

influence. French concluded that occupational choice may be viewed as a decision

making process involving a series of compromising, balancing interests, preferences,

attitudes, and capabilities against available opportunity (p. 141).

Leddy (1998) states that an individual‟s personal characteristics influence the

professional characteristics exhibited. The personal self-system and the professional self-

system demonstrate a reciprocal relationship in which both are always open to change in

relation to constraints or opportunities experienced by the person (p. 115).

Research supports the assertion that collegialism in nursing is further weakened

by differentially valued kinds of training programs. The program remains the chief

influence on orientation to the occupational role throughout professional education.

(Simpson 1979, p. 33, 35).

Essentially, professional identity can be viewed as a predecessor to

professionalism as the very behaviors and attitudes that are embraced by a student or

member of the profession become the basis for their professional transition into practice.

The most reliable method in which to understand the manner in which practicing

registered nurses in South Texas exhibit professional behaviors is to ask them because

professional identification or commitment is a crucial ingredient in the profession‟s

survival (Miner, Crane, Vandenberg, 1994, p. 89). Socialization can be viewed as an

interactive process between individual processes of learning, development, and

environmental influences (Leddy, 1998).

Kramer (1974) summarizes the following principles from the study of theories on

adult socialization:

(a) To become functional in the adult occupational world, one must be

congruently socialized into the values and corresponding role-specific

behaviors
 (b) Professional socialization contains many elements of childhood socialization

emphasizing “shoulds” and role-general behaviors.

(c) Because there is little plan for guided role transformation in school,

socialization into role-specific behaviors occurs after graduation. This role

transformation, occurring concomitantly with adult socialization, is frequently

unguided and unexamined

(d) Socialization consists of both internal and external changes in an individual

(pp. 42-43).

Additionally, Du Toit (1995) writes that: professional normative standards are

learned on a formal level (for example, at a university) and at the informal level (during

the process of professional socialization and contact with the peer group, as well as

informal sanctions), while Bonito (1975) indicated that the socialization perspective was

not the sole explanatory model to account for the formation of professional attitudes in

medical students (p. 22).

Professional Development

The nursing profession holds the majority membership in the field of health care

professions yet nurses continue to be cast into subordinate roles within professional

relationships despite possessing unique but analogous knowledge, credentials and

professionalism (McKinnon, 1999). The American Nurses Association is a strong

proponent for the professional development of nurses as a lifelong process of actively

participating in learning activities which assist in the development and maintenance of

continuing competence, enhancement of professional practice, and support in the

achievement of career goals (p. 4). Levett-Jones (2005) proposes that investing in
continuing education of nurses demonstrates not only that quality education results in

enhanced knowledge and skills, but that there is also a positive correlation between

professional development and factors such as staff satisfaction, staff retention, and

quality patient care (p. 229).

Professional schools are responsible for the education of students who will be

skilled and committed to perform in their chosen profession. With much attention

focused on nurses and the nursing profession, nurse‟s self-evaluation of their

contributions toward personal and professional growth is needed (Heath, 2001). Simpson

(1979) states that schools control the inflow of labor into its parent profession by

selection of persons to be admitted to the profession; education in professional

knowledge and skills; and instillation of appropriate professional orientations (p. 17).

Fitzgerald (1992) offers another perspective in the assessment of professional

socialization when he purports that “without significant attention to personal and

professional development, there is a limit on the ability of meet the demands of change”

(p. 84). He defines training as: the acquisition for knowledge and skills for present tasks,

a tool to help individuals contribute to the organization and become successful in their

current positions (p. 81). He defines development as: the acquisition of knowledge and

skills that may be used in the present or the future, the preparation of individuals to

enrich the organization in the future, and the act of being involved in many different

types of training activities and classes (p. 81). Eraut (1994) writes that the initial period

during which novice professionals develop their proficiency in the general professional

role continues well beyond their initial qualifications (p.11).

Heath, Andrews, & Graham-Garcia (2001) assessed professional development

characteristics among critical care nurses to determine the level of involvement in

professional opportunities and the perception of factors which influence professional

development. The questionnaire was based on “anecdotal” professional characteristics of

nurses who continually enhance their role as nurses based on these questions:1) level of

involvement in professional development activities, and 2) about factors which

influenced professional development (p. 20). They surveyed (N=100) participants at a

regional conference. The results indicated that critical care nurses exhibited high levels

of professional development in the areas of education, certification, and membership in

professional nursing organizations. The author notes that surprisingly the level of

involvement with professional nursing organizations, promotion of nursing peers, and

participation in scholarly activities was less than expected. Factors which were most

influential in professional development accounted for only 4% of the responses: self-

motivation, nursing facility, and nursing peers in clinical setting. Factors which on an

average influenced professional development accounted for 24% of the responses:

nursing preceptor or mentor, nursing peers in education, nursing peers in professional

organizations. Factors which were least influential in professional development

accounted for 72% of the responses were: employing agency, nursing peers in

administration, others not in nursing. Dealy and Bass (1995) assert that one of the most

influential factors for professional development was socialization with colleagues.

Professional development is then a continual process among nurses occurring throughout

a nurse‟s career.

Fitzgerald (1992) asserts that development differs from training in that it does not

occur during a class but that real development is the outcome of what happens after the
class. Minor, Cran & Vandenbert (1994) also report that professional training is a means

by which jobs are learned; while on the job training serves as a means of professional

development for career development. No matter what the profession, the obvious

validation of such development is a change in the knowledge base, skill level, attitudes,

or behaviors of the person or group.

Leddy (1998) purports that all developmental theories are based on the

assumption that human growth and development is sequential and that successful

negotiation of earlier developmental tasks is critical to the negotiation of later

developmental tasks (p. 102). In Table 3, a correlation is made between Leddy (1998)

tasks and goals in professional development to Erikson‟s stages of the life cycle. The

degree of achievement of each goal in each stage of professional development influences

what the person as a professional is like (p. 102). This model strongly correlates with

Hall‟s Professionalization Model (1968) in defining how occupations move along the

professionalization continuum in their development toward professionalism.

Ducheny, et al. surveyed psychology graduate students (N = 593) to assess

personal development in the areas of statistics and research, theories of behavior, and

ethics. They offer a definition of professional development for psychology as:

professional development is an ongoing process through which an individual derives a

cohesive sense of professional identity by integrating the broad based knowledge, skills,

and attitudes within psychology with one‟s own values and interests (p. 4). Elman (2005)

adds that professional development is a broad, albeit vaguely defined construct that

underlies psychologists” education and training and is intrinsic to professional

functioning, or professionalism (p. 367). This definition is adaptable to nursing, other

disciplines and occupations.

Expounding further upon training versus development, Fitzgerald (1992) warns

that without significant attention to personal and professional development, we limit our

ability to fulfill more demanding expectations in the future (p. 84).

Table 2
Comparison of Erickson‟s Stages of the Life Cycle and the Leddy Professional
Development Cycle

STAGE TASK PROFESSIONAL GOALS

DEVELOPMENT

Infancy Trust Beginning Professional - Develop abilities to fulfill professional role

Orientation through mentors, guides, and teachers

Childhood Autonomy Beginning Professional – View self as autonomous in practice some

Post Orientation of the time, a professional in one‟s own

right, depend on more mature professionals

for guidance some of the time

Initiative Young Professional – Independently anticipate professional role

Moving into responsibility while being held accountable

Independence for own actions

Industry Growing Professional – Experience Competence in independently

Developing Expertise performing tasks of the profession while

expanding knowledge of nursing

Adolescence Identity Professional with own Competent in role as a professional nurse,

Identity commitment to the profession

Adulthood Intimacy Maturing Professional Independent professional who can develop

collaborative relationships with clients,

peers, and other colleagues

Generatively Productive Professional Professional role which is productive for

self and others while contributing to society

through education, practice, and research

Integrity Older Professional Accomplishment of oneself and others in

professional pursuits
Professional Socialization

The outcome of professional development is in the continuity of attitudes and

behaviors as an individual moves along the socialization continuum from role to role, and

organization to organization. Nurses have developed professional identity through

professional socialization (Moloney, 1992).

Kramer (1974) abstracts the following principles from theories of adult and

professional socialization:

(a) To become functional in the adult occupational world, one must be

congruently socialized into the values and corresponding role-specific

behaviors.

(b) Professional socialization contains many elements of childhood socialization,

emphasizing “shoulds” and role-general behaviors.

(c) Because there is little plan for guided role transformation in school,

socialization into role-specific behaviors occurs after graduation, occurring

concomitantly with adult socialization, and is frequently unguided and

unexamined (p. 42).

She urges that adult socialization focuses on the learning of behaviors which in turn can

be associated with the reality of why nurses leave nursing.

Simpson (1979) explains that there are three requirements which are necessary

during professional education to lay the foundations for occupational behavior from

training to work arenas. These requirements are:

(a) Enough cognitive preparation for a person to perform the role

(b) Orientations that inform a person‟s perception of demands of the role and
 behavior to meet the demands

(c) Motivation sufficient to make the transition from one situation to another (p.

13).

She concludes that socialization is commonly conceived as learning the behaviors, skills,

and outlooks that prepare one to perform in a role and specifically makeing the individual

the significant unit in the process with the outcome seen as evidence of how well the

learning has succeeded (p. 226).

Clark (2004) explored the differences in professional socialization between

graduating students of two-plus-two baccalaureate completion nursing programs and

generic baccalaureate nursing programs in a 15-state region of the United States. It was

concluded that no significant difference was found between the levels of professional

socialization of graduating students from the two types of programs (p. 346). Martin

(2003) concluded that no differences existed in professional values of graduating students

attending ADN and BSN nursing programs in Texas. Significant differences were found

on five subscales: right to privacy, assumes responsibility and accountability, exercises

informed judgment, implements and improves standards of nursing, and collaborates with

others (p. 295).

Heath, Anderson, & Graham-Garcia (2001) studied the professional development

characteristics of critical care nurses (N-100) who were in attendance at a regional

conference of the Association of Critical Care Nurses. Within the study population, 73%

were members of at least one professional nursing organization, 76% reported a high

level of passion about nursing and promoting the profession, and 72% reported

agreement with fostering individual professional development. Of those respondents,

28% held a diploma or associate degree, 38% held a bachelor‟s degree, and 34 % held a

master‟s or higher degree (includes a bachelor‟s degree).

Entry Level Into Professional Practice

Professional disciplines are defined by the educational degree required to practice

however, nursing is not one of those disciplines (Kidder, 2006, p. 15). Entry-level

practice relates to the education an/or training required to qualify a person to practice in a

certain field, occupation, or profession however, Lannon (2007) suggests that basic

nursing education, whether in a baccalaureate degree, associate degree, or hospital-based

program, prepares the novice to take a nationally certified examination that validates his

or her entry-level knowledge (p. 18). Education has always been an issue of contention

in nursing (Al‟aitah, Cameron, Armstrong-Stassen, & Horsburgh, 1999). There are three

different levels of education today in which students seek entrance into the nursing

profession. The two to three-year diploma programs although still available, have

become the least sought after program today because traditionally nurses worked and

lived in the hospital for which they earned a diploma. The two-year associate degree

program and the 4-year baccalaureate remain the most popular programs today. Both

programs prepare the nurse for roles within a hospital setting. The two-year associate

programs are offered in a junior, community, or university settings and offer entrance

into professional nursing for a shorter program commitment. The four-year baccalaureate

program is offered by colleges and universities and is designed to prepare the

professional nurse for leadership in clinical, educational, or administrative practice.

North Dakota was the only state that was successful in changing their nurse

practice act for the approval of only baccalaureate programs being the approved
educational level for licensure as a Registered Nurse (Nelson, 2002). There has been a

wave of nurses who have chosen to obtain the associate degree. One explanation is that

although associate degree programs have been increasingly available, there has been a

shift toward older students and males choosing nursing as a first or second career. The

decision about which program to enroll into depends on many personal factors. The

literature cites a number of gender barriers for men in the nursing education process,

mainly due to feminization of this process and the profession (Sherrod, Sherrod, &

Rasch, 2005).

Approximately 17.5% of all practicing American registered nurses receive their

initial professional preparation in diploma programs, 34% in associate degree programs

and 34.2% in baccalaureate programs, while 55.4% of Registered Nurses who obtained

their nursing education within the past 5 years, graduated from associate degree

programs, 38% from baccalaureate degree programs, and 6% from diploma schools

(Department of Health Human Services, 2006). However, when the perspective shifts

from initial entry preparation to that of educational preparation achieved over a lifetime,

a different picture is evident (D‟Antonio, 2004).

Rambur, Mcintosh, Palumbo, & Reinier (2005) convey that Nursing is an

anomaly among major professional workforces outside of health care in that graduates of

hospital-based diploma programs, 2-year associate degree programs, an 4-year

baccalaureate degree programs are equally accepted for a single licensing exam, and in

turn, serves as the basis for entry and employment into the profession with little

differentiation in pay or assignment (p. 185).

Chaska (1978) in examining nursing as a profession recommends that nurses who

are technically oriented should continue to be concerned with the routine prescribed

management of patient, judged from the perspective of efficient and effective

management of procedures. Nurses who are professionally oriented should develop the

understanding and ability to use the scientific method as a basis for the nursing process.

She states that some nurses may be proficient in both areas, but if there is no commitment

to maintain a broad knowledge base, the profession is in jeopardy (p. 8). It could be

argued that all professional nurses then and even more today should possess the ability to

answer this call as they work side by side within work environments and professional

endeavors.

Auerbach, Buerhaus, & Staiger (2000) findings suggest that the rapid aging of

the RN workforce can not be directly attributed to the rise in the number of older-aged

graduates of associate degree programs (p. 178). They surveyed the National Sample

Survey of Registered Nurses as the principal source for demographic, employment, and

educational data on all licensed to practice as an RN in the United States. The

explanation given was that associate degree programs have become increasingly

available, and this has drawn students to these programs. An alternative explanation

offered was that the 2-year programs are more popular with older students, ant these

programs make it easier for women in mid or late career to become nurses. In sum, the

authors report that although the nursing profession may have lost much of its appeal to

other careers from the perspective of a college bound 18 year-old, it remains a good

option for women in their late 20s and 30s who may find the 2-year associate degree

program an enticing entry into a new career (p. 184).

Giddens (2006) reports that her study of (N=96) registered nurses employed in
direct patient care at a large university-based health care facility in the southwestern

United States yielded more questions than answers. She found that in her assessment of

the frequency of physical examination techniques by BSN and ADN prepared nurses was

not influenced by education or years of experience (p. 138).

Although beyond the scope of this study, Kidder & Cornelius (2006) offer yet

another perspective to the multilevel entry into nursing practice. They suggest a goal for

nursing to attain by the year 2015 is to secure a 1 entry level into professional nursing

practice. They suggest that in order for registered nurses to be recognized as

professionals, and earn the status they deserve from other professions is to mandate one

entry level (p. 16).

The profession of today is faced with the challenge to produce a registered nurse

workforce that reflects the diversity of the population we serve (Sherrod, Sherrod, &

Rasch, 2005), and to foster a community of members competent in practice. Education

has a positive effect on the knowledge and competencies of nursing practice (Domino,

2005), and the hallmark of professional nursing has been baccalaureate nursing (BSN)

education (Clark, 2004, p. 347).

Competency

Farren (1997) asserts that in every profession, you need certain competencies to

be successful (p. 115) while Bradshaw (1998) reports that competence is developmental

and has to be linked to lifelong learning (pg. 105). Competency is defined as effective

demonstration by the time of graduation, of knowledge, judgment, skills, and

professional values derived from the nursing and general education content (BNE, 2002).

The Texas Board of Nurse Examiners purports that the curriculum of each nursing
program differs resulting in differentiated entry-level competencies. Educational

preparation for RN licensure examination may be obtained through diploma, associate

degree, or baccalaureate degree programs each providing the necessary preparation for

practice as a registered professional nurse and is approved by the BNE. However, the

curriculum of each type of nursing program differs, resulting in differentiated entry-level

competencies for graduates who will eventually work side by side in nurse practice

environments (p. 19). The 14 differentiated entry-level competencies address knowledge,

judgment, skills, and professional values from the nursing and general education content

expected of entry-level nurses as nurses who have been in practice and progressed

beyond the novice level are not affected (p. 20). The competencies describe statements

addressing: provider of care, coordinator of care, and member of profession. Sarp (2005)

defines competence as: the habitual and judicious use of communication, knowledge,

technical skills, clinical reasoning, emotions, values, and reflection in daily practice, for

the benefit of the individual, and the community being served (p. 227).

Waters, Chater, Urrea, & Wilson (1972) attempted to document the differences in

practice of graduates of associate and baccalaureate degree programs. Utilizing

structured interviews, data was obtained from twelve directors of nursing and twenty-two

head nurses from twelve hospitals. The purpose was to examine three aspects of practice:

(a) the nature of problems practitioners solve and characteristics of the decision-making

process, (b) scope of practice, and (c) attitudes of the practitioner toward their practice.

The two groups of managers were asked to describe any perceived differences in the

practice of the types of nurses. All of the head nurses reported differences in the practice

between the two types of nurses. All except two directors of nursing reported

differences
between the two types of nurses. They concluded that baccalaureate-prepared nurses

acted independently in their approach to the solving of patient problems. The overall

differences reported between the groups were: identification of problems, taking

initiative, and problem solving approaches.

Ongoing competency assessment of the knowledge, skills, attitudes, and

behaviors reflective of the new nursing functions must be evident in nursing practice.

Kelly (2002) points out that to graduate competent professional nurses, competence in

practice and teaching are essential requirements for faculty and the problem arises when

there are too few faculty who are educated as teachers, let alone experienced as teachers

of nursing (p. 24).

Attitude Development Perspective

Studies on attitudes have shown a high correspondence between the attitudes

measured and the behavior of the respondents (Monnig, 1978). Remmers (1959) defined

attitude as an affectively tuned idea or group of ideas predisposing the individual to

action with reference to specific attitude objects (p. 24).

Ajzen and Fishbein (1980) in their efforts to understand attitudes and the

prediction of social behavior proposed that a person‟s attitude about a behavior is

determined by his or her salient beliefs about the behavior or attitude as a function of

beliefs. According to their Theory of Reasoned Action (TRA), only salient beliefs, that

is, those which are uppermost in one‟s mind are determinants of attitude. In the theory,

attitude is determined by and individual‟s belief that a given outcome will occur if he or

she performs a behavior along with the individuals evaluation of the outcome f

performing the behavior (pp. 6-7)

 Morrison (2002) utilized Ajzen and Fishbein‟s TRA to model the intentions

toward use, and actual use of marijuana in a sample of adolescent mother‟s. TRA

predictors for marijuana use were attitude, perceived social norm, outcome, and intention.

The importance of understanding the attitude toward performing this health threatening

behavior and the perceived social implications of the participants was utilized to design

interventions that could be useful to change their beliefs: therefore their attitudes about

the risk. This was a longitudinal study to assess pregnant and parenting adolescents

(N=241) for correlates of drug and alcohol use. The findings were that attitudes about

using marijuana were based largely on an expected positive outcome; belief that

marijuana reduced stress, belief that marijuana would help them fit in. Prior use was seen

as predictor of current use (p. 12). The importance of understanding professional attitudes

toward performing professional behaviors in a sample of nurses in South Texas can be

utilized to design interventions that could be useful in enhancing members‟ professional

status.

Lima-Basto (1995) states that a person‟s attitude towards a behavior is his or her

positive or negative evaluation of the performance of that behavior whereas the attitude is

the function of their belief that the behavior leads to certain outcomes (p. 3).

Professionalism then includes accountability and autonomy for personal actions meaning

that the nurse is answerable for their own behavior (Leddy, 1998). At this crucial

juncture, the ability to influence behavior must be viewed with respect to the foundations

of professional and attitude development.

Werner (2001) studied nursing staff members (N=303) from an 800-bed hospital

in Central Israel in the examination of nursing staff members attitudes, subjective norms,
moral obligations, and intentions to use physical restraints for elder care. A questionnaire

designed to measure the variables of: intention, attitude, subjective norm, and perceived

behavioral control) by the Theory of Reasoned Action. They concluded that personal

attitudes were the main determinants of intention to use physical restraints with older

people suggesting that personal beliefs were more influential than the opinions of others

(p. 7).

Hemsley-Robinson (1995) examined nurses (N=65) from a 1,100-bed hospital in

South Atlanta about their attitudes toward cost-effectiveness from stratified educational

preparation (diploma, associate, or baccalaureate degree). The nurses sampled were from

the intensive care and operating room areas. The attitude scale utilized was the

Blaney/Hobson Nursing Attitude Scale. In light of this small convenience sample, nurses

displayed positive attitudes about cost-effective nursing practice. The intent of this study

was to assess nurse‟s attitudes toward cost-effectiveness issues before involving them in

cost-containment programs. The expected outcome was that all nurses demonstrate by

their behaviors an increase in economic accountability in their professional practice.

Baccalaureate nurses had the most positive attitudes toward cost-effectiveness with

associate nurses having the lowest.

Sarp (2005) examined the attitudes and behaviors of health professionals and

managers on time management utilizing the Time Management Inquiry Form in Turkey.

There were 143 medical managers and medical specialists from the State Hospital, Social

Security Hospital, and University Hospital. Four broad areas were assessed: hospital,

attitude and behavior toward time management, effective working hours, and time

wasting factors. It was determined that educational status and age did influence time
management attitudes. Work hours, managerial status, environment, perception of

having sufficient time, work schedules, day of the week, clearness of responsibility and

rights simply affected the time management attitudes. Working hours was not found to

be significant. Sarp stresses that although competency assessments during training years

reliably test core knowledge and basic skills, what may be underemphasized is the

important domains of professional practice such as interpersonal skills, life long

learning, professionalism, and integration of core knowledge into clinical practice (p.

229).

Kaplan (2000) demonstrated that 80 of the 87 Icelandic occupational therapists

demonstrated high levels of professionalism. The survey explored possible differences of

opinion between therapists in regard to attitudes toward professionalism with respect to

background variables such as level of education, professional experience, and country of

education. One-way ANOVAs were used for comparisons by professional experience

and country of education, and T-tests were uses when comparing the means of attitudes

toward professionalism by educational levels (p. 69). Similar to nursing, the majority of

therapists were female. The most common educational level was a diploma (83%),

studying for a Masters degree (9%), and Masters prepared (7%). The data showed that

baccalaureate/masters therapists, and masters students were prepared to commit

substantial time to the advancement of their profession, considered themselves leaders in

their field, read professional journals, held presentations at international conferences,

participated in international seminars, teach within the Icelandic curriculum with or

without supervision, than therapists holding a diploma. Ironically, therapists with twelve

or more years of professional experience (N=30) attested to having more influence on the

development of the profession and considered themselves leaders over those therapists
with less experience outside of levels of education.

Vogel (2007) shares a perspective about attitude in relation to the characteristic of

willingness. She asserts that:

Willingness relies on the authority of inner wisdom and critical

discernment to understand the implications of political and sociocultural “norms.”
Meaning and interpretation are bounded by cultural “norms”. Emancipative discourse
requires the capacity to imagine possibilities and reflect from the margins of mainstream
thinking. It also requires an attitude congruent with the notion of willingness (p. E75)

Osborn, Waerkerle, & Perina (1999) in their research on mentorship write that

attitude can be a supporter or a saboteur as it directs focus, defines character, and

encourages commitment. With a poor attitude, the focus is on difficulties. With a

positive attitude, the focus is on solutions. They urge the reader to commit to daily

improvement: spiritually, intellectually, professionally and embrace a personal standard

of excellence (p. 288)

Indicators of attitude have been operationalized by Hall (1968) and utilized by

numerous researchers (Chan, Chan & Scott, 2007, Green, 2006, Chisholm, et al., Cohen

& Yardena, 2004, Wynd, 2003) to describe the professionalism of members in various

professions. Five operational definitions of concepts serve as indicators of the concepts

for attitudes toward professionalism. The sum of the five items in each concept

(dimension) will be utilized to measure the position of agreement or disagreement by the

score of the respondent. Chan, Chan & Scott (2007) report that Hall” Professionalism

Scale lacks the ability to capture the true behavioral dimensions of professionalism but is

well established in reflecting identification with professionalism attributes (p. 1014).

Hall (1968) five dimensions with the sixth dimension added by Schack and Hepler (1979)

are utilized in this study to indicate:

 1. Use of the professional organization as a major reference means that the
professional organization and the members of the profession serve as the
major resource of ideas and judgments for the work of the individual
professional.
2. Belief in service to the public means that the profession is regarded
as being indispensible to society by the professional,
3. Belief in Self-Regulation means that the work of the professional can
and should only be judged by members of the profession because of their
inherent qualifications.
4. Sense of Calling to the Field means that the professional is dedicated to
the work of the profession and would desire to be a member of the
profession even if the rewards were decreased.
5. Autonomy means that professionals should be knowledgeable and skillful
in making decisions and judgments about their work.
6. Continuing education means that the professional believes that, in order
to maintain an adequate level of competence and to remain abreast of new
concepts, he must accept personal commitment to continually extend
professional knowledge (pp. 98-99).

Wilson, Lindsey & Schooler (2000) argue that new attitudes can override, but not

replace, the old one resulting in dual attitudes. Dual attitudes are defined as different

evaluations of the same attitude object being implicit (automatic attitude not requiring

cognitive capacity nor motivation for its activation) and explicit (and attitude that is not

automatic and requires more capacity and motivation to retrieve). Interestingly, an

example correlating what the authors suggest that the attitude-behavior relationship is

likely to depend on the type of attitude involved (implicit or explicit) and the type of

behavior involved (implicit or explicit) that the same individual can have both attitudes

which will predict different kinds of behavior. (p. 33). The nurse with the implicit

attitude that strongly agrees with the use of the professional organization as a major

referent will probably read professional journals, join professional organizations, etc. or

is unlikely to construct a new attitude that is contradictory (p. 30). The nurse with the

implicit attitude that strongly disagrees with the use of professional organization as a

major referent will probably not engage in behaviors to change that attitude or the
evaluation constructed will be the only attitude (p. 30). The authors suggest that for a

dual attitude to exist, an implicit attitude has to be weak enough so as not to prevent the

construction of a new attitude but strong enough to persist after the construction of the

new attitude (p, 30) or in the case of the nurse with the neutral or moderate implicit

attitude.

Theoretical Basis for Behavior and Behavioral Change

A single change in behavior can be one of the most difficult things we as humans

(nurses) have to do, however, change will be much easier if seen clearly as to how the

change will help achieve shared successes and benefits to you, your organization

(Broscio, & Scherer 2003, p. 10), and nursing as a profession.

Gruber (2003) in her case study on the cognitive dissonance theory makes the

point that in order to create lasting change, it is believed that a change in attitudes,

beliefs, or values may be necessary suggesting that changing of behavior ultimately will

lead to a change in attitude (p. 243). Values define appropriate and inappropriate

behavior, and while social norms and values regulate and help channel behavior by

defining certain goals and means of attaining them (Taylor & Field, 1997, p. 93).

Fishbein, et al., (2001) dissected five theories of behavior in the identification of 8

variables which appear to demonstrate why a person (nurse) performs or doesn‟t perform

a given behavior:

(1) The person (nurse) has formed a strong positive intention (or made a

commitment) to perform the behavior.

(2) There are no environmental constraints that make it impossible for the

(nurses‟) behavior to occur.

 (3) The person (nurse) has the skills necessary to perform the behavior.

(4) The person (nurse) believes that the advantages of performing the behavior

outweigh the disadvantages; in other words, the person (nurse) has a positive

attitude toward performing the behavior.

(5) The person (nurse) perceives more social pressure to perform the behavior

than not to perform the behavior.

(6) The person (nurse) perceives that performance of the behavior is more

consistent than inconsistent with his or her self-image.

(7) The person‟s (nurse‟s) emotional reaction to performing the behavior is

more positive than negative.

(8) The person (nurse) perceives that he or she has the capabilities to perform the

behavior.

In order to demonstrate the value of being a professional, and establish a

professional climate, nurses must engage in professional behaviors (Eagelson, 2001).

Fishbein, Triandis, Kanfer, Becker, Middlestadt, & Eichler (2001) performed some

extensive research on multiple theories of behavior, behavior change and referenced the

Theory of Reasoned Action in their behavioral research on victims of Auto Immune

Deficiency Syndrome (AIDS).

According to The Theory of Reasoned Action, performance or nonperformance of

a given behavior is primarily a function of the person‟s intention to perform (or to not

perform) that behavior. The intention is viewed as a function of two primary

determinants: the individual‟s attitude toward performing the behavior which is based on

their beliefs about the consequences in terms of costs and benefits of performing the
behavior, and their perception of the social (or normative) pressure exerted on them to

perform the behavior (Fishein, et al, p. 4). It is plausible that the assessment of

professionalism will vary along a continuum among members in the profession where the

manifestations of weak to strong attitudes are evident in the display of certain

professional behaviors. The stronger the intention of the nurse to exhibit professionalism,

the more likely they will display professional behaviors. The authors further assert that

individuals will not form a strong intention to perform a behavior unless they first believe

that behavioral performance will lead to more positive than negative outcome and/or they

believe that they have the skills and abilities necessary to perform that behavior (p. 5).

Although personal characteristics of nurses vary from population to population, by

training nurses who function differently as “member of the profession” can impact not

only the individual members‟ strength of intention, but ultimately upon the value

associated with the professional behavior by other nurses. In addition to the social

pressure created by individuals‟ perceptions (or beliefs) that specific referents think they

should or should not perform a given behavior, their behavior is often also influenced by

the behavior of others (Fishbein, et al, p. 12).

Stern (2006) also emphasizes that in the pursuit of the highest ideals of

professionalism, medical educators are bound to: set clear expectations for behavior,

design meaningful experiences that promote professional values, and apply robust

behavioral outcome measures across the continuum of medical education and practice.

In critical reflection, the act of learning is nothing more than a change in attitude

and behavior, which begins with a change in an individual‟s frame of reference; an

intrinsic process that stimulates an individual to question ingrained perceptions about

interpretation of and response to various situations and question such examination by

others (Domino, 2005). The overall goal to increase the professional behaviors among

members within the profession will in turn increase the professionalism within the nurse

professional or the normative group as a whole.

Some nurses will be reluctant to change as these nurses‟ performance will be

guided by the skills, (Domino, 2005) and attitudes they possess. Change ultimately will

shape individual and collective attitudes and perceptions necessary for lifelong learning

and eventually, for more successful nursing performance (Domino, 2005), and practice.

Porter-O‟Grady (2003) reminds us that change must somehow enhance or improve the

work or the workplace as the direction change takes, its application in human experience,

and its impact are what humans (nurses) can influence and affect (p. 59)

Professionalization

Professionalization is viewed as a matter of power, a high degree of success in the

struggle for autonomy; the formation of a self-regulating community, and the altruistic

codes of conduct by such communities as part of their collective identity (Collins, 1979),

and results in the accrual of considerable power to occupational groups who achieve it

since admission is controlled by its members, as are matters of conduct and discipline

(Colyer, 2004). Rutty (1999) offers nursing something to think about when she

concludes an article by stating: “Within the literature there are powerful arguments for

and against the continuation of the professionalization process, as well as warnings

concerning the selection of what are deemed desirable features of professionalism”, also

reporting that some writers even suggest that nurses should stop trying to convince

themselves that they are professionals at all.

 When professionalization of an occupation takes place certain aspects become

more prominent; for example, the existence of a professional subculture with an explicit

or implicit code of conduct, esprit de corps among members of the same profession on

the grounds of lengthy study and training in a particular field, and maintenance of the

profession through research, professional literature and legislation (Jackson, 1970). This

writer needs no convincing that nurses are indeed a member of the professional core of

occupations essential to the wellbeing of this world. The point can be made that the

professionalization of nursing to a full-fledged profession continues to be unsettled in the

minds of many based upon differentiated entry into practice through three different

program types? More importantly, does education influence professionalism? Jacox

(1972) points out that both performing a needed service for society and attaining

specialized knowledge through a long period of education are important attributes of a

profession (p. 14).

Utilizing Halls Professionalism Scale, Underwood (2001) surveyed Victim

Assistance Practitioners from seven states with results suggesting that as group, they hold

moderately strong attitudes toward professionalism. The factors that had a statistically

significant affect on at least one of the attitudinal dimensions included level of education,

role in the organization, membership in a professional organization, and continuing

education (p. 91). Professionalism is defined as the attributes that the members of an

occupation exhibit. Nursing as a profession supports addressing the attitudinal attributes

of professionalism in this study.

Profession albeit Professionalism Varies

Professionalism has primarily been studied either on the basis of the structural

attributes of an occupation, or on the level of attitudinal commitment of practitioners to

their occupation (Freeman, 1994). Within professions, there is no universal measure or

standard for the ongoing assessment of professionalism. Lusch & O‟Brien (1997) in their

study of professionalism in market research make the distinction between profession and

professionalism by stating that: “profession” is an occupation that requires extensive

formal education and formal requirements such as state licensing, professional

certification, etc., while “professionalism” is an attitudinal an behavioral orientation such

as thinking of it as a calling and using colleagues in the profession as major reference for

work-related behaviors (p. 23). Friedson (1977) similarly defines a “profession” as an

occupational monopoly with these distinguishing characteristics: knowledge available to

a specific group of people, conduct that is expected from this group, control that the

group has over its training, and state registration. Larson (1990) asserts that “profession”

historically is the name given when there is the establishment of structural links between

relatively high levels of formal education and relatively desirable positions and/or

rewards in the social division of labor.

Du Toit (1999) explains that the most important characteristics of professions are:

(a) The profession determines its own standards of education and training

(b) Professional practice is often legally recognized by some form of licensure

(c) Licensing and admission boards are serviced by members of the

profession

(d) Most legislation concerned with the profession is shaped by the profession
 (e) The occupation gains in income, power, and prestige ranking, and

can demand higher-caliber students

(f) The practitioner is relatively free of lay evaluation and control

(g) The norms of practice enforced by the profession are more stringent than

legal controls

(h) Members are more strongly identified and affiliated with the

profession than are members of other occupations with theirs

(i) The profession is more likely to be a terminal occupation: members do not

care to leave it, and a higher proportion assert that if they had to do it over

again they would choose that type of work

(j) The student professional goes through a more far-reaching adult

socialization experience than the learner in other occupations (p.

165).

Flexner (2001) in his work exploring social work as a profession outlined six

criteria for professional status:

(1) Involve essentially intellectual operations with large individual responsibility

(2) Derive their raw material from science and learning

(3) Work up the raw material to a practical and definite end

(4) Possess an organized and educationally communicable technique

(5) Tend to self-organize

(6) Become increasingly altruistic in motivation (pp. 155-158)

In stark comparison of nursing and social work, the aligning of individual interests helps

the entire profession and can enhance the image of the nursing profession. Each criterion

is action based and requires the individual professional to be an active participant.

 Specifically, while by most, nursing is a fully recognized profession, and if

nursing is to be a respected and valued profession, assessment of individual

characteristics of professionalism and opportunities for growth are necessary (Heath,

2001). Professionalism involves the application of knowledge and skills, a high standard

of practice, leadership, self-regulation, professional commitment, social value, and

service-directed activity, which begins with individual actions and accountability

(Muller, 1998, Eagelson, 2001).

A profession and its respective professional constituents consist of two attributes

of professionalism: structural and attitudinal. Since 1948, registered nurses are licensed

after formal education requirements have been met and successful licensing examination.

Nurses are certified in many specialized roles, and through professional organizations

they are guided by continuing education standards. As a profession, nursing has fulfilled

the structural requirements of professionalism. The attitudinal attribute then as a

subjective, personal, and behaviorally determined component is that professional

component which members possess toward the profession.

Friedson (2001) throughout his career studied professions and explored five

interdependent elements of professionalism:

(1) Specialized work in the officially recognized economy that is believed to be

grounded in a body of theoretically-based discretionary knowledge and is

given special status in the labor force

(2) Exclusive jurisdiction in a particular division of labor created and controlled

by occupational negotiation

(3) A sheltered position in both external and internal labor markets that is based
 on qualifying credentials created by the occupation

(4) A formal training program lying outside the labor market that produces the

qualifying credentials, which is controlled by the occupation and associated

higher education

(5) An ideology that asserts greater commitment to doing good work than to

economic gain and to the quality rather than the economic efficiency of work.

(pp. 122-123)

Coulon, Nursing, Mok, Krause, & Anderson (1996) explored the meaning of

excellence in nursing care held by nurses. They collected qualitative data from (N=156)

undergraduate and postgraduate nurses through the use of open-ended questionnaire.

Four themes emerged from the findings: (1) professionalism, (2) holistic care, (3)

practice, and (4) humanism (p. 817). According to the respondents, nurses who deliver

excellent nursing care and implement nursing in a professional and competent manner

must demonstrate a holistic approach to caring, possess certain personal qualities which

enhance practice, and relate to patients, families, peers, hospital administrators and

community members in a competent, cooperative manner (p. 817).

Miller (1984) developed a Model of Professionalism in Nursing in efforts to

identify the behaviors necessary for professionalism within nursing. This professional

model provided nurses with a method to evaluate the existence or non-existence of

professional behavior. It is referred to as “The Wheel of Professionalism in Nursing” and

within it, an inventory of behaviors can be found (Miller, Adams & Beck, 1993). The

nine categories are believed to be essential for professionals and can be utilized to assess

professional behavior as stand alone entities understanding that all are equally important
 in the making of a successful, thriving profession. It is clear in the research that these

categories of behavior can influence professionalism. Millers Wheel of Professionalism

(1984) encompasses some of the major themes to be explored within this study.

Miller, Adams & Beck (1993) report the following 9 essential elements of

professionals:

(1) Professional Organization Participation

Farren (1997) asserts that one of the easiest and least expensive ways to enhance

your professional standing and development is to join a professional association (p. 116).

The profession is the primary object of loyalty and provides for the member work

enjoyment, satisfaction, and represents the organizations position (Miner, Crane, &

Vandenberg, 1994). Key to the function of the professional organization are five types of

organizational role prescriptions which fuel professional work behavior and activates the

organizational desire to learn and desire knowledge, desire to exhibit independence,

desire to acquire status, desire to help others, and value-based identification with the

profession (pp. 88-89). Without this identification, members can and will leave the

profession or even more importantly, act in unprofessional ways. Active membership in

professional organizations and professional specialty organizations enhance nurses‟

accountability, credibility, and professional development, and is another avenue to obtain

continuing education opportunities (Domino, 2005, Lannon, 2007).

Pipes, Holstein, & Aguirre (2005) propose that when individuals enter a

profession, the question arises as to what behaviors if any they agree to modify or give up

as a result of becoming a member of a profession (p. 334). On the other hand, they report

that professional associations such as the American Psychological Association assume a

vested interest in the behavior of their members for a number of reasons, inclusive of:

(1) reputation of the association, (2) the overall image of the profession, (3) the desire to

enhance the education and competency of the members, and (4) the protection of

students, clients, supervisors, organizations, and research participants with whom

members work (p. 334). If a question arises about the behavior of psychologists under

the auspices of the APA Ethics Code, the determination is made as to whether the

behavior in question is part of the professional role, or purely private conduct.

Fetzer (2003) studied the professionalism in ADN-prepared nurses. She offers

that theoretically, the BSN-prepared nurse has obtained professionalism through

induction and exposes the ADN to professional attitudes, behaviors, and values in the

workplace (p. 141). The study hypotheses were: (1) There is a positive relationship

between perceived self-actualization and the degree of professionalism among ADN

nurses, (2) ADN nurses employed full time have greater degree of professionalism than

those employed part time, and (3) There is a positive relationship between length of

nursing experience an the degree of professionalism among ADN nurses (p. 141). An ex

post facto methodology was utilized to obtain the data along with the Short Index of Self-

Actualization (SISA) and Hall‟s Professionalism Scale (HPS). The SISA with a reported

reliability of α = .72, contains 15 statements for which the respondent indicates their

degree of agreement. The HPS with a reliability of α = .72 to .85assesses five behavioral

attributes of professionalism for which the respondent indicates their degree of agreement

with 25 attitudinal and behavioral statements. All respondents were graduates of an ADN

nursing program and were currently practicing in nursing. Of the 302 respondents, an

82% return rate was realized. The results of the hypotheses were: (1) A significant
positive correlation supported the hypothesis of a positive relationship between self-

actualization and professionalism among ADN nurses (p. 142), (2) The hypothesis for

degree of professionalism was not statistically significant and the was not supported (p.

142), and (3) No significant correlation was found between the length of nursing

experience and the HPS scores, therefore the hypothesis was not supported (p. 142). In

sum, the author endorses the contention that individual professionalism can develop after

an individual occupies a role, and the inductive model of acquiring professional values,

attitudes, and behaviors is clearly not the only path to professional socialization (p. 143).

In some cases, professional organizations may substitute for mentor relationships by

providing access and information that is required for career development (Walsh, 1999).

(2) Autonomy and Self-Regulation

Autonomy is the hallmark of professional status (Domino, 2005, p. 196), and is an

essential attribute for achieving professional status existing in either individuals or groups

(Moloney, 1992, Setterson, 1991). Additionally, Dempster (1994) when discussing the

issue of autonomy posits that it is important to realize that autonomy is never absolute or

complete because there are always limits and/or constraints set by others. Cullen (2000)

states that “It is not always clear whether higher levels of autonomy are a feature of the

work setting, the educational foundation or the personal characteristics of the individual

nurse” (p. 53), whereas it is possible that nurses who lack professional autonomy are

more willing to leave their jobs and occupation in favor of more appealing professions

(Apker, Ford, & Fox, 2003, p. 227).

Kennerly (2000) reports that autonomy has been studied for many years in

relation to job satisfaction, job performance, and the retention of nurses (p. 611). Nursing
offers variety of task, routine, patients, teamwork, and employs different levels of skill

and degrees of autonomy (Newman, 2002). Attitudes towards professional nurse

autonomy are introduced during baccalaureate nursing education programs and therefore

analysis and application of the concept is warranted to achieve full professional status

(Wade, 1999, p. 310). Professionals who find it difficult to act independently, or are

afraid to do so, run the risk that their special knowledge will not be used (Minor, Crane,

& Vandebert, 1994, p. 87).

Autonomy is justified in principle by the professionals‟ claim of possessing a

special and superior knowledge, which is to be free of lay evaluation and protected from

inexpert interference (Larson, 1990, p. 31). Eraut (1994) states it best as he explains that

the special knowledge base of a profession also confers status upon it and provides the

centerpiece of its claim to autonomy and holds that only fellow members of the

profession are sufficiently knowledgeable to judge the work of their colleagues. (p. 223).

More importantly, autonomy is an important determinant of nurses‟ job satisfaction and

turnover (Ludeman & Brown, 1989, Wade, 1999, Upenieks, 2000).

According to Weisman (1982), baccalaureate-prepared nurses are thought to be

socialized to expect autonomy in their work environment, and are thus likely to be

dissatisfied than their non-baccalaureate counterparts when autonomy is not experienced

(p. 613). While nurses are prepared at different educational levels, Schutzenhofer

(1987) contends that professional nurse autonomy is the practice of one‟s occupation in

accordance with one‟s education, with members of that occupation governing, defining,

and controlling their own activities in the absence of external controls (p. 278). Williams

& McGowan (1995) reported that nurses educated in university based undergraduate
nursing programs demonstrated a more positive attitude toward professional autonomy

than nurses educated in hospital based undergraduate programs.

Mrayyan (2004) surveyed (N=317) hospital nurses through the use of selective

listservs in the United States of America, Canada, and the United Kingdom. Two

hundred and sixty four were from the United States of America. The study was

conducted to examine the role of nurse managers in enhancing hospital staff nurses‟

autonomy. The questionnaire consisted of four parts: (1) autonomy scale (α = 0.78 and α

= 0.92), (2) Nurse Managers‟ Actions Scale (α = 0.88), (3) demographic data sheet, and

(4) open-ended questions: (a) three factors that they considered important to enhancing

their autonomy, and (b) three factors that they considered hindered their autonomy.

Nurses indicated that the three important factors that increased their autonomy were:

supportive management, education, and experience. The three most important factors

that staff nurses indicated hindered their autonomy were: autocratic/non-participative

management, physicians, and workload. Additionally, the shortage of nurses and

increasing workload was identified by nurses as decreasing or hindering their autonomy

(p. 331). Overall, the findings were that education enhances autonomy (p. 333).

Mrayyan (2004) summarizes that the primary consequence of autonomy is

accountability. Professional nurse autonomy leads to empowerment of self and others and

may influence the individual‟s ability to change the work environment. The linkage

between work autonomy and professional nurse autonomy is reflected in satisfaction with

one‟s job, commitment to the profession and ultimately the professionalization of nursing

(p. 314).

Liaschenko & Peter, (2003), report that nursing does not now nor never did have
autonomy most significantly because nurses work in complex hierarchies where they are

subordinate to organizational structures, professional agendas, and the culturally-endorses

cognitive authority of medicine while Dempster (1994) maintains that when discussing

the issue of autonomy, the importance lies in realizing that autonomy is never absolute or

complete because those who seem to have full autonomy, in fact do not because there are

always limits and/or constraints set by others (p. 229).

(3) Competence

Education has a positive effect on the knowledge and competencies of nursing

practice (Domino, 2005). Professional knowledge is viewed as the most important

knowledge possessed, and accordingly, leadership derives from professional competence

(Minor, Crane, Vandebert, 1994, p. 87). Eraut (1994) reports two concepts of

competence. A competent professional is seen as no longer being a novice or beginner

and can be trusted with a degree of responsibility in the areas of his or her competence,

but not yet proficient or expert. He makes an interesting point when contrasting training

and education utilizing a binary scale to assess judgment of whether someone is

competent, or not yet competent. He suggests that binary scales were inappropriate in the

assessment of professional knowledge and incompatible with the notion of lifelong

learning (p. 215). Also, Eraut (1994) asserts:

A professional person‟s competence has atleast two dimensions, scope and

quality. The scope dimension concerns what a person is competent in, the range
of roles, tasks and situations for which their competence is established or may be
reliably inferred. The quality dimension concerns judgments about the quality of
that work on a continuum from being a novice, who is not yet competent in that
particular task, to being an expert acknowledged by colleagues as having
progressed well beyond the level of competence (p. 167).

In the nursing profession, can both these dimensions of competence be inferred upon
practicing registered nurses, and correlated to their basic education level? Will the nurse

prepared at the baccalaureate level exhibit higher competence in the work environment

than the nurse prepared at the diploma or associate level? Eraut (1994) posits that it can

be difficult to base a qualification even on agreed standards of minimum competence

because whatever the scope for planning teaching in educational settings, there will

always be constraints on learning opportunities in work settings (p.168). That being said,

the opposite can be true of nurses in varying work settings who experience differing

opportunities.

Bradshaw (1998) in her analytical review of the definition of competency agrees

with Eraut stating “as Eraut has shown, the current educational philosophy over-

optimistically underestimates fallibility, and nurses themselves are encouraged to be

confident and assertive” (pp. 107-108). The nurse therefore needs confidence to know

the standard of competency and whether or not she has the necessary knowledge and

skill, or conversely whether she does not (Bradshaw, 1998).

Woods & Powers (1987) researched a developmental model for competence and

make the point that:

Competence is distinguished from the competencies assessed in contemporary

testing programs. It rests on an integrated deep structure of understanding and on
the general ability to coordinate appropriate internal cognitive, affective, and
other resources necessary for successful adaptation. A successful
conceptualization of competence would show how specific competencies are
integrated at a higher level and would accommodate changing patterns of salience
among these skills and abilities at different ages in different contexts (p. 414).

The work of Gonzi (1993) lays a solid foundation for the exploration of

competence and competency. Two bold statements about competence and competency

are useful in this study:

 (a) Competence is not directly observable; rather it is inferred from performance
(p. 6).

(b) The competence of professionals derives from their possessing a set of

relevant attributes such as knowledge, skills, and attitudes. These attributes
which jointly underlie competence are often referred to as competencies. So a
competency is a combination of attributes underlying some aspect of
professional performance, and attributes of individuals do not in themselves
constitute competence. Nor is competence the mere performance of a series
of tasks, rather the notion that competence integrates attributes with
performance. (p. 5-6).

Competence is focused on the description of an action or behavior, while competency is

focused on the individual‟s behavior that underpins the competent performance

(McMullin, Endacott, Gray, Jasper & Miller, 2003). Kramer (1974) makes some of the

same points about competence when listing these characteristics of a profession:

(a) Specialized competence having an intellectual component

(b) Extensive autonomy in exercising this special competence

(c) Strong commitment to a career based on a special competence

(d) Influence and responsibility in the use of special competence

(e) Development of training facilities that are controlled by the professional group

(f) Decision-making governed by internalized standards (p. 15)

Scott (2008) notes that the defining attributes of competency in nursing are the

application of skills in all domains for the practice role, instruction that focuses on

specific outcomes or competencies, allowance for increasing levels of competency,

accountability of the learner, practice-based learning, self-assessment, and the

individualized learning experiences (p. 58).

Attitudes are manifested in behavior, and key to this study is the self reports of

practicing registered nurses and their associated behaviors used to demonstrate the value
placed on attributes of professionalism. Jordan, Thomas, Evans, & Green (2008) assert

that it is imperative for a profession which prepares nurses differently to assure the public

of a competent nursing workforce, and a method to assure ongoing assessment. Texas

State Board of Nursing is one of the few who have adopted standards of practice and

continuing education requirements.

(4) Continuing Education

The acquisition of new knowledge is the hallmark of professional behavior

(Domino, 2005, Armstong, Johnston, Bridges, & Gessner, 2003). Continuing education

plays a vital role in the nurses‟ development once she enters the workforce and the very

nature of nursing as a profession requires that its practitioners possess specialized

knowledge and skills, and lifelong learning is required to progress within the profession

(Lannon, 20007, p. 17). Nurse‟s return to school for personal satisfaction, to fulfill

requirements for certification or graduate school, to advance their careers, improve

practice, and elevate the practice (Leonard, 2003) while Smalley (2005) also found that

lifelong learning provides competency and nursing satisfaction (p. 59.

Griffitts (2002) purports that continuing education may be the tool to promoting

and maintaining competency, and strengthening the profession. Currently 30 state boards

of nursing and most credentialing bodies require evidence of continuing education

participation in the form of contact hours for license and certification renewal (Lannon,

2007, p. 17). Basically, one central purpose of continuing professional education is to

bring practicing professionals into contact with new knowledge and ideas (Eraut 1994, p.

25).

Armstrong, Johnston, Bridges, & Gessner, (2003) report that the three major
methods for continued learning in nursing are:

(a) Continuing education activities

(b) Academic courses

(c) Professional literature (p. 20)

They also report that reading remains the most consistent, economic, and accessible

learning resource for most nursing information. In their extensive review, they sought to

examine the amount of time spent reading and the major purpose for the reading of RNs

entering graduate school and those who had completed a graduate program in nursing (p.

21). The average time reported spent reading professional literature for the entry group

was 10 hours and 50 minutes per week and for the alumni group, the average time spent

reading professional literature was 6 hours per week (p. 23). A main finding was that

alumni had significantly more memberships in nursing organizations and journal

subscriptions than entry students (p. 23).

Hom (2003) assert that nurses require different types of education, mentoring, and

coaching because of skill levels, past experiences, learning styles, different types of

attitudes toward life, cultural influences, and their concepts and definitions of work ethics

(p. 49).

In November 200, the Josiah Macy, Jr, Foundation convened a conference to

address complex issues concerning continuing education in health professions. It was

concluded that the fundamental purposes of continuing health professional education are:

to improve the quality of patient care by promoting improved clinical knowledge, skills

and attitudes by enhancing practitioner performance, to assure the continued competency

of clinicians, to provide accountability to the public, and more importantly, to maintain

professional competence as a core responsibility of each health professional regardless of

discipline, specialty, or type of practice (p. 114).

(5) Research and (6) Nursing Theory Development

Theories clarify and define nursing and the purpose of nursing practice to

distinguish it from other caring professions by setting professional boundaries (Tanaka,

2008). Nursing research, nursing theory, nursing publications, and accreditation of

schools and colleges of nursing have all been strengths that have contributed to the

development of a nursing body of knowledge and have supported practitioner education

(Pinkerton, 2001). Involvement in professional organizations increases nurses‟ exposure

to research, ethics, theory, and evidence-based practice (Smalley, 2005, p. 59). Nursing

practice, therefore, occurs within a large context and framework that is shaped by

theories (McEwen & Wills, 2007), and pertinent research.

Landreneau (2002) contends that the profession of nursing and professionalization

of nursing should and will continue to forge its own way through the continued use of

philosophy, theory, and knowledge through the many nursing scholars‟ whose

contributions refine the professional base (p. 285). Rutty (1998) while exploring the

nature of philosophy of science, theory and knowledge relating to nursing and

professionalism agrees that professions achieve distinction from one another by virtue of

the unique theories which guide the clarification of the key suppositions and values that

are particular to them, which in turn assist in determining the nature, outcome and

purpose of their practice (pp. 244-245).

(7) Publication and Communication

A component of professionalism includes participating in community service, and

contributing to the field‟s body of knowledge which includes teaching, conducting

research, and writing for publications (Garmon, Evans, Krause, & Anfossi, 2006).

Publications are a means to sharing and disseminating knowledge reflective of the

interests and responsibilities among members but might be missed by those who do not

subscribe, read or discuss professional issues. All respondents who are currently licensed

in the state of Texas are governed by the Nurse Practice Act. The mission of the Texas

Board of Nursing (BON or BNE) is to protect and promote the welfare of the people of

Texas by ensuring that each person holding a license as a nurse in this state is competent

to practice safely. The Board fulfills its mission through the regulation of the practice of

nursing and the approval of nursing educational programs. This mission, derived from the

Nursing Practice Act, supersedes the interest of any individual, the nursing profession, or

any special interest group (Texas Board of Nursing Nurse Practice Act, 2007). This

publication communicates such practice guidelines as licensure, renewal, prohibited

practices, disciplinary action, and peer review. One area „duty to report violations and

patient care concerns‟ defines for nurses “Conduct subject to reporting” interpreted as

conduct by a nurse that:

(a) Violates the chapter or a board rule and contributed to the death or serious

injury of a patient;

(b) Causes a person to suspect that the nurse‟s practice is impaired by

chemical dependency or drug or alcohol abuse;

(c) Constitutes abuse, exploitation, fraud, or a violation of professional

boundaries; or
 (d) Indicates that the nurse lacks knowledge, skill, judgment, or conscientiousness

to such an extent that the nurse‟s continued practice of nursing could

reasonably be expected to pose a risk of harm to a patient or another person,

regardless of whether the conduct consists of a single incident or a pattern of

behavior. Professional attitudes are a precursor to professional behaviors.

Professional attitudes are a precursor to professional behaviors.

(8) Adherence to ANA Code of Ethics

A central theme of professionalism involves understanding the formal and

informal expectations of conduct (Garmon, Evans, Krause, & Anfossi, 2006). The

American Nurses Association (ANA) Code of Ethics for nurses and serves several

purposes:

(a) It is a succinct statement of ethical obligations and duties of every individual

who enters the nursing profession

(b) It is the profession‟s nonnegotiable ethical standard

(c) It is an expression of nursing‟s own understandable of its commitment

to society (American Nurses Association, 2008)

According to Nursing World, The American Nurses Association (ANA) is the

only full-service professional organization representing the nation's 2.9 million

registered nurses (RNs) through its 54 constituent member associations. The ANA

advances the nursing profession by fostering high standards of nursing practice,

promoting the rights of nurses in the workplace, projecting a positive and realistic view

of nursing, and by
lobbying the Congress and regulatory agencies on health care issues affecting nurses and

the public.

(9) Community Service

Outside of the work environment, giving back to the profession may be

accomplished be participating in community service by serving as an advocate for

patients, families, and the community (Garmon, Evans, Krause, & Anfossi, 2006). For

all intents and purposes, professions exist for the sole purpose of meeting societal needs

(Burkhardt & Nathaniel, 2002).

Tanaka (2008) in her study of professionalism of nurse leaders noted that

professionalism in nursing has increased in selected comparative studies from 1993

through 2001. She concluded that nurse leaders (N=131) with at minimum of an

associate degree in nursing and held a leadership role were intensely involved in all of the

professional behaviors described by Miller (1984) and exceeded the results of the

previous studies.

Hampton & Hampton (2000) reported the findings of an exploratory study on the

level of professionalism among certified-nurse midwives (CNMs). They explored the

relationship between organizational reward structures, level of education, and

professionalism. The construct of professionalism was measured utilizing Hall‟s

Professionalization Scale. They surveyed (N=685) CNMs from the American College of

Nurse Midwives Association. The educational level of the participants was that of a non-

bachelor degree CNMs, bachelor degree CNMs, master‟s degree and CNM, or Ph.D.

Two of the 25 items of the scale were dropped based upon low factor loadings. The

factors demonstrated high reliability with coefficient alphas of .66 to .80 and utilized to
measure professionalism items within the five factors: 1) belief in public service, 2) sense

of calling, 3) professional associations as a major referent, 4) autonomy, and 5) belief in

self-regulation (p. 220). The two factors which CNMs exhibited the highest levels of

professionalism were belief in public service and sense of calling to midwifery. Within

the other three factors there was a demonstrated high level of professionalism. The

findings of the study support the notion of a causal relationship between education and

professionalism whereas the higher the level of education of the CNM, the higher the

level of professionalism exhibited (p. 225).

Welling (2003) conveys this about physician professionalism:

Professionalism is a learned human behavior. It transcends specific job-related functions

and can and should be a part of every individual‟s life. Simply put, professionalism is a
behavior that describes relationships. In medicine, these relationships are multiple and
varied. They occur with patients and their families, peers, students, other health care
personnel, and the community. Physicians are expected to act with integrity and skill in
all these relationships and are evaluated on their behavior in them. (p. 262)

It can be concluded that not only physicians, but all professions by standard are expected

to embrace that very concept.

Barondess (2003) writes that professionalism for the individual physician is

expressed primarily in clinical transactions which include the following components:

(a) Competence, the irreducible expectation the physician must have of him or

herself

(b) Engagement, includes a capacity to communicate effectively

(c) Reliability, to be personally responsive to another‟s need

(d) Dignity, dignified clinical transaction and dignified physician

(e) Agency, fiduciary responsibility and implies alliance and advocacy

(f) A dual focus on illness and disease; which are not necessarily congruent
 (g) Concern for quality in clinical care, clearly a central expression of

competence, and thereby of professionalism (pp. 145-146)

The conclusion in this research study with regard to professionalism in nursing is that

ultimately, expressions of professionalism in the individual physician and expressions of

a reinvigorated public role for the profession are the same thing as neither is likely to

flourish in the absence of enhancement of the other, and conversely, both will continue to

suffer unless both are addressed (p. 148)

Table 3 displays the comparison of the aforementioned structural elements of

professionalism to the six attitudinal elements of professionalism which are main topics

of interest in this study.

Table 3
Comparison of Structural and Attitudinal Elements of Professionalism from the
Professional Model
Structural Elements of the Professional Attitudinal Elements of the Professional
Model Model
Professional practice is often Professional Organization As a
legally recognized by some form of Major Referent
licensure, licensing and admission
boards are serviced by members of
the profession, most legislation
concerned with the profession is
shaped by the profession, active
membership in professional
organizations

The profession determines its own Belief in Continuing Competence

standards of education and training,
specialized competence having an
intellectual component, extensive
autonomy in exercising this special
competence, strong commitment to
a career based on a special
competence, influence and
responsibility in the use of special
competence, decision-making
governed by internalized standards

The norms of practice enforced by Belief in Self-Regulation

the profession are more stringent
than legal controls

Members are more strongly Sense of Calling to the Field

identified and affiliated with the
profession, the profession is more
likely to be a terminal occupation

The practitioner is relatively free of Autonomy

lay evaluation and control
Provide an important service to Belief in Service To The Public
clients and society as a whole
Professionalism and Use of Foreign Born and Agency Nurses

It is a well known fact that the use of agency nurses to augment staffing

requirements in acute care, home health, and clinic settings is part of the solution to the

nursing shortage today. This means that agency nurse providers are increasingly required

to offer quality nurses who can perform nursing duties competently and efficiently

(Manias, 2003). Buerhaus, Staiger, & Auerbach (2004) revealed that the new entry of

foreign-born nurses, along with the reentry of older nurses accounts for the increased

growth of nurses in the 2002 workforce. Harvey (2006) through an extensive literature

review offers a broad set of relevant criteria which he states needs to be addressed when

recruiting foreign nurses to include: the role in the healthcare organization, professional

skills, conflict resolution, leadership, and communication skills, culture, family situation,

and openness to pursing a career path.

Manias (2003) conducted a study which examined agency nursing work from the

perspective of eight hospital nurse managers from three metropolitan hospitals (public,

private, and public teaching) and agency nurse providers from the three largest agencies

in Melbourne, Australia. Through interview data, the themes that emerged were:

planning and nurse allocation, communication and support, and professionalism. They

expressed concerns focusing on agency nurses responsibility for professional

development and agency nursing as a career choice. Nurse mangers were of the opinion

that hospitals were only to ensure the competence of agency nurses in the work setting

but not to be responsible for their continuing education needs. The agency nurse

providers attested to the importance of providing educational resources to help address

the needs of their agency staff. Unfortunately, nurse managers felt that agency nurses did
not possess the same professionalism because of their career choice. “Agency nurses

were perceived to lack professional commitment, career pathway, adoption of evidenced-

based practice, and predominant role as a health care team member because their

motivation for work was for monetary gain rather than professional status” (p. 462). In

contrast, all agency providers agreed that agency nursing was a good career choice for

experienced nurses and in the professional sense, this temporary form of nursing

provided opportunities for individuals to practice their diversity of skills in different

settings (p. 462). Although it is accepted that nurses make career choices based on

individual goals, these nurse mangers reported that lack of professionalism among some

agency nurses affects morale and causes stress among their staff.

Fuller (1995) offers this perspective: “while it is important that nursing

registration authorities maintain high standards in licensing for who is able to practice as

a registered nurse, there does appear to be some difficulty in recognizing the value of

nurses who qualified in non-english speaking countries to the health system.” (p. 469).

Consequently, if nurse vacancies continue in health care facilities, and domestic

reduction falls short of the demand, then foreign nurses are likely to remain a viable

lucrative strategy for plugging holes in the U.S. nurse workforce (Brush, Sochalski, &

Beger, 2004, p. 84).

In contrast, reports that the traditional methods of plugging gaps with bank and

agency nurses, together with a national recruitment advertising campaign as well as

overseas recruitment has proved insufficient to meet the rising demand for healthcare

Newman (2002).

Spremtino & Simunek, (1991) shared insight into nurse‟s perceptions of working
for an agency in the provision of supplemental staffing at least once during their career.

They surveyed (N=93) registered nurses in South Florida. The respondents were: 87%

female, 11% male, 41% BSN, 56% ADN, and 3% Associate. Fifty-nine percent of those

nurses surveyed were employed as independent contractors and in addition, 14% of those

also worked within a pool , 15% also worked within a hospital, and 12% also worked

within other agencies (p. 58). In diminishing order, they found the reasons that nurses

work as independent contractors are do to: (a) flexible time schedule, (b) additional

income, (c) pays more than hospital, (d) day off when desired, (e) same day pay, (f) job

satisfaction, (g) ability to change shifts worked, (h) ability to work on the different units,

(i) ability not to work with people they disliked, (j) ability to choose type of patient, (k)

do not have to comply with policy, (l) able to do private duty nursing, (m) job security,

(n) ability not to have to answer for mistakes to supervisor (p. 59). Additionally, there

were disadvantages to working as an independent contactor: (a) no paid sick time, (b) no

paid vacation time, (c) no paid health insurance, (d) no paid malpractice insurance, (e) no

tuition reimbursement, (f) cannot find work at all times, (g) resented by full-time staff,

(h) cannot find work on same shift, (i) not respected by supervisors (p. 60). Nursing

agencies have enhanced the value and status of nurses, and while excellent work is

expected, control of practice lies solely with the individual nurse (p. 61). However, when

organizations recruit international workers, they will inherently incur a non-monetary

cost resulting from nursing consumers‟ perception that they will receive a sub-standard

level of nursing (Harvey, Buckley & Novicevic, 2006). Ruyter (2005) relates that many

view agency nursing as a means to broaden their career horizons, or as a transitional step

to leaving the nursing workforce entirely (p. 72).

Other Variables Which May Influence Degree of

Professionalism Age

McNeese-Smith (2003) identified the extent to which values are associated with

age group and job stage (independent variables) to job satisfaction, productivity, and

organizational commitment (dependent variables), in order to determine if any

relationships existed among the variables of education, generation, ethnicity, gender and

role (p. 260). The key concept in the study was value and how values filter the

information used to judge, and make decisions. Values also influence the selection of

priorities which are acted upon in the personal and professional lives of nurses. The

importance that an individual places on either intrinsic or extrinsic values may differ with

age, life cycle phase, and professional status (p. 261). Job and career stages identified

another way of conceptualizing influences that may affect employee performance and

attitude (p. 262). A random sample (N=412) were surveyed from three moderately sized

hospitals in Los Angeles County. Ninety-five percent of the sample were women, 46%

held at least a bachelor‟s degree in Nursing, and 67% received their nursing education in

the United States. Sixty-six percent were staff nurses, 15% were middle management,

and the rest were charge nurses or supervisors. The average number of years of

experience was 15.6. The Work Values Inventory (Cronbach‟s α = 0.62 to 0.91), Job

Identity Stages Questionnaire, Job Satisfaction Scale (Cronbach‟s α = .85), Productivity

Scale (Cronbach‟s α = 0.91), and the Organizational Commitment Scale (Cronbach‟s α =

0.90) were utilized in this study. ANOVA showed some significant differences for values

among educational levels (p. 265). Post hoc comparisons showed that nurses with

bachelor‟s degree had significantly higher scores than associate-degree nurses in relation
to esthetic, creativity, and management values. Roles showed a significant difference in

values between managers and staff nurses in creativity, and management. There was a

positive relationship between esthetics and age while job satisfaction did not show a

positive correlation to work values or economic value. The value differences found

depended upon age, educational background, roles of nurses, and gender (p. 266). The

factor of question in this study was whether the value assessment came as a result of

previous role changes within the nurses‟ career. Basically, younger nurses entering the

workforce may have attitudes and values toward work and career that differ from older

nurses (p. 261).

Shader, Broome, Broome, West & Nash (2001) performed a cross-sectional study

within a university hospital in the southeastern United States to answer four research

questions with only three being referenced here: (1) which factors best predict anticipated

turnover (2) what factors predict anticipated turnover for nurses of different age groups

and (3) is there a relationship between anticipated turnover and actual turnover?

Utilizing a self report questionnaire, the researchers addressed these factors: nurse

perception of job stress, work satisfaction, group cohesion, and anticipated turnover. The

sample consisted of (N=5) nurse managers and (N=241) staff nurses. Fifty-two percent of

the nurses held a baccalaureate degree. Twenty-five percent reported 2-3 years of total

nursing experience while twenty-four percent had held their current position for 2-3

years. Along with a demographic questionnaire, several instruments were used to gather

data. The Index of Work Satisfaction was used to measure satisfaction in two parts. Part

A determined the perceived importance of factors essential to satisfaction and Part B

measured the current level of satisfaction. The Cronbach α for each component ranged
from 0.70 to 0.90. Only Part B was used in this study. A modified version of the Job

Stress Scale which measures the amount of stress that nurses perceive in relationship or

their jobs and work environment was used with an overall Cronbach α = 0 .86. The

Bryne Group Cohesion Scale measures perceptions of integration into the organizational

and colleague environment with a reported Cronbach α = 0 .87. The Anticipated

Turnover Scale was used to measure the nurses‟ intent to leave their current job with a

Cronbach α = 0.86. The factors which were determined to be predictors of anticipated

turnover were work satisfaction, weekend overtime, job stress, and group cohesion.

Within the 20-30-year old group, work satisfaction and job stress were significant

predictors of anticipated turnover. Within the 31-40-year-old group work satisfaction

was predictive of anticipated turnover. Within the 41-50-year-old group work

satisfaction and group cohesion were predictive of anticipated turnover.

Apostodlidis, Beka, & Polifroni (2006) purport that healthcare agencies face not

only a shortage of nurses, but also an integration of a new generation of baby boomers

(1941 – 1964) and generation Xers (1960- 1981) making essential the understanding of

the unique characteristics of each generations with regard to values, and job satisfiers (pg.

506). They compared two groups: Group I were baby boomers who were nurses older

than 41 years of age (51%), and Group 2 who were nurses younger than 41 years of age

(49%). They utilized a questionnaire and the Index of Work Satisfaction survey

instrument to elicit data from (N=98) nurses. In comparison of the two groups, baby

boomers were most satisfied with autonomy over professional status. They ranked

professional status first, followed equally by interaction, autonomy, pay, and task

requirements, with organizational policies as the least satisfier. Generation Xers were
most satisfied with professional status, followed by interaction, autonomy, organizational

policies, and task requirements, with pay being the leaser satisfier (p. 507). Irvine &

Evans (1995) concluded similar results noting that the variables related to nursing job

satisfaction, work content and work environment have a stronger relationship with job

satisfaction than economic or individual differences.

Older individuals usually possess more experience with life in general and with

the health care arena in particular, both of which may influence their professionalism

(Clark, 2004), while fewer young people are entering the nursing profession, in part

because or the broader range of career choices for women (Valentin, 2002). That being

said, the cost of replacing and recruiting nurses of all ages today continues to be costly

for healthcare organizations and diminishes the return on investment.

Gender

Nursing is viewed as a highly gendered profession (Muldoon and Reilly, 2003).

According to Johnson & Johnson (2002), only one man in ten would consider nursing as

a career and fewer people are entering nursing because other professions are doing a

better job of attracting a new generation of workers, men and women alike (Mee &

Robinson, 2003).

Brady & Sherrod (2003) assert that men continue to represent a small percentage

of the nursing workforce (p. 159). Men‟s participation in nursing has been shaped by

social and political factors, as well as by prevailing notions of masculinity and feminist

roles. O‟lynn (2004) alludes to the fact that unlike nurse shortages of the past, there is no

longer an unlimited supply of women to become nurses, and women have more available

career options, nursing competes with other professions for bright talented women, hence
nursing recruitment for ethnic minorities and men is helping to fill the professions present

and future vacancies (p. 230).

In a study by Okrainec (1994) factors influencing satisfaction with nursing

education was reported for male and female students. For male students, factors

influencing satisfaction were: relationships with nursing instructors, relationships with

peers, and the length of the nursing program, whereas factors influencing satisfaction for

female students were mostly relationship with peers, and responsibilities in the clinical

setting, followed by relationships with faculty.

Holyoake (2002) in an ethnographic approach identified themes about the

attitudes, behaviors, and symbolism typically associated with male psychiatric nurses.

He was interested in determining why nurses adhere to certain prescribed representations

to maintain an identity associated with: caring, high skill levels, and sense of

professionalism (p. 33). In her construct validation of identity, the author writes:”if male

nurses have the same responsibility and desire to uphold codes of professional practice,

then it would seem that, in theory, there is no identity difference between the two sexes.”

(p. 34). Although many cultural themes were documented, they are beyond the scope of

this research topic.

Yang, Gau, Shiau, Hu, Wei-Herng, & Fu (2004) utilized a convenience sample

(N=15) of Taiwanese baccalaureate-prepared male nurses through semi-structured

interviews to analyze: (a) their motivations for becoming a nurse, (b) their professional

developmental process, (c) difficulties hindering both professional and gender

development, and (d) strategies they use to cope with difficulties. These males had

worked in Taiwan for at least 12 months, and reported no history of alcohol, drug, or
mental disorders (p. 643). The researchers concluded that based upon the nature of

nursing work and clinical experiences, Taiwanese male nurses believed that nursing was

a profession suitable for both men and women (p. 642).

Shift Work and Employment Status

Shifts are classified as days, afternoons, and nights with staff working a

combination of two or more of the shifts that change periodically (p. 212) and may also

be worked on a rotating or permanent basis. There is scientific evidence that the adverse

physiological and psychological effects of shift work are inclusive of disruption in

biological rhythm, sleep disorders, health problems, diminished performance at work,

job dissatisfaction, and social isolation (Admi, et al., 2008). Nursing staff have been the

main professional group to work shifts in hospitals (Wilson, 2002, Levett-Jones & Dip,

2005). Brooks (2000) recognizes that time at work is part of an often strained

relationship between financial, social, and health dimensions of life as the ills of shift

work have an impact on both individuals and organizations, and not to forget that among

healthcare professionals, fatigue has been found to increase over the duration of a shift

regardless of the length of it (Poissonnet & Veron, 2000).

As nursing remains a predominantly female occupation, in her review of the

literature of studies on shift work, Wilson (2002) found that women‟s reasons for

working shifts varied because of the presence or absence of dependents in their family,

whereas men‟s reasons for working shifts were unrelated to their family characteristics

and rotating shifts were more problematic for women, parents, and for workers with little

control over the work schedule (p. 214). Additionally, Trinkoff, et al. (2006) found that

nurses with more than one job and single parent nurses were more likely to work 12 or
more hours per day and long weeks (50-60 hours).

Brooks & Swailes (2002) examined the relationships between nurses shift

patterns, shift preference, and commitment to nursing in the United Kingdom National

Health Service for (N=2087) nurses by a survey questionnaire with 90 questions

concerning current employment and attitudes toward work. The majority of responders

were staff nurses. Approximately 60% of the nurses working a mixed early, late, and

night shift or early and late shift preferred another shift pattern compared to

approximately 30% of the nurses on permanent night or day shift. Commonly, the

preferred shift to work was the day and early shifts, or flex-time. Although only a small

effect size was realized, ANOVA revealed that shift patterns and influence over shift

choice had a positive association with commitment to nursing (pp 125-126).

Every health-care facility must operate with a mix of full-time and part-

time employees as well as casual or temporary full-time and part-time employees. Lewis

(1997) reports that flexible arrangements include part time or reduced hours, additional

career breaks, job sharing, compressed work weeks, and flexible work schedules.

Membership in Professional Organizations and Professional Certification

Currently in many states, a practitioner is determined to be competent when

initially licensed and thereafter unless proven otherwise which has propelled

certifications (Whitaker, Winifred & Smolenski, 2000). “Professionalism pays” by

Elizabeth Eyre (2009), she reports research revealing the extent to which people,

organizations, and the economy benefit from professional qualifications and membership

(p. 23). Sharran, Merriam & Brockett (1996) assert that certification is different from

licensure, which is a mandatory legal requirement in some professions and is often tied to
professionalization of the field (p. 277). The process of certification may serve to

generate a customized career long learning design or an individual curriculum for the

highly motivated, self-directed learner (White, 1992). She suggests some key benefits to

professional certification to include: recognition and incentives for excellence,

recognition of competence, creditability, common core of knowledge and skill, promote

professionalism, and prestige.

Salary and award structures can be built around professional certification which

can be gained through professional organization memberships. There is no question that

the benefits of both can significantly raise the return on investment for the individual,

organization, and profession as examples reported by Frank (2005) were: control

professional destiny, increase awareness of nursing issues and support collective actions

among nurses, networking opportunities to connect with peers, mentors, and nurse

leaders, share ideas, collaborate on issues and projects, educational, personal, and

professional development, visibility, continuing education, submission of articles, give

presentations, ad attend conventions (p. 13).

Role in Organization

Nurses make up the greatest single component of hospital staff (Siela, Twibell, &

Keller, 2008). They report that of the 3 million nurses employed in the United States in

2004, overall, 56.2% of all working registered nurses were employed as hospital nurses,

and the next highest employment setting for nurses was in community and public health

settings, followed by nursing homes and extended care facilities. Studies have shown

that an individual‟s professional beliefs, attitudes, and their behaviors are reflective of

their professional organizations membership, nursing roles, sources of supportive

communication, and sense of professional autonomy (Haley-Andrews, 2001, Stein, 2001,

Apker, et al., 2003). Monnig (1978) reported that nurses with greater than five years

experience reported higher levels of professionalism than nurses who had less than five

years of experience.

Trachsel (1998) performed an exploratory study to investigate the possible

influence that the type of educational delivery format exerted on professional attitudes

and perceptions of the professional nursing role. Graduates (N=54) of a Registered Nurse

Baccalaureate in the Science of Nursing (RN-BSN) distance learning program and

graduates (N=19) of a traditional Baccalaureate in the Science of Nursing (BSN) program

were surveyed on their attitudes toward professionalism and perceptions of their

professional nursing role. The findings noted that both types of graduates held similar

attitudes toward professionalism and perceptions of the professional nursing role.

Laschinger, Spence & Havens (1996) support Kanter‟s Theory of Structural

Power in the shaping of work behaviors and attitudes in relation to an individuals

position, and the situations that arise in an organization (p. 27). This refutes the assertion

that individual socialization experiences are the sole reason. The findings demonstrated

that perceptions of access to opportunity, support, information, and resources impact the

employee‟s work effectiveness and satisfaction.

Practice Years

The number of nurses entering the workforce via associate degree programs has

increased and these nurses are generally older, will carry with them the issues of aging

(physical, cognitive, and emotional), typically work fewer hours, and leave the workforce

sooner (Cooper, 2003).

Practice Setting

Nurses are represented in greater numbers in hospitals however Oughtbridge

(1998) reports that each organization has its own unique culture of shared beliefs,

practices, atmosphere and history while the physical and social environment, language

and actual behavior of members constitute the culture (p.22).

If the profession of nursing is to be promoted, there must be a continual effort to

birth and nurture professionals who are professional in deed and action. As nursing seeks

to become more representative of the population it serves, they must recruit and retain a

diverse cohort of students and faculty, including males (Anthony, 2004). Table 4

displays by percentage that nurses in clinical practice settings has changed over time

while nurses in other than clinical setting has also experienced some variations in

representative work settings.

Table 4
Comparison of Surveys of Nurse Work Settings
Work Settings HRSA RN National HRSA RN AMN
Sample Report National Sample Healthcare
(2000) Survey (2004) National Sample
(N=35,579) (N=35,724) Survey (2007)
(N= 1,831)
Hospitals 59.1% 44.2 % 52.6%
Public and Community 18.3% 11.7 % 6.2%
Health
Ambulatory Care 9.5% 8.9 % 8.6%
Nursing Homes or 6.9% 5.1 % 9.1%
Extended Care Facilities
Nursing Education 2.1% 2.0 % 3.0%
Other Settings 3.6% 4.5 % unknown
HRSA (2000) Response rate of 72.0%
HRSA (2004) Response rate of 70.7 %
AMN Healthcare Response rate of 24.4%

Practice Environment

Nurses‟ attitudes and behavior are probably influenced by the overall climate

within their work environment. Environments that are conducive to learning and

development will improve staff satisfaction, staff retention, and quality care (Levett-

Jones, 2005). Smith, Hood, Waldman, Smith (2005) agree that the practice environment

has the potential to positively influence a nurses‟ job satisfaction (p. 525); while the

same can be said regarding the practice environment having the potential to negatively

influence a nurse‟s job satisfaction. They investigated and affirm that the practice setting

nurses experience is a strong predictor of job satisfaction and turnover. Nurses were

asked to assess the extent to which their practice expectations on graduation from nursing

school were being met, and whether the current practice setting meets, exceeds, or falls

short of their expectations. Measurements focused around attitudes toward practice

environment, and job outcome attitudes. Forty five percent of nurses‟ demonstrated

attitudes toward their practice environment which meets their expectations, 24.1%
indicated that the setting exceeds their expectations, and 31% felt that they were not able

to practice the quality of medicine they expected on graduating from nursing school (p.

529). In terms of satisfaction with their current nursing practice, 48% of nurses were

very satisfied, 42.3% of nurses were somewhat satisfied, 5.8% of nurses were somewhat

dissatisfied, and 3.8% of nurses were very dissatisfied. It was also concluded that nurses

practice expectations were negatively correlated with job satisfaction and organizational

commitment. In contrast, nurses practice satisfaction was positively correlated with their

job satisfaction and organizational commitment. As nurses express greater satisfaction

with their practice, they are more satisfied with their jobs and committed to their

organization. The work organization can be likened to the professional organization (pp.

433-434)

Nevidjon & Erickson (2001) report that the work environment in the United

States differs from the last time the healthcare industry experienced significant shortages.

They reported these six trends which have impacted organizations in all industries related

to: retention, time over money, increased demand for knowledge workers (especially

technically or scientifically gifted), balancing professional and personal demands, rising

super class of employees, how Gen Xers (23-40 years of age) view the workplace

differently, and collaborative management.

Simply put by Doheny (2006), “the nursing work environment needs

improvement”, as “working conditions drive nurses into early retirement or career

switch”, and “half a million nurses have active licenses but no longer work in health

care” (p. 42). It is reasonable to speculate that when nurses perceive their work

environment to be empowering, they feel more supported to practice in a professional

manner (Lesinger, Almost, Tuer-Hodes, & Donnalene (2003) and therefore, nurses may

practice more professionally when the environment provides opportunities and power

through resources, support, and information (Manojlovicj, 2005).

Continuing Education and Competence

Continuing professional education can make a positive contribution to nursing

practice, the individual, and the professional development of nurses (Perry, 1995),

challenging them to learn new skills, change behaviors, and reconsider attitudes (Noe &

Wilk, 1993). In most professions, completion of a specified amount of ongoing

education each year is mandatory and furthermore, continuing education has the potential

to develop attributes such as analytical ability, critical thinking, communication,

teamwork, flexibility, and the ability to adapt to change (Levett-Jones, 2005). The

American Nursing Association (ANA) has embarked on the development of policy

addressing the continuing competence of practicing registered nurses (Whitaker,

Winifred & Smolenski, 2000). The definition used by the ANA for continuing

professional nursing competence is ongoing professional nursing competence according

to level of expertise, responsibility, and domains of practice as evidenced by behavior

based on beliefs, attitudes, and knowledge matched to and in the context of expected

outcomes as defined by nursing scope of practice, policy, Code of Ethics, standards,

guidelines, and benchmarks that assume safe performance of professional activities. An

expert panel convened and formulated eight assumptions regarding continued

competence:

1. The purpose of ensuring continuing competence is the protection of the public

and advancement of the profession through the professional development of
nurses
2. The public has a right to expect competence throughout nurses‟ careers
 3. Any process of competency assurance must be shaped and guided by the
profession of nursing
4. Assurance of continuing competence is the shared responsibility of the
profession, regulatory bodies, organizations/workplaces and individual nurses
5. Nurses are individually responsible for maintaining continuing competence
6. The employer‟s responsibility is to provide an environment conducive
to competent practice
7. Continuing competence is definable, measureable, and can be evaluated
8. Competence is considered in the context of level of expertise, responsibility,
and domains of practice (American Nurses Association, 2000)

Nurses seek more than financial incentives but rewarding work environments,

opportunities to further their knowledge, and career growth opportunities (Levett-

Jones & Dip, 2005).

Salary

Nelson & Folbre (2006) assert that if high pay is given in such a way that nurses

feel respected and rewarded for their care and professionalism, feelings of vocation can

be reinforced and expanded, and the lack of wage incentives in the U.S. are only one

factor leading to the labor shortage and the need for recruitment of foreign-trained nurses

(pp. 127-130). The fact that temporary nurses earn more and can choose their own

schedules makes temporary nursing an attractive option for nurses, and a source of

dissatisfaction for the staff nurse working alongside them for less pay and little control

over his or her work schedule (JCAHO, 2001)

Mee (2008) reported similar results from the Nursing 2006 Salary Survey with

respect to factors affecting the salaries of the 1,100 registered nurse respondents.

Overall, male respondents earned significantly higher salaries than female respondents

which may have been based upon: more males reporting who work in hospitals, working

in large facilities, being certified, and holding management positions (p. 46). Although

all educational levels reported significant increases in annual salaries as well as advances
in education, the relatively high salaries of diploma nurses reflected the length in time for

which they have been in nursing (p. 47). Nurses who were certified earned more than

uncertified nurses (p. 47) although reimbursement for continuing education was reported

to have decreased in organizations (p. 48). Hospitals continued to pay nurses better than

other practice settings and hospital size affected reported salaries as the more beds in a

facility, the higher the salaries reported by nurses (p. 48). Work settings as well as the

following units: emergency department, oncology, intensive care, and operating room,

were reported to pay the highest salaries (pp. 48-49).

Conversely, low salaries and lack of pay increases have a direct impact on

satisfaction in the healthcare environment and in the retention of aging nurses (Cooper,

2003). Nelson & Folbre (2006) reporting on why a well paid nurse is a better nurse

purport that people with real financial responsibilities for themselves and their families

would find it difficult to choose a low-wage nursing job however caring, competent, and

vocation-oriented. They will instead take jobs that pay wages sufficient to support

themselves and their families in other occupations (p. 128)

Job/Career Satisfaction

Work satisfaction is a complex construct derived from attitudes and perceptions

of various elements of work (Shader, Broome, Broome, West, & Nash, 2001). The

activities and attitudes of nurses may be an important contributing factor to the overall

job satisfaction of nurses. Satisfaction arises from attitudes related to work, such as (1)

degree of enjoyment (2) perceptions of the work environment (3) reward system (4)

autonomy, and (5) professional status (Shader, Broome, Broome, West, Nash, 2001, p.

211).
 McNeese-Smith (1999) collected data through semi-structured and taped

interviews from thirty staff nurses working in a university affiliated hospital in

California. The purpose of the study was to identify and describe staff nurses views of

their job satisfaction and dissatisfaction. By the use of content analysis, themes were

identified describing what creates and contributes to both job satisfaction and job

dissatisfaction. Nurses were recruited from an earlier survey on job satisfaction as this

methodology was used to increase the probability of interviewing nurses who had clearly

identified feelings about their jobs (p. 1334). Of the predominantly female study

population, 23% were diploma-prepared, 23% were associate-prepared, and 43% were

baccalaureate-prepared in their basic education programs. Of interest, 67% obtained their

nursing education outside of the United States. Factors which caused job satisfaction

were described as: patient care, environment, balanced workload, relations with co-

workers, personal factors, salary and benefits, professionalism, cultural background, and

career stage. Factors which caused job dissatisfaction were described as: patient care,

feeling overloaded, relations with co-workers, personal factors, organizational factors,

and career stage of the nurse. In the area of professionalism, five themes were identified:

the centrality of nurses to patient care, opportunities for independent thinking,

opportunities for input to the organization, opportunities for professional growth, and

opportunities for learning in a university medical center (p.1336). Although there were

several themes that caused job satisfaction as well as job dissatisfaction, the environment,

salary and benefits, and cultural background were not described in relation to job

dissatisfaction. In the area of relations with co-workers, seven themes were identified:

co-workers and other departments who provide poor patient care, poor job performance
tolerated by the organization, negative attitudes of coworkers, co-workers don‟t follow

policy, criticism from co-workers, physicians blame nurses, and rude physicians. These

factors related to nurses, no matter what their educational preparation. High levels of

professionalism by nurses in the work environment can serve to mediate job

dissatisfaction and intent to leave the profession.

Lynn & Redman (2005) surveyed (N=787) registered nurses from 5 states about

their intent to leave nursing or nursing career regressed onto organizational commitment,

work satisfaction, age, education, financial status, hospital size, and the adequacy of

staffing. Negative predictors of intent to leave current position were: professional

satisfaction, satisfaction with workload, extent to which nurses liked to work, and their

satisfaction with colleagues (p. 268). Negative predictors of intent to leave nursing were:

professional satisfaction, satisfaction with intrinsic rewards and the nurses‟ financial

situation (p. 268).

Murphy (2005) provides data on the level of job satisfaction reported by Iowa‟s

nursing home administrators, their intention to remain within the profession, and loyalty

to their organizations. The demographics of this group mirror the data published from

similar studies utilizing nurses. The mean values for the respondents were: age was

46.87 years, 12.65 years to retirement, worked 49.87 hours per week, licensed for 11.87

years, worked in the facility for 2.61 years, with the percentage of males being 44.3% to

that of females at 55.7%. The Job Descriptive Index (work, pay, people at work,

supervision/assistance) tool was used to measure five aspects of job satisfaction along

with the Job In General Scale that evaluates overall job satisfaction. Of significance was

that as the respondent‟s satisfaction about their current work increased, so did their
general attitude about their career choice and less significance was seen between attitudes

about coworkers and their job in general (p. 339). Also, when respondent‟s reported their

coworkers in a more positive light, their satisfaction with their work increased (p. 339),

and pay status was reported as “well paid” (p. 342). Career retention, job satisfaction and

dissatisfaction of nursing home administrators compares to that of other occupations.

A number of models have been developed to explain nurse turnover behavior.

While they vary in level of complexity and in factors singled out to predict behavior, they

all describe a multistage, attitudinal (involving some aspect of satisfaction), decisional,

and behavioral process (Irvine & Evans, 1995, p. 246). Perry (2008) makes the

connection to achieving career satisfaction for the registered nurse stating that:

(a) Registered nurses who achieve genuine career satisfaction thrive

professionally

(b) Nurse‟s experience career satisfaction when they uphold the vulnerable and

go the extra mile

(c) Meaningful nurse patient connections promote career satisfaction

(d) Nurse educators play a vital role in facilitating career satisfaction for

registered nurses (p. 23)

Consistent with the findings of Hoffman (2003) who sampled registered nurses

from the Michigan Nurses Association concluded that pay, autonomy, and professional

status were the most important determinants of career satisfaction and the least important

determinants of career satisfaction were interaction with other nurses and physicians, task

requirements of their position, and organizational policies (p. 339).

Retention and Intent to Stay

Cowin (2002) studied the effect of job satisfaction on retention. A longitudinal

design was utilized to elicit nurse‟s attitudes toward their job satisfaction and retention

plans. The Nurses Retention Index (NRI) utilizing a newly created eight-item index

measuring nurse‟s intention of staying in their nursing job or leaving to find other work

was utilized. The participants for this study were two groups of nurses differentiated by

their nursing experience. The first group were in their last semester of the Bachelor of

Nursing program in Sydney, Australia, and the second group were experienced nurses in

NSW, Australia. There were eight declarative statements utilized with forced choices

and a Likert type scale. The results demonstrated that nurses view themselves as

professionals affects their intention to continue in their nursing career. The researchers

expected that new graduates retention plans would exceed experienced nurses. What was

evident was that the graduate group rated their retention plans as less than the

experienced nurse group.

Conversely, Cameron (1994) used a multivariate approach while surveying

registered nurses and comparing demographics, work environment, and goodness of fit.

They found that nurses were moderately satisfied with their jobs however, those with

greater seniority reported higher levels of job satisfaction, lower levels of burnout, and

were less likely to leave their current work positions.

Irvine & Evans (1999) suggest that behavioral intentions are directly related to

turnover behavior. In their theoretical model, economic, sociological, and psychological

variables were identified as being related to turnover behavior, primarily through the

relationship with job satisfaction (p. 249). They found a positive relationship indicating
that as nurses develop their intentions to leave, they are inclined to follow through with

turnover behavior (p. 247).

Duffield, Pallas, & Aitken (2004) sought to study nurses who had left nursing and

were currently working in positions outside of nursing by investigating why they became

nurses, how long they had been in nursing, and their reasons for leaving (p. 664). They

concluded that the reasons for becoming a nurse included altruistic reasons, nursing as a

stepping-stone and as a default choice. In stark contrast, the reasons why nurses left the

profession included legal and employer issues, external values and beliefs about nursing,

professional practice issues, work and home life balance, and contract requirements.

Higher initial nursing qualifications were associated with shorter tenure; however, higher

educational attainment after initial entry to the profession was associated with longer

tenure, as with holding a more senior nursing position (p. 665). This would imply that

other factors may contribute to the enhancement of professional identity and

commitment.

Similarly, Nogueras (2006) utilized the Three-Component Model of Occupational

Commitment to explore perceptions of affective (attachment), normative (obligation),

and continuance (penalty for leaving) commitment with respect to the profession of

nursing (p. 86) to sample RNs (N=908) utilizing the Nursing Spectrum website. The

inclusion criteria were that the participant must hold a current RN license and be

currently employed as an RN practicing in a clinical setting. After testing the model, she

revealed that: in all three aspects, the higher the commitment the less likely nurses intent

to leave the profession, as age or years of experience increased, nurses‟ levels of

commitment to the profession increased significantly, as level of education increased so

did level of professional commitment, and gender demonstrated no correlation with

organizational commitment (pp. 92-93).

At the very least, all nurses assume more responsibilities and struggle to adapt to

changing roles. Failure to adapt to change becomes obvious with the loss of talented

nursing staff at any level of the organization and is expensive in terms of costs of

recruiting, orienting, and replacing the nurse (Jost, 2000). It is essential that nurses work

together to change the public image of nursing and to change their own attitudes that hold

them back from introducing innovation and change (Oughtibridge, 1998, p. 24).

Williams, Stotts, Jacob, Stegbaurer, Roussel, & Carter (2006) provided an

understanding of why inactive registered nurses in Mississippi chose to become inactive

and what it would require for them to return to nursing. They surveyed (N=238)

registered nurses utilizing questions aimed at factors encouraging the inactive registered

nurse to return to the nursing work force (preference of full-time/part-time, shifts, limited

duty/non patient care, reduction in patient load), and additional questions related to salary

incentive, accommodation for education, and work-related decisions. The education

levels for the sample population were: Associate degree (50%), Diploma degree (9%),

and Baccalaureate degree (35%). The gender distribution was: men (9%) and women

(91%). The Index of Work Satisfaction tool evaluated previous job satisfaction, pay,

autonomy, task requirements, organizational policies, professional status, nurse-nurse

interactions, and nurse-physician interactions. Results demonstrated that a major portion

(28%) of the nurses left nursing because of parenting duties and scheduling conflicts

(14%), and salary (13%). They indicated that returning to work would be feasible with

more flexible scheduling, decreased shifts and workload. The lowest concentration of
Registered Nurses per 100,000 population exists in the western South Central states of

Arkansas, Louisiana, Oklahoma, and Texas as well as in the Pacific states of Alaska,

California, Hawaii, Oregon, and Washington (Valentino, 2002).

Rambur (2005) studied a population of (N=878) registered nurses in Vermont

during the fall of 2002. She hypothesized that when comparing BSN to AD-educated

nurses, they will have different career patterns followed by greater longevity in the

workplace, and BSN-educated nurses compared to AD-educated nurses will report higher

levels of job satisfaction related to job and organizational dimensions. This study

population was part of a previous RN Job Analysis and Retention Study. Findings

indicated that satisfaction with supervision and pay were slightly lower for both groups,

satisfaction with autonomy, growth, and job security were higher for both groups, and

BSN nurses were significantly more satisfied than AD nurses to such satisfaction factors

as: opportunity for autonomy and growth, job stress and physical demands, job and

organizational security. There were no differences in job satisfaction related to

supervision, career, continuing education, pay, promotion, pay and benefits (pp. 190-

191). Although these variables are unique to this group, they are relevant variables of

interest in study in all nurse populations as a determinant of degree of professionalism,

and intent to remain in the profession.

Mentorship

A mentor provides the protégé with knowledge, advice, challenge, counsel, and

support in the protégé‟s pursuit of becoming a full member of a particular profession, and

demonstrates the many behaviors specific to the profession which often produces faster

learning than direct experience (Clark, 2000). More importantly, a mentor is simply
someone who helps someone else learn something the learner would otherwise have

learned less well, more slowly, or not at all. Nurses at every educational level would fair

well to consistently monitor and engage in attainable professional behaviors in order to

be active participants in moving the profession forward. Nurses who have used mentors

in their nursing careers reported the ability to emulate the positive traits demonstrated by

their mentors, such as discipline and job dedication (Carey & Campbell, 1994) as well as

the mentor gaining a degree of personal satisfaction from the relationship while

contributing to the professional development of the mentee (Grindel, 2003).

Zey (1997) outlines a hierarchy of mentoring in 4 levels and infers that the

contributions received from each of these functions are not of equal value to the protégé:

Level I – Teaching – protégé receives instruction in organizational and

management skills, social graces, and insider information
Level II – Psychological/personal - mentor enhances protégé‟s self-confidence,
and may help in personal life
Level III – Organizational – mentor intercedes on behalf of protégé in
organizational setting
Level IV – Sponsoring – mentor recommends protégé for promotion or more
responsibility (p. 8)

Dreher & Ash (1990) explored gender differences in mentoring experiences

associated with career outcomes in managerial and professional occupations among

degree programs and class years. They concluded that individuals who experienced

extensive mentoring relationships reported receiving more promotions, higher incomes,

and were more satisfied with pay and benefits than those who reported less extensive

mentoring relationships.

Lafoley (2000) offers that while education prepares us to practice, mentoring

enables us to survive, develop, and achieve full potential (p. 94). If one understands

mentoring as a partnership, it is easy to see that a natural course may be one in which the
person mentored develops confidence and independence, and the role of mentor-teacher

evolves from authority to guide, and finally to colleague and companion (Bligh, 1999)

leaving the mentor with the personal satisfaction that comes from helping others realize

their potential or beyond (Wynn, 1998). Simply put, mentoring is what mentoring does;

teach, coach, and designed in part to impact attitudes and behaviors of currently

practicing registered nurses both formally and informally.

While registered nurses in all states exhibit a different measure of

professionalism, there is no deviation from the Code of Ethics for which we are bound to

uphold as licensed professional nurses. Table 5 compares the similarity of the attitudinal

dimensions from Hall‟s Professionalism Scale and the ANA Code of Ethics provision

statements from the state Nurse Practice Act. Both serve as tools to evaluate the

compliance to values, attitudes, and standards of professional behavior.

Study Hypotheses

Based on the findings in the literature, the hypotheses in this study are:

Hypothesis 1: The degree of professionalism will significantly differ by basic

educational level among practicing registered nurses in South Texas.

Null Hypothesis1: The degree of professionalism will not differ by basic educational

level among practicing registered nurses in South Texas.

Hypothesis 2: The degree of professionalism will significantly differ by basic educational

level among practicing registered nurses in South Texas when controlled for by age.

Null Hypothesis 2: The degree of professionalism will not differ by basic educational

level among practicing registered nurses in South Texas when controlled for by age.

Hypothesis 3: Level of education is a strong predictor of degree of professionalism when

correlated to: age, gender, shift worked, employment status, professional organization

membership, professional journal subscription, professional certification, role in

organization, practice years, practice setting, continuing education hours, salary,

expressed degree of satisfaction, and mentorship.

Null Hypothesis 3: Level of education is not a strong predictor of degree of

professionalism when correlated to: age, gender , shift worked, employment status,

professional organization membership, professional journal subscription, professional

certification, role in organization, practice years, practice setting, continuing education

hours, salary, expressed degree of satisfaction, and mentorship.

Table 5
Comparison of Hall‟s Professionalism Attributes to the ANA Code of Ethics Statements
Hall‟s Professionalism Scale,(1965)
revised by Schack & Hepler, (1979)
Dimensions
Professional Organization as a Major
Referent
for
Belief in Continuing Competence
Belief in Self-Regulation
Sense of Calling to the Field
Autonomy
Belief in Service to the Public
ANA Code of Ethics for Nurses (2001)
Provisions
The profession of nursing, as represented by
associations and their members, is responsible
articulating nursing values, for maintaining the
integrity of the profession and its practice, and for
shaping social policy.
The nurse owes the same duties to self as to
others, including the responsibility to
preserve
integrity and safety, to maintain competence, and to
continue personal and professional growth.
The nurse is responsible and accountable for
individual nursing practice and determines the
appropriate delegation of tasks consistent with the
nurse's obligation to provide optimum patient care.
The nurse participates in the advancement of
the profession through contributions to practice,
education, administration, and knowledge
development.
The nurse, in all professional relationships, practices
with compassion and respect for the inherent
dignity, worth and uniqueness of every individual,
unrestricted by considerations of social or economic
status, personal attributes, or the nature of health
problems.
The nurse's primary commitment is to the patient,
whether an individual, family, group, or community.
The nurse participates in establishing, maintaining,
and improving healthcare environments and
conditions of employment conducive to the
provision of quality health care and consistent with
the values of the profession through individual and
collective action.
The nurse collaborates with other health
professionals and the public in promoting
community, national, and international efforts
to meet health needs.
 CHAPTER III
RESEARCH METHODOLOGY

The primary objective in this research utilizing a cross-sectional, survey method was

to determine if differences existed in the degree of professionalism defined by Hall (1968)

and revised by Schack and Helpler (1979) in actively practicing registered nurses educated

in three basic educational programs and other workplace variables. Hall (1968) proposed

five attitudinal attributes toward professionalism exist in occupations (professions): Use of

the Professional Organization as a Major Referent, Belief in Service to the Public, Belief in

Self-Regulation, Sense of Calling to the Field, Autonomy with the sixth attribute of Belief

in Continuing Competence added by Schack and Helpler (1979). While nurses who

received their basic nursing degree from three types of nursing programs achieve

professional status through the same licensing examination, can differences in the degree of

professionalism be solely attributed to education or can other variables influence these

attitudinal attributes as demonstrated in practice. It is hypothesized that there is a difference

in professionalism specifically the attitudinal attributes in this sample of practicing

registered nurses and can be documented by survey methodology. Additionally, there are

professionalizing agents inside and outside of the work environment which may also

influence attitudinal attributes toward professionalism. The target population for this study

was currently practicing registered nurses randomly selected from 64 counties comprising

South Texas.

Data Collection

A questionnaire was mailed to collect demographic and attitudinal data during the

Fall of 2007. Dillman (2000) suggests that by mixing different survey modes, it serves to

141
 142

improve response rates and reduce non-response. The Texas Board Of Nursing provided a

list of actively practicing registered nurses in Texas by county and of those, 64 counties

were determined by the Texas Map Master to be representative of South Texas. From this

list, a computer program randomly selected 776 names which served as the sample

population for this study. After approval by the institutional review board, the first mailing

was the prenotice postcard (Appendix B) informing nurses that they will be asked to

participate in an important survey. Due to the holiday season and the usual processing

timeframe for the United States Postal Service to deliver postcards, it was decided to delay

the initial mailing of the initial survey packet for a few additional days. That time was

utilized to evaluate the number of possible returned postcards that would lead to returned

packets due to undeliverable addresses for future mailings. Two weeks later, the second

mailing included a cover letter (Appendix E), survey tool and demographic form

(Appendix D), token bookmark (Appendix I), and a stamped, self-addressed return

envelope. Four weeks later, the third mailing of a second postcard (Appendix C) was sent

to all potential respondents thanking them and encouraging them to participate by

completing the survey if they hadn't already done so or to utilize the website to complete the

secure electronic survey. The web address for the electronic version of the questionnaire

was also available for prospective study participants to utilize in lieu of returning the mailed

survey. A fourth mailing was sent to non respondents 4 weeks later with a cover letter

(Appendix E), survey tool (Appendix D) and a stamped, self-addressed return envelope

without a second token bookmark. The internet survey was maintained on a secure server

through the Survey Monkey website and remained open until the survey closing date.

Surveys returned through April 31, 2008 were included. In order to maintain anonymity,
respondents were assigned an identifying survey code that contained no personal reference

information. The same identifying survey code was utilized on the electronic and hardcopy

survey for return documentation only. Additionally, most nursing research studies involve

the use of self-reports which is accomplished by indirectly questioning participants

regarding the phenomena of interest (Polit, 1999). A 59% return rate was achieved

(409/694).

Design

A quantitative, descriptive research design and questionnaire methodology was

utilized to provide insight, and descriptive data to answer the research questions. A

voluntary survey was utilized and based upon self-reports provided a cross-sectional

investigation of demographic and educational characteristics for the sample population of

South Texas practicing Registered Nurses. This design was preferable as it allows for larger

population sampling during a specified period. The use of simple random sampling

methods accomplished computation of an unbiased sample such that every actively

practicing registered nurse in the South Texas population has an equal chance of being

selected into the survey sample. A mixture of descriptive, correlational, and inferential

statistical methods were deployed. Gay (1992) reports that descriptive research is effective

in the assessment of attitudes, opinions, demographics, information, conditions, and

procedures (p. 13) while Gall, Borg, & Gall (1996) report that correlational research is

utilized to discover the direction and magnitude of the relationship among variables (p.

756). Inferential research is particularly important in this study as the use of this sample

was designed to be representative of the entire available population. Approval to conduct

the study was obtained from the Institutional Review Board for Health Sciences at TUI
University International.

Sample

The population of interest was 20% of all currently employed Registered Nurses in

South Texas. A listing obtained from the Texas Board of Nursing containing the names,

physical addresses, employment status, basic educational degree, and gender of 62,527

Registered Nurses within 64 counties representative of South Texas. A computer program

was used to randomly select 776 names which became the study sample. The inclusion

criterion was that participants must work more than 20 hours a week and are currently

employed within the designated South Texas counties. A sample size of 409 was achieved.

The study population was determined to be 388 based upon the power analysis in Appendix

D. The desired sample size of 388 was not achieved partially due to mailed data collection

challenges such as undeliverable questionnaires, declined participation, holiday mailing and

return delays, and hesitation to use the available electronic resource.

Of the 776 questionnaires mailed, 244 were returned completed, (20 were received

electronically), 88 declined participation, 77 did not meet the inclusion criteria while 82

were returned undeliverable. The hard copy questionnaires were entered into the secure

electronically maintained database for a return rate of 59% (409/694). Although an overall

35% response rate (244/694) was achieved for this analysis, the data provides valuable

information, and implies that there is need for further exploration of this topic.

Additionally, although believed to add greater accessibility for participation, as reported by

Duffy (2002), web-based research is reported to have a lower response rate than traditional

mailed surveys.
 Based upon the Texas Board of Nurse Examiners biannual licensure data, the

demographic characteristics of these respondents are representative of nurses practicing in

Texas. A potential bias exists in studies that fail to acquire a response rate of at least 80%,

such that it cannot be determined whether the non-respondents are different from the

respondents (Irvine & Evans, 195, p. 247). There has also been a decrease seen in the

response rates for the National Sample Survey of RNs which is conducted by the Division

for Nursing of the Health Resources and Services. A 20% to 30% response rate for

unsolicited mailed surveys is to be expected (Fink, 1995)

Participants were instructed to respond to the items based upon the way they felt and

behaved as a member of the nursing profession.

Research Instrument

Hall‟s Professionalism Scale assesses five attitudinal attributes toward

professionalism. Schack & Hepler (1979) added the sixth attribute. This instrument was

designed to measure the professional attitudes of practitioners from various occupations.

Structural variables such as age, gender, shift worked, employment status, professional

organization membership, professional journal subscription, professional certification, role

in organization, practice years, practice setting, continuing education, salary, expressed

degree of satisfaction, mentorship which have been associated with professional behavior

were added as control variables. The demographic sheet was utilized to collect information

on these variables. The professionalism scale utilizes a combination of both positively and

negatively oriented questions to score nurses responses to situational activities, value

judgments, and opinions which are applicable to their practice experiences. Using attitude

scales can enhance the ability to correctly measure the phenomenon under investigation
since a scale provides the opportunity to view responses to individual items within the

context of the individuals overall response thus minimizing the possibility of

misinterpretation based on a single item indicator (Adams, 1998). Analysis was undertaken

in order to describe differences within groups.

Hall's Professionalization Scale was originally tested by collecting self reported data

utilizing professions such as physicians, nurses, teachers, accountants, lawyers, social

workers, stockbrokers, librarians, engineers, personnel managers, and advertisement

executives. Snizek (1972) studied aeronautical, nuclear, and chemical engineers, chemists,

and physicists, while Schack & Hepler (1979) studied pharmacists with the addition of the

sixth dimension which was intended to broaden the requirements of the ideal professional

attitude set and to increase measurement reliability (p. 99). Professionalism is

operationalized through the six-attitudinal dimensions within Hall‟s Professionalism Scale

(1969) as revised by Schack & Hepler (1979):

1) Use of the Professional Organization as a Major Referent

This dimension suggests that for the professional, professional organizations,

associations, and colleagues exist to enhance and reinforce the values, beliefs, attitudes, and

identification with a profession. Members of the occupation are socialized into the

profession by reading journals, publications, attending workshops and conferences, as this

will influence the adoption of norms and standards of the profession (Snizek, 1972; Schack

& Hepler, 1979)

2) Belief in Service to the Public

This dimension reviews the extent to which members believe that their occupation is

indispensable and beneficial to both society and the member (Snizek, 1972; Schack &
Hepler, 1979). Practitioners may be slow to develop this when the general public has

difficulty believing in the indispensability of the services rendered (Snizek, 1972).

3) Belief in Self-Regulation

This dimension expounds for the professional the belief that a major form of control

for the occupation is by peer or colleague control. Only fellow professionals should judge

the performance of the professional. Outsiders to the occupation are not in the position or

needed to judge the work of those within the occupation (Snizek, 1972; Schack & Hepler,

1979.)

4) Sense of Calling to the Field

This dimension frames for the professional the commitment of the member to the

occupation. A professional is totally devoted to his/her work. The practitioner shows pride

in his/her work, and derives a great deal of personal satisfaction from the services he/she

performs (Snizek, 1972; Schack & Hepler, 1979).

5) Autonomy

This dimension recognizes the freedom and right to make decisions about work

related issues that are free of external pressures from persons who are not members of the

profession which may influence behavior (Snizek, 1972; Schack & Hepler, 1979).

6) Belief in Continuing Competence

In order to maintain an adequate level of competence, and remain abreast of new

concepts, the professional must make a personal commitment to continually extend his or

her professional knowledge (Schack & Hepler, 1979).

Hall‟s Professionalism Scale was scored utilizing a five point Likert Scale with 6

dimensions, each consisting of 5 items. Rensis Likert designed the scale as part of his work
in developing procedures for studying people‟s attitudes (Salopek, 2004). Reliability and

validity for this scale has been well established within multiple studies across numerous

professions. Of the original fifty questions with a reliability coefficient of .80, Snizek

(1972) recommended the use of only 25 items to assess five attributes or factors of

professionalism with an overall reliability coefficient of .78. The sixth attitudinal

dimension that was added by Schack and Hepler (1979) brought the total to thirty questions

with a reliability coefficient of .81. Behaviorally oriented statements have been slightly

modified so that they are attitudinally oriented and the questions are evenly spaced in

sequence by dimensions so that every sixth question refers to the attribute of continuing

competence (Underwood, 2001). Underwood (2001) applied this 30 item scale in his study

of victim assistance practitioners and further modified in this study to suit the nursing

profession. The scale of possible choices ranged from strongly agrees to strongly disagree

as a measure of a „strong‟ or „weak‟ association with the attitudinal or behaviorally

worded statement. One point will correspond to the attitudinal item of “strongly agree” and

five points will correspond to the attitudinal item of “strongly disagree”. Since the point

range for each attitudinal dimension can range from five to twenty-five points, the total

score is treated as a continuous variable. Within each attitudinal dimension, the lower the

cumulative score of items, the greater the identification or association with that attitude, and

the greater the cumulative score, the lower the identification or association with that

attitude. Ajzen (1980) in his early work records that standard attitude scaling methods

resulted in a single score representative of a given person‟s general evaluation of

favorableness or unfavorableness toward the behavior in question.

 The time for completion of the questionnaire along with demographic information

will take less than 20 minutes manually and no longer than 15 minutes electronically.

Inclusion criteria was: a) licensure as a currently practicing registered nurse in the state of

Texas, and b) employment as a registered nurse working greater than twenty hours weekly.

Participation in this survey was voluntary and completion of the survey was interpreted as

providing consent for use of the data. In order to maintain anonymity and privacy, mail

contact was the only contact method utilized. The respondent was asked to return the

uncompleted survey or reply on the website if they did not meet the inclusion criteria and

keep the token bookmark as a professional token of appreciation. All participants were

provided the same web link for easy access. Each hard copy questionnaire contained a

unique code and internet respondents were asked to provide that code when utilizing the

secure survey site maintained by SurveyMonkey.com. Once the respondent accepted the

request to proceed and completed the survey, the IP addresses were not tracked or stored.

The paper survey (Appendix D) mirrored the web based survey and were manually entered

upon receipt into the data base for ease of tracking and future analysis. The codes were not

connected to demographic information but served as an indicator to verify participation and

return rate.

Respondents were also asked to provide information on the following control

variables which have been widely used in the literature to explore professionalism: basic

nursing degree, age, gender, employment status, years of practice, employment setting,

professional certification, journal subscription, professional organization membership, role

in organization, practice years, practice setting, continuing education hours, salary,

expressed degree of satisfaction and mentoring relationship (Hall, 1968, Snizek, 1972,

Settersien, 1991, Freeman, 1994, Underwood, 2001, Shafer, Park & Liao, 2002).

Independent and Dependent Variables

The independent variable (IV) in this study is basic educational level and the

dependent variable (DV) is attitudinal attributes toward professionalism. Hall‟s

Professionalism Scale serves to operationalize six attitudinal attributes toward

professionalism reflected by this study sample. An exploration of the independent,

dependent, and control variables offers an opportunity to further examine the relationship of

basic educational level and attitudes toward professionalism among actively practicing

registered nurses in South Texas. Table 6 displays the research questions as they pertain to

those variables and the statistical tests deployed.

Pilot Study

The pilot group participants were convened to review the item statements for content

validity. The statements were slightly modified for this sample of nurses and have been

utilized since 1968 by a myriad of professions to test professionalism. Additionally, the

group participants were asked to detect any problematic areas in utilizing the web server to

complete the electronic version of the questionnaire. The electronic questionnaire was

piloted by twenty currently practicing nurses in various states, at various educational levels,

role affiliations, and settings to identify sentence structure difficulties and/or technical

difficulties related to the web server. Based upon the pilot study, the time requirement to

complete and submit the electronic questionnaire ranged from five to fifteen minutes. The

group evaluated and compared the hard copy questionnaire to the electronic version

finding the functionality of the electronic web-based version to be adequate.

Table 6
Research Questions Related to the Dependent and Independent Variables
Research Question Variable Scale Statistical Test

1. Will baccalaureate- Dependent: ordinal Kruskal-Wallis

prepared practicing registered attitudes toward categorical
nurses report a higher degree professionalism discrete Chi-square
of professionalism within all continuous
dimensions as compared to Factor
associate and diploma- Independent: nominal
prepared practicing registered basic nursing degree ordinal Analysis
nurses in South Texas?

2. Will baccalaureate- Dependent: Kruskal-Wallis

prepared practicing registered attitudes toward categorical
nurses in South Texas report a professionalism discrete Chi-Square
higher degree of continuous
professionalism within all Independent: Generalized
dimensions regardless of age? basic nursing degree nominal
age ordinal Linear Model

and Logistic

Regression

3. Is there a positive Dependent: nominal Kruskal-Wallis

correlation with degree of attitudes toward ordinal
professionalism of actively professionalism continuous Chi-Square
practicing registered nurses basic nursing degree
prepared at the baccalaureate Generalized
level to: gender, age, shift Independent:
worked, employment status, age, gender, shift Linear Model
professional organization, worked, employment
journal subscription, status, professional categorical and Logistic
professional certification, role certification/journal/org
in organization, years of anization, role in dichotomous Regression
nursing practice, practice organization, practice
setting, continuing education, years, practice setting, discrete
salary, expressed degree of job continuing education,
satisfaction, mentorship? Of annual salary, expressed
these variables, which has the degree of job
greater effect or are more satisfaction, mentor
strongly associated with relationship
professionalism?
Procedure / Data Analysis

The sample was obtained from a listing provided by the Texas Board of Nursing.

The sample size calculation and the power analysis are illustrated in Appendix C. Three

hundred and eighty eight participants were required to detect a 10% effect size in

professionalism, using an alpha of .05 with a power of 80%. The smaller 10% effect size

was selected in a conservative approach to identify a larger sample size in order to measure

the strength of the relationship between variables. Demographic characteristic information

is displayed using the mean and standard deviation, frequency and percentage for discrete

variables. Any continuous variables were examined for normality. If the variable was

found to be of non-normal distribution, it was appropriately transformed or a non-

parametric method test was utilized instead.

Comparisons of mean professionalism scores were evaluated between the three basic

nursing degrees. Scores for negatively worded items were reversed so that lower scores

(strongly agree) will consistently reflect a more positive attitude and higher scores (strongly

disagree) will consistently reflect a more negative attitude. Items were examined utilizing

the Kruskal-Wallis test to measure attitudes toward professionalism among basic nursing

degrees. Chi-square test with resultant p-value determined whether there were differences in

degree of professionalism between respondents of associate, diploma and baccalaureate

basic degree programs, and the Tukey-Cremer test for multiple comparisons. Generalized

linear model regression analysis and logistic regression (dichotomized dependent variable)

was utilized to learn more about the relationship between several independent or predictor

variables (age, gender, shift worked, employment status, professional organization

membership, professional journal subscription, professional certification, role in

organization, practice years, practice setting, continuing education hours, salary, expressed

degree of satisfaction, mentorship) toward the dependent variable (attitudinal attributes

toward professionalism). Linear regression provided a way to analyze whether a dependent

variable is affected by several independent variables (Babbie, 2001). Items will be

evaluated based on the mean score < 2 or > 4, standard deviation < 0.95 and, the coefficient

of variation < 20% for sufficient variance.

The scree test and parallel analysis criterion was utilized to determine the number of

meaningful factors. A principal component for exploratory factor analyses with oblique

rotation was performed to account for correlated factors. Items with communality < .2 or

loadings < .40 in the factor analyses were evaluated, as were those with item-total

correlation < .20 for the overall scale. Internal consistency for scale items was examined

using Cronbach‟s coefficient alpha for scale reliability. Statistical analysis was performed

utilizing SAS Version 9.3 (SAS Institute Inc., Cary, N.C.). The P-value < 0.05 was the

chosen level of significance.

The assumption of this analysis is that the level of agreement with the 5 item

statements is used to indicate the level of professionalism of that specific attribute.

Glassman (2006) supports the assumptions that attitudes predict behaviors. He found that

those behaviors represented as a continuous measure (ex: continuing education hours) better

captured different degrees of favorableness toward an object. They were more reliable

indicators of behavior compared to dichotomous measures (ex: journal subscription).

After approval from the Institutional Review Board, questionnaires were mailed to

the home address listed for the 776 practicing registered nurses. Confidentiality and

anonymity was protected. The survey end date was extended in order to maximize the
number of completed surveys. All surveys received by April 31, 2008 were utilized in the

data analysis.

Research Questions

The purpose of this study was to explore the level of professionalism among

registered nurses prepared in different basic degree programs utilizing six attitudinal

indicators of Hall‟s Professionalism Scale.

1. Will baccalaureate-prepared practicing registered nurses report a higher degree

of professionalism within all dimensions as compared to associate and diploma-prepared

practicing registered nurses in South Texas?

2. Will baccalaureate-prepared practicing registered nurses in South Texas report

a higher degree of professionalism within all dimensions regardless of age?

3. Is there a positive correlation with degree of professionalism of actively

practicing registered nurses prepared at the baccalaureate level to: age, gender , shift

worked, employment status, professional organization membership, professional journal

subscription, professional certification, role in organization, practice years, practice

setting, continuing education hours, salary, expressed degree of satisfaction, and

mentorship. Which of these variables has the greater effect or are more strongly associated

with professionalism?

Conceptualization of Attitudes Toward Professionalism

Professional Organization as a Major Referent

Shared beliefs and values reinforce professional identity, group norms, and

standards of practice for members within the nursing profession. One of the easiest and

least expensive ways to enhance professional standing and development is to join

professional associations (Farren, 1997). Once the practitioner acquires this consciousness,

he becomes more strongly influenced by standards established by his professional

organization (Schack and Hepler, 1979). Membership allows for dissemination of

information and planned meetings for the purpose of education and comrodarie among

nurses of all levels.

Belief in Service to the Public

This belief in public service is evidenced by the professional putting the interests of

his or her clients above their own interests (Schack and Hepler, 1979). The professional

nurse believes that their work is indispensible and beneficial to society.

Belief in Self-Regulation

This belief in self-regulation is evidenced by belief in the practice of colleague

control (Schack and Hepler, 1979). If nurses as the professional group cease to be judges of

fellow members‟ performance, the loss of authority and control over their work might

ensue.

Sense of Calling to the Field

This belief in a sense of calling is evidenced by much pride in the work of the nurse

and the derivation of a great deal of personal satisfaction from the services performed

(Schack and Hepler, 1979) which can exist beyond the economic concept of value for

services rendered. Nursing has been understood as a calling, vocation, profession, and most

recently, a practice (Liaschenko & Peter, 2003).

Autonomy

The nurses‟ ability to responsibly exercise personal judgment and independent

decision making while working within their scope of practice. Autonomy is not an all-or-

nothing affair and will exist to varying degrees in different people suggesting that a certain
level of intellectual and emotional maturity (Scott, 1998). Nurses can be helped toward

greater autonomy.

Continuing Competence

The professional believes that, in order to maintain an adequate level of competence

and to remain abreast of new concepts, he must accept personal commitment to continually

extend his professional knowledge (Schack and Hepler, 1979). The nurse believes in

reading current literature and be involved in formal continuing education in order to

provide competent service (p. 99).

This study was designed to utilize the six attitude dimensions to explore whether

differences exist in the degree of professionalism among currently practicing registered

nurses in South Texas. Additionally, relationships to other demographic variables were

explored.

Measurement Levels of Other Demographic

Variables Education

Currently practicing Registered Nurses in South Texas who have graduated and

awarded a Diploma, Associate (ADN) or Baccalaureate Degree in Nursing (BSN).

Age

Currently practicing Registered Nurses in South Texas report their age to be in the

range of 20 years old or less, 21 – 30 years old, 31 – 40 years old, 41 – 50 years old, 51 – 60

years old, or 61 years old or more.

Gender

Currently practicing Registered Nurses in South Texas report their gender to be male

or female.
Shift Worked

Currently practicing Registered Nurses in South Texas report their primary shift of

duty to be the night shift (8 hour or 12 hour), day shift (8 hour or 12 hour) or evening shift

(8 hour or 12 hour). One shift tour may overlap with another however, the stated tour of

duty represents the majority hours worked of the chosen shift or tour of duty.

Employment Status

Currently practicing Registered Nurses in South Texas work on a part time basis;

more than twenty hours per week or are considered full time by their employing

organization.

Professional Organization

Currently practicing Registered Nurses in South Texas report yes or no to whether

they belong to a professional organization and if yes, give the name(s) of the

organization(s).

Journal Subscription

Currently practicing Registered Nurses in South Texas report yes or no to whether

they subscribe to a professional journal and if yes, give the name(s) of the professional

journal(s). Membership in many professional organizations provides the member with a

complimentary journal subscription.

Professional Certification

Currently practicing Registered Nurses in South Texas report yes or no to whether

they have been awarded national certification(s) and if yes, give the name(s) of the

professional certification(s).
Role in Organization

Currently practicing Registered Nurses in South Texas report their role to be a staff

nurse, supervisor, administrator, instructor or educator, advanced practice, school or office

nurse, researcher or consultant, nurse anesthetist, or other if none of the above.

Practice Years

Currently practicing Registered Nurses in South Texas report their years of nursing

practice to range as <5 years, 6 to 10 years, 11 to 15 years, 16 to 20 years, 21 to 25 years, 26

to 30 years, 31 to 35 years, and >36 years.

Practice Setting

Currently practicing Registered Nurses in South Texas report their practice setting to

be a hospital, outpatient clinic, health department, military installation, nursing home,

industrial organization, school, agency or nursing pool, doctor‟s office, emergency center,

home health, self employed or private duty, correctional medicine, flight nursing or other

setting if none of the above.

Continuing Education

Currently practicing Registered Nurses in South Texas report attaining continuing

education hours within the previous full calendar year ranging from 20 hours or less, 21 –

40 hours, 41 - 60 hours, or 61 hours or more.

Salary

Currently practicing Registered Nurses in South Texas report their annual salary

to range from $20,000 or less, $20,000 - $29,999, $30,000 - $39,999, $40,000 –

$49,999, 50,000 - $59,999, $60,000 - $69,999, $70,000 - $79,000, $80,000 - $89,999,

$90,000 - $99,999 or $100,000 or more.

Job /Career Satisfaction/Intent to Leave

Currently practicing Registered Nurses in South Texas report satisfaction with

their role in nursing now as very satisfied, satisfied, marginally satisfied, dissatisfied, or

intent to leave the profession.

Mentorship

Currently practicing Registered Nurses in South Texas report yes or no to whether

they have been involved in a mentoring relationship in their nursing career and if yes, they

list the number of mentor(s) and whether the mentor(s) was within and/or outside of the

nursing profession. Each nurse responds to both so that a zero means that the mentor was in

only one category (within and/or outside of nursing).

 CHAPTER IV

DATA ANALYSIS AND RESULTS

Descriptive, quantitative, cross sectional research design was utilized to address the

research hypotheses. It is an appropriate approach in describing and explaining the results at

one point in time. Numerical data was collected by questionnaire and subjected to

appropriate statistical analysis. Data analysis for this study employed basic descriptive

statistics such as scale mean scores, standard deviations, frequency distribution, Cronbach

Alpha Coefficient, and inferential statistics to draw inferences about the sample population

using SAS Version 9.3 (SAS Institute Inc., Cary, N.C.). In descriptive research, there is no

intent to describe a relationship between variables and there may be a focus on more than

one variable. Data was analyzed to determine whether there was a statistically significant

difference in attitudes toward professionalism among diploma, associate, and baccalaureate-

prepared registered nurses. Respondents were asked to respond to answer the 30 item

statements according to the extent of their agreement or disagreement. Variables were

subjected to the SAS FREQ Procedure by description of frequency distribution of variables

by basic nursing degree with a Mantel-Haenszel Chi-Square (to account for cell values

which may be less than 5) and resultant p-value, SAS MEANS Procedure for the mean

values of the professionalism scores for each variable with the Wilcoxin Rank Sum Test and

Kruskal-Wallis test for Chi-Square with resultant p-value and the generalized linear

regression model utilizing the SAS GENMOD procedure by class and levels to evaluate the

relationship or interaction between dependent variables to multiple independent variables.

The nonparametric Kruskal-Wallis test was used to determine whether diploma, associate,

or baccalaureate-prepared registered nurses influence on professionalism scores based

upon

160
 161

one independent variable with two or more levels. It is also referred to as a non-parametric

version of ANOVA. Generalized univariate linear regression analysis was used to associate

the dependent variable such as a nurse‟s attitude score with the independent variables such

as the gender. Eleven variables inclusive of basic nursing degree were determined to be

important predictors of professionalism and were subjected to generalized multivariate

linear regression analysis (basic nursing degree, age, gender, employment status,

professional organization membership, professional certification, role within organization,

salary, expressed degree of satisfaction, continuing education hours, and mentor

relationship. In the final analysis of the variables of significance, logistic regression was

performed utilizing the SAS LOGISTIC Procedure; binary logit model. Results of data

were reported by a random sample of Registered Nurses (N=244) currently employed

within various healthcare settings in South Texas. There was no missing data however

percentages do not always equal 100 due to rounding of data.

The instrument utilized in this study was Hall‟s Professionalism Scale consisting of

six dimensions or factors with five items or statements each for a total of thirty item

statements. This study addressed the following hypotheses based on findings in the

literature:

Hypothesis 1: The degree of professionalism will significantly differ by basic

nursing degree among practicing registered nurses in South Texas.

Null Hypothesis 1: The degree of professionalism will not significantly differ by

basic nursing degree among practicing registered nurses in South Texas.

Hypothesis 2: The degree of professionalism will significantly differ by basic

nursing degree among practicing registered nurses in South Texas when

 controlled for by age.

Null Hypothesis 2: The degree of professionalism will not significantly differ by

basic nursing degree among practicing registered nurses in South Texas when

controlled for by age.

Hypothesis 3: Basic nursing degree is a strong predictor of degree of

professionalism when correlated to: age, gender, shift worked, employment

status, professional organization membership, professional journal subscription,

professional certification, role in organization, practice years, practice setting,

continuing education hours, salary, expressed degree of satisfaction, and mentor

relationship.

Null Hypothesis 3: Basic nursing degree is not a strong predictor of degree of

professionalism when correlated to: age, gender, shift worked, employment

status, professional organization membership, professional journal subscription,

professional certification, role in organization, practice years, practice setting,

continuing education hours, salary, expressed degree of satisfaction, and mentor

relationship.

Results of this study indicate that further research is needed to explore certain

factors found to influence attitudes toward professionalism in currently practicing registered

nurses in South Texas and can be used to target desirable behaviors.

Construct Validity

By definition, construct is the hypothetical variable that is being measured (Hatcher,

1994). Principle Factor Analysis was performed to examine the communality of the 30 item

statements. Although this tool has been widely utilized to assess professionalism in many
professions, factor analysis was performed on the basis of this population utilizing the SAS

NFACTOR criterion procedure where three principal factors were retained. A scree plot

demonstrated that there were 3 to 4 factors indicated by Eigen values greater that 1 and

factor loading. Items were considered to load to a factor if the loading was greater than

0.40. Chan, Chan & Scott (2007) utilized Hall‟s Professionalism Scale to survey

professionals in the construction industry (N=510) and suggested that their validation was

consistent with a five-factor scale and consistent with the research of Yoder (1995)

research among staff nurses. Underwood (2001) maintained the six-factor scale within his

population to assess the attitudinal dimensions for the construct of professionalism. The

factor structure correlations are contained in Table 7 with possible explanations offered.
Table 7
Initial Factor Method: Principal Components Analysis With Factor Loading
Principle Factors Professional Self-Regulated Autonomous Public
Competence Sense of Calling Service
1 2 3
1. Professional Association As a Major Referent Factor
1. I believe it important to systematically read the
0.65799 0.12281 0.23902
professional journals.
2. I am committed to regularly attend professional meetings at 0.50737 0.12129 0.02789
the local level.
0.68038 0.13447 0.27376
3. I believe that the professional organization(s) should
be supported. 0.46511 0.22716 0.56018*
4. The professional organization doesn‟t really do much for
0.60584 0.03483 0.42705
the average member.
5. Although I would like to, I don‟t think it is a priority to read
the journals too often.

2. Belief in Continuing Competence

1. I can maintain an acceptable standard of practice 0.41725 0.05145 0.55518*
without attending continuing education programs.
0.68297 0.22021 0.47043
2. Continuing education such as self-study or seminars is essential
for my work. 0.43841 0.03492 0.76226*
3. My daily practice is all the continuing education I need.
0.60681 0.08708 0.58441
4. Continuing education is of little importance to my practice.
5. My practice would suffer if I did not attend continuing education 0.51284 0.17400 0.52917*
programs.

3. Belief in Self-Regulation Factor

1. My fellow professionals have a pretty good idea about each 0.24889 0.58612 0.10660
other‟s competence.
0.16589 0.48879 0.38272
2. A problem in this profession is that no one really knows
what his/her colleagues are doing. 0.25515 0.33108 0.61729*
3. We really have no way of judging each other‟s competence.
0.20372 0.20665 0.58216*
4. There is not much opportunity to judge how another
person his/her work. 0.14503 0.67931 0.17140
5. My colleagues pretty well know how well we all do our work.

4. Sense of Calling to the Field Factor

0.42089 0.55214 0.09719
1. People in this profession have a real “calling” for their work.
2. The dedication of people in this field is most gratifying. 0.46407 0.57663 0.19034
3. It is encouraging to see the high level of idealism which is
0.44052 0.45044 0.00584
maintained by people in this field
4. Most people would stay in the profession even if their incomes 0.22463 0.37130 0.03493
were reduced.
5. There are very few people who don‟t really believe in their work. 0.07089 0.34275 0.04124

5. Autonomy Factor
0.34668 0.36425* 0.22592
1. I make my own decisions in regard to what is to be done in
my work. 0.16078 0.33548 0.56449
2. I don‟t have much opportunity to exercise my own judgment.
0.08410 0.32682* 0.28672
3. My own decisions are subject to review.
4. I am my own boss in almost every work-related situation. 0.09195 0.44266* 0.20468
5. Most of my decisions are reviewed by other people.
0.05126 0.42537* 0.37503

6. Belief In Service To The Public Factor

1. Other professions are actually more vital to society than mine. 0.03131 0.04939 0.32012
2. I think that my profession, more than any other, is essential
0.30718* 0.24389 0.08783
for society.
3. The importance of my profession is sometimes over stressed. 0.11101 0.02306 0.60860
4. Some other occupations are actually more important to
0.30738 0.11082 0.40436
society than is mine.
5. If ever an occupation is indispensible, it is this one. 0.04533 0.32512* 0.09815

* = item statements that load to other factors

 Three principle factors were retained. Each has been renamed for the purpose of

explanation only.

Factor 1 – Professional Competence with the appreciable factor structure correlations were

between Professional Association as a Major Referent and Belief in Continuing

Competence which accounted for 4.4% of the variance.

Professional Association as a Major Referent Factor - All but one item

loaded on this factor. Item 4 could have possibly had different implications

for the study sample. A plausible explanation offered may have been related

to the referencing of „average member‟ which could cause some uncertainty

as to whether there is applicable benefit at the member level especially for

non-members.

Belief in Continuing Competence Factor – All but three items loaded onto

this factor. Item 1, 3, 5 could have possibly had different implications based

on the statement reference „practice‟ which might be addressed by

respondents based upon implications to autonomous practice without respect

to the intended inquiry about continuing competence.

Factor 2 – Sense of Self-Regulation and Calling with the appreciable factor structure

correlations were between Belief in Self-Regulation and Sense of Calling to the Field which

accounted for 3.4% of the variance.

Belief in Self-Regulation Factor – All but two items loaded on this factor.

Item 3, 4 could have possibly had different implications related to the

statement reference „judge‟ or „judging‟ of a colleague and not

necessarily
 related to self which might also be addressed under autonomous practice or

competency to judge practice.

Sense of Calling to the Field Factor - All five items loaded to this factor.

Factor 3 – Autonomous Public Service with the appreciable factor structure correlations

were between Autonomy and Belief in Service to the Public which accounted for 4.6% of

the variance.

Autonomy Factor – Only one item loaded onto this factor. Items 1,3,4,5

could have possibly been related to the statement reference „my own

decisions‟ and could have close association with Belief in Self-

Regulation.

Belief in Service to the Public Factor – Item 2 remains difficult to discern as

to the implications of this loading as it has everything to do with public

service. Item 5 could have possibly caused some uncertainty in that the

occupation of nursing as being indispensible and might be addressed

differently by those having greater or lesser Belief in Self-Regulation and

Sense of Calling to the Field.

The item statements within the respective 6 factors were systematically alternated to

minimize elicitation of block responses giving each item greater opportunity to be

considered independently whereby every six statement pertained to factor 6 (Belief in

Continuing Competence). Not surprisingly, feedback was received from two respondents

stating that the item statements were at times redundant. Those items which did not load to

the respective attitudinal dimension are highlighted by an asterisk. Sense of Calling to the

Field was the only true one-dimensional factor where the set of item statements loaded
entirely to that factor. This demonstrated that these item statements contained value

indicating that they were not interpreted differently by the sample population.

Table 8 presents the mean and standard deviation with the calculated Cronbach‟s

Alpha Coefficient to assess internal reliability for each of the individual item statements in

the six dimensions. Cronbach's alpha is an unbiased estimate of the generalizability.

Cronbach's alpha can be viewed as a measure of how well the sum score captures the

expected score in that factor, even if that factor is heterogeneous. About.com: economics

defines Cronbach's alpha as a test for a model or survey's internal consistency to assess the

reliability of a rating summarizing a group of test or survey answers which measure some

underlying factor (e.g., some attribute of the test-taker). It is therefore most beneficial to

know whether the items within the 6 attitudinal dimensions of professionalism are capturing

responses consistently and reliably. Nunnaly (1978) indicates that 0.7 is an acceptable

reliability coefficient however lower thresholds are often accepted in the literature while

George and Mallery (2003) offer the following rules of thumb: > .9 = Excellent, > .8 =

Good, > .7 = Acceptable, > .6 = Questionable, > .5 = Poor, and < .5 = Unacceptable (p.

231). Belief in Service to the Public was the single dimension that demonstrated 4 out of 5

item statements with values falling below this standard threshold while all of the other

dimensions met the .5 or greater threshold. Interestingly, Belief in Continuing Competence

was the dimension that demonstrated the highest mean professionalism scores and also the

highest alpha scores. Also of note is that the results have everything to do with the number

of respondents in the sample population.

Table 8
Standard Cronbach‟s Alpha Coefficient and Attitudes Toward Professionalism (Mean, SD)
Statement or Item for Professionalism Mean±SD Alpha
Coefficient
Professional Association As a Major Referent Factor
1. I believe it important to systematically read the professional journals. 2.13 ±0.88 0.6269
2. I am committed to regularly attend professional meetings at the
2.90±1.02 0.7063
local level.
3. I believe that the professional organization(s) should be supported. 2.16±0.77 0.6502
4. The professional organization doesn‟t really do much for the 2.65±0.96 0.6989
average member.
2.38±0.96 0.6416
5. Although I would like to, I don‟t think it is a priority to read the
journals too often.

Belief in Continuing Competence Factor 2.29±1.11 0.8061

1. I can maintain an acceptable standard of practice without
1.90±0.86 0.7841
attending continuing education programs.
2. Continuing education such as self-study or seminars is essential for my 1.95±0.87 0.7682
work. 1.81±0.82 0.7670
3. My daily practice is all the continuing education I need.
2.22±0.96 0.7789
4. Continuing education is of little importance to my practice.
5. My practice would suffer if I did not attend continuing
education programs.

Belief in Self-Regulation Factor

1. My fellow professionals have a pretty good idea about each 2.30±0.87 0.6839
other‟s competence.
2.29±0.86 0.6680
2. A problem in this profession is that no one really knows what
his/her colleagues are doing. 2.12±0.85 0.6556
3. We really have no way of judging each other‟s competence. 2.22±0.82 0.7006
4. There is not much opportunity to judge how another person
2.40±0.91 0.6846
his/her works.
5. My colleagues pretty well know how well we all do our work.

Sense of Calling to the Field Factor

1. People in this profession have a real “calling” for their work. 2.25±0.92 0.5407
2. The dedication of people in this field is most gratifying.
232±0.86 0.5593
3. It is encouraging to see the high level of idealism which is
maintained by people in this field 2.56±0.84 0.5733
4. Most people would stay in the profession even if their incomes 3.65±1.01 0.6277
were reduced.
2.71±0.89 0.6755
5. There are very few people who don‟t really believe in their work.

Autonomy Factor 2.02±0.92 0.6583

1. I make my own decisions in regard to what is to be done in my work.
2.01±0.89 0.6472
2. I don‟t have much opportunity to exercise my own judgment.
3. My own decisions are subject to review. 3.20±1.06 0.6493
4. I am my own boss in almost every work-related situation. 2.83±1.08 0.5962
5. Most of my decisions are reviewed by other people.
2.80±1.00 0.5404

Belief In Service To The Public Factor

1. Other professions are actually more vital to society than mine.
1.94±0.84 0.3614*
2. I think that my profession, more than any other, is essential for society.
3. The importance of my profession is sometimes over stressed. 2.03±0.94 0.3799*
4. Some other occupations are actually more important to society than 2.20±0.97 0.3831*
is mine.
2.23±0.93 0.2479*
5. If ever an occupation is indispensible, it is this one.
2.54±1.40 0.4876*

*Cronbach‟s Alpha Coefficient <0.5

Relationship Between Respondents to Attitudes Toward Professionalism

Univarate and multivariate analysis was performed to explore the effects of basic

nursing degree and other demographic variables to Hall‟s (1968) attitudinal attributes

toward professionalism. In the final analysis, age, shift worked, practice years, practice

settings, professional certification, and professional journal subscription, had no statistical

significance to attitudinal attributes of professionalism. However, basic nursing degree,

gender, employment status, professional organization membership, continuing education

hours, role in organization, expressed degree of satisfaction, mentorship, and salary

demonstrated statistical significance as predictors of several attitudinal attributes toward

professionalism.

Respondents Frequency Distribution by Basic Nursing Degree

Specifically, Table 9 summarizes the frequency distribution of the reported

demographic characteristics of the nurse respondents per the basic nursing program. Eighty

two percent of the nurses were females (199) with the majority holding a baccalaureate

degree in nursing (99) followed by those with an associate degree in nursing (72). The

majority of male nurses held an associate degree (22/45). No statistically significant

difference was demonstrated between basic nursing degree and gender (p=0.0765).

Approximately eighty five percent of the nurses (208) were between the ages of 31

to 60 years old. The majority was represented by the group of 41 to 60 year old nurses

(155) where baccalaureate degree nurses (98) dominated followed by associate degree

nurses (81). There were no nurses less than the age of twenty and only fourteen nurses were

over the age of sixty across degree programs. A statistically significant difference was

demonstrated between basic nursing degrees and age (p=0.0007).

 The day shift was the primary shift worked by seventy one percent of nurses (174)

and was represented fairly equally by associate degree nurses (78) and baccalaureate degree

nurses (70). The evening shift represented the shift least worked while the majority of

baccalaureate degree nurses worked the night shift (333/51). No statistically significant

difference was demonstrated between basic nursing degrees and shift worked (p=0.3023).

Eighty nine percent of respondents work full-time (216) with the majority of those

nurses holding a baccalaureate degree (103) followed by associate degree nurses (84). The

distribution of part time nurses was fairly equal across degrees. Although close, no

statistically significant difference was demonstrated between basic nursing degree and shift

worked (p=0.0612).

Thirty four percent of the nurses reported membership in professional organizations

(82) with baccalaureate degree nurses (54) representing the majority holding membership.

Sixty six percent reported non membership (162), with the majority represented by

associate degree nurses (76) followed by baccalaureate degree nurses (59). Additionally,

respondents were asked to list the professional organizations for which they held

membership whether at the local, state, and national level and their responses are displayed

in Table 10 (Appendix J). The most represented professional organization was the

American Nurses Association and the Texas Nurses Association. A statistically significant

difference was demonstrated between basic nursing degrees and professional organization

membership (p=<0.0001).

Fifty three percent of nurses did not subscribe to professional journals (129) which

exceeded those who were subscribers (115) and was fairly equally distributed within and

between nursing degrees. Baccalaureate degree nurses represented the majority of both
journal subscribers (59/115) and non subscribers (54/129). Table 10 (Appendix K)

summarizes the list of journals subscriptions reported. Many journal subscriptions are

included in the professional organization membership dues as a benefit to the member while

other journals or magazines may be distributed complimentary from professional

organizations. This list is intended to represent the journals available to nurses and to gain

insightful information into work settings and specialties of nurse respondents. The journals

most referenced were the American Journal of Nursing (22), RN Magazine (24), Nursing

2007 (20), and Journal of Critical Care (11). No statistically significant difference was

demonstrated between basic nursing degrees and journal subscription (p=0.1845).

Seventy two percent of nurses (175) lack professional certification in their

professional fields of expertise. Associate degree nurses represented the majority of non-

certified nurses (77) followed by baccalaureate degree nurses (69), while baccalaureate

degree nurses represented the majority with professional certification (44/69). Table 11

(Appendix L) presents the list of professional certifications that were reported. The top

reported certifications held by this sample were in Emergency Nursing (10), Critical Care

Nursing (10), BC and Medical Surgical Nursing (6). A statistically significant difference

was demonstrated between basic nursing degrees and professional certification (p=0.0042).

Not surprising, sixty-four percent of nurses held the organizational role of staff

nurse (156). Baccalaureate degree nurses (68) shared this role only slightly above associate

degree nurses (57). The second highest role held was that of Supervisor/ Head Nurse (34)

and in majority by associate degree nurses (21). A statistically significant difference was

demonstrated between basic nursing degrees and role in organization (p=<0.0022).

Table 9
Demographic Characteristics and Frequencies by Basic Nursing Degree
Degree
Variable Overall Diploma Associate Baccalaureate P-value
(N=37) (N=94) (N=113)
Gender
Male 45 (18.4) 9 (24.3) 22 (23.4) 14 (12.4)
Female 199 (81.6) 28 (75.7) 72 (76.6) 99 (87.6) 0.0765
Age (yrs)
<20 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
21-30 22 (9.0) 0 (0.0) 9 (9.6) 13 (11.5)
31-40 53 (21.7) 2 (5.4) 26 (27.7) 25 (22.1)
41-50 82 (33.6) 14 (38.0) 30 (31.9) 38 (33.6)
51-60 73 (29.9) 13 (35.0) 25 (26.5) 35 (31.0)
>60 14 (5.7) 8 (21.6) 4 (4.3) 2 (1.8) 0.0007*

Shift
Night 51 (20.9) 9 (24.3) 9 (9.6) 33 (29.2)
Day 174 (71.3) 26 (70.3) 78 (83.0) 70 (62.0)
Evening 19 (7.8) 2 (5.4) 7 (7.4) 10 (8.8) 0.3023

Employment Status
Full Time 216 (88.5) 29 (78.4) 84 (89.4) 103 (91.2)
Part Time 28 (11.5) 8 (21.6) 10 (10.6) 10 (8.8) 0.0612

Professional Organization
Member 82 (33.6) 10 (27.0) 18 (19.1) 54 (47.8)
Non-Member 162 (66.4) 27 (73.0) 76 (80.9) 59 (52.2) <0.0001*

Professional Journal
Subscription
Subscriber 115 (47.1) 13 (35.0) 43 (45.7) 59 (52.2)
Non-subscriber 129 (52.9) 24 (65.0) 51 (54.3) 54 (47.8) 0.1845

Professional Certification
Certified 69 (28.3) 8 (21.6) 17 (18.1) 44 (38.9)
Non-certified 175 (71.7) 29 (78.4) 77 (81.9) 69 (61.1) 0.0042

Role In Organization
Staff Nurse 156 (63.9) 31 (83.8) 57 (60.6) 68 (60.2)
Supervisor/HN 34 (13.9) 3 (8.1) 21 (22.3) 10 (8.8)
Administrative 12 (4.9) 1 (2.7) 6 (6.4) 5 (4.4)
Instructor/Educator 12 (4.9) 0 (0.0) 2 (2.1) 10 (8.8)
Advance Practice Nurse 5 (2.1) 0 (0.0) 0 (0.0) 5 (4.4)
School/Office Nurse 19 (7.8) 2 (5.4) 7 (7.4) 10 (8.8)
Researcher/Consultant 5 (2.1) 0 (0.0) 1 (1.1) 4 (3.5)
Infection Control 1 (0.4) 0 (0.0) 0 (0.0) 1 (0.01) 0.0022

*p<0.05 Note: Frequencies (percent)

 Approximately forty percent of the nurses reported practice years between 11 - 15

years (48) and 21 - 25 years (49) followed by thirty percent of nurses reporting practice

years between 6 - 10 years (38) and 16 - 20 years (35). The distribution was fairly equal

for practice years from <5 to 30 years among associate and baccalaureate degree

nurses. Although diploma-prepared nurses (4) represent only a small sample in this

study, they represent the majority of nurses with practice years exceeding 36 years (3). The

least amount of nurses reporting 31 years of practice and over (16). A statistically

significant difference was demonstrated between basic nursing degree to years

of nursing practice (p=<0.0190).

One of the requirements for renewal of nursing licensure in the state of Texas

is twenty hours of continuing education hours and also exists in many other states. Forty

one percent of associate degree nurses (45) and thirty one percent of baccalaureate degree

nurses (41) received < 20 hours of continuing education (108). Fifty percent of

baccalaureate degree nurses (52) received 21 - 40 hours of continuing education. A

statistically significant difference was demonstrated between basic nursing degrees and

continuing education hours (p=0.0039).

Not surprisingly, the primarily employment setting for sixty-five percent of

respondents was in hospitals (156) where baccalaureate degree nurses (76) dominated by

associate degree nurses (56). The second largest practice setting was school nurses (20)

with the majority being baccalaureate degree nurses (11) followed by associate degree

nurses (7). Home health care settings (12) and outpatient clinics (12) ranked third. The

other practice settings were diverse across nursing degrees. No statistically significant

difference was demonstrated between basic nursing degrees and continuing employment
setting (p=<0.6523).

Approximately eighty-five percent of salaries reported ranged from $40,000 -

$89,000 dollars (209). Baccalaureate degree nurses dominated equally within the $40,000 -

$49,000 (21) and the $70,000 - $79,000 (21) range whereas associate degree nurses

dominated within the $50,000 - $69,000 range (46). There were no baccalaureate degree

nurses earning less than $30,000 just as there were no diploma nurses earning over $90,000.

A statistically significant difference was demonstrated between basic nursing degree and

salary (p=0.0004).

Satisfaction was assessed as a statement of expressed contentment for the current

professional role ranging from very satisfied to intent to leave their current role in the

profession. There was no intent to place time limits or document circumstances for the

responses presented. Twenty-seven percent of nurses reported being very satisfied (66)

with baccalaureate degree nurses representing forty-eight percent (32). Fifty three percent

of nurses reported being satisfied (130) with forty-six percent of baccalaureate degree

nurses (61) representing the majority followed by associate degree nurses (49). Dissatisfied

(9) and intent to leave (7) was reported in majority by associate degree nurses (10/16). The

majority of marginally satisfied nurses were baccalaureate degree nurses (18/32). No

statistically significant difference was demonstrated between basic nursing degree and

satisfaction with role in nursing. (p=0.1802).

Table 9
Demographic Characteristics and Frequencies by Basic Nursing Degree (cont‟d)
Degree
Variable Overall Diploma Associate Baccalaureate P-value
(N=37) (N=94) (N=113)
Years of Nursing Practice
<5 28 (11.5) 0 (0.0) 16 (17.0) 12 (10.6)
6 – 10 38 (15.6) 0 (0.0) 14 (14.9) 24 (21.2)
11 – 15 48 (19.7) 6 (16.2) 22 (23.4) 20 (17.7)
16 – 20 35 (14.3) 6 (16.2) 17 (18.1) 12 (10.6)
21 – 25 49 (20.1) 14 (38.0) 13 (13.8) 22 (19.5)
26 - 30 30 (12.3) 8 (21.6) 8 (8.5) 14 (12.4)
31 – 35 12 (4.9) 0 (0.0) 4 (4.3) 8 (7.1)
> 36 4 (1.6) 3 (8.1) 0 (0.0) 1 (0.01) 0.0190*
Continuing Education Hours
< 20 108 (44.3) 22 (59.3) 45 (47.9) 41 (36.2)
21 – 40 104 (42.6) 14 (38.0) 38 (40.4) 52 (46.0)
41 – 60 27 (11.1) 1 (2.7) 8 (8.5) 18 (16.0)
> 61 5 (2.0) 0 (0.0) 3 (3.2) 2 (1.8) 0.0039*
Practice Setting
Hospital 156 (64.9) 24 (65.0) 56 (59.5) 76 (67.2)
Outpatient Clinic 12 (4.9) 3 (8.1) 4 (4.3) 5 (4.4)
Health Department 2 (0.8) 0 (0.0) 2 (2.1) 0 (0.0)
Military Installation 7 (2.9) 1 (2.7) 1 (1.1) 5 (4.4)
Nursing Home 11 (4.5) 1 (2.7) 8 (8.5) 2 (1.8)
Industrial Setting 1 (0.4) 0 (0.0) 1 (1.1) 0 (0.0)
School 20 (8.2) 2 (5.4) 7 (7.4) 11 (9.7)
Agency/Nursing Pool 10 (4.1) 2 (5.4) 4 (4.3) 4 (3.5)
Doctor‟s Office 7 (2.9) 0 (0.0) 3 (3.2) 4 (3.5)
Home Health 12 (4.9) 3 (8.1) 7 (7.4) 2 (1.8)
Correctional Medicine 1 (0.4) 0 (0.0) 0 (0.0) 1 (0.01)
Flight Nurse 1 (0.4) 0 (0.0) 1 (1.1) 0 (0.0)
Other 4 (1.6) 1 (2.7) 0 ( 0.0) 3 (2.6) 0.6523

Salary ($)
<20,000 1 (0.4) 1 (2.7) 0 (0.0) 0 (0.0)
20,000 – 29,999 4 (1.6) 2 (5.4) 2 (2.1) 0 (0.0)
30,000 – 39,999 11 (4.5) 2 (5.4) 4 (4.2) 5 (4.4)
40,000 – 49,999 46 (18.9) 6 (16.2) 19 (20.2) 21 (18.6)
50,000 – 59,999 50 (20.5) 10 (27.0) 23 (24.5) 17 (15.0)
60,000 – 69,999 51 (20.9) 9 (24.3) 23 (24.5) 19 (16.8)
70,000 – 79,999 39 (16.0) 5 (13.5) 13 (13.8) 21 (18.6)
80,000 – 89,999 23 (9.4) 2 (5.4) 4 (4.3) 17 (15.0)
90,000 – 99,999 9 (3.7) 0 (0.0) 2 (2.1) 7 (6.2)
>100,000 10 (4.1) 0 (0.0) 4 (4.3) 6 (5.3) 0.0004*

Satisfaction With Role In

Profession Now
Very Satisfied 66 (27.0) 9 (24.3) 25 (26.6) 32 (28.3)
Satisfied 130 (53.3) 20 (54.1) 49 (52.1) 61 (54.0)
Marginally Satisfied 32 (13.1) 4 (10.8) 10 (10.6) 18 (16.0)
Dissatisfied 9 (3.7) 3 (8.1) 6 (6.4) 0 (0.0)
Intent to Leave 7 (2.9) 1 (2.7) 4 (4.3) 2 (1.8) 0.1802
*p<0.05 Note: Frequencies (percent)
 Seventy-six percent of nurses reported not having a mentor (186) during their

nursing career. Ali & Panther (2008) explored the role of mentorship and professional

development stating that mentoring is an important role that every nurse has to assume,

formally or informally; sooner or later in their professional life to help other nurses (p. 35).

Fifty-one percent of baccalaureate degree nurses (30) reported having a mentor during their

nursing career. Forty-four percent of baccalaureate degree nurses (84) reported not having a

mentor during their nursing career followed by thirty-five percent of associate degree nurses

(76). Nurses were asked to reveal the number of mentor relationships which they have had

and whether their mentor relationship was with a mentor who was within (a nurse) or

outside of nursing (not a nurse). Of the nurses who reported having a mentor relationship

(58), the majority of nurses reported one mentor within nursing (38) and one mentor outside

of nursing (32). There were two baccalaureate degree nurses who reported having 4 and 6

mentors within nursing and one baccalaureate degree nurse reported having 6 mentors

outside of nursing. There was a wide distribution among nursing degrees whether a mentor

was inside or outside of nursing. No statistically significant difference was demonstrated

between basic nursing degrees to mentorship (p=0.4054) whether inside (p=0.1854) or

outside of nursing p=0.3204).

Table 9
Demographic Characteristics and Frequencies by Basic Nursing Degree (cont‟d)
Degree
Variable Overall Diploma Associate Baccalaureate P-
(N=37) (N=94) (N=113) value

Mentorship during nursing career

Mentor 58 (23.8) 10 (27.0) 18 (19.1) 30 (26.5)
No mentor 186 (76.2) 27 (73.0) 76 (80.9) 84 (74.3) 0.4054

Mentor Relationships

Mentor Within Nursing (N=58) (N=10) (N=18) (N=30)

0 5 (8.7) 1 (10.0) 1 (5.5) 3 (10.0)

1 38 (65.5) 8 (80.0) 13 (72.2) 17 (56.7)
2 12 (20.7) 1 (10.0) 3 (16.7) 8 (26.7)
3 1 (1.7) 0 (0.0) 1 (5.5) 0 (0.0)
4 1 (1.7) 0 (0.0) 0 (0.0) 1 (3.3)
5 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
6 1 (1.7) 0 (0.0) 0 (0.0) 1 (3.3) 0.1854

Mentor Outside of Nursing

0 11 (18.9) 1 (10.0) 5 (27.7) 5 (16.7)

1 32 (55.2) 7 (70.0) 9 (50.0) 16 (53.3)
2 12 (20.7) 2 (20.0) 3 (16.7) 7 (23.3)
3 1 (1.7) 0 (0.0) 1 (5.5) 0 (0.0)
4 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
5 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
6 2 (3.5) 0 (0.0) 0 (0.0) 2 (6.7) 0.3204

p<0.05 Note: Frequencies (percent)

First Hypothesis

The hypothesis that the degree of professionalism will significantly differ by basic

nursing degree among actively practicing registered nurses in South Texas, was supported.

Baccalaureate degree nurses demonstrated a higher degree of professionalism overall and

by exhibiting greater mean professionalism scores to more items per dimension in every

dimension.

Figure 2 displays the average mean professionalism scores by attitude dimension.

This sample population associates with Belief in Continuing Competence (2.13) as the

strongest professionalism attitude and Sense of Calling to the Field (2.70) as the weakest

professionalism attitude.

Figure 2
Average Mean Scores for Attitudes Toward Professionalism Dimensions

5-point Likert Scale (1=high degree of professionalism and 5= low degree of professionalism)

Org = Organization as a Major Referent

Comp= Belief in Continuing Competence
Self= Belief in Self-Regulation
Sens= Sense of Calling to the Field
Auto= Autonomy
Serv= Belief in Service to the Public

The overall mean scale scores by basic nursing degree to the six professionalism

dimensions are presented in Table 13. Baccalaureate and associate degree nurses reported
Belief in Continuing Competence as their strongest professionalism dimension and Sense of

Calling to the Field as their weakest professionalism dimension. Diploma degree nurses

reported Belief in Self-Regulation and Belief in Service to the Public as their strongest

professionalism dimension and Professional Organization as a Major Referent as their

weakest professionalism dimension. There was a statistically significant difference between

baccalaureate and diploma degree nurses in the dimensions of Belief in Continuing

Competence (p=0.0026) and Professional Organization as a Major Referent (p=0.0019).

Table 13
Overall Mean Professionalism Scores by Basic Nursing Degree

PROFESSIONALISM DIPLOMA ASSOCIATE BACCALAUREATE χ2 p-value

DIMENSIONS (N=37) (N=94) (N=113)

Professional Organization as a Major 2.71±0.70 2.51±0.60 2.31±0.60 12.49 0.0019*

Referent

Belief in Continuing Competence 2.46±0.87 2.05±0.62 1.89±0.66 11.92 0.0026*

Belief in Self-Regulation 2.29±0.68 2.33±0.60 2.19±0.56 2.818 0.2443

Sense of Calling to the Field 2.69±0.63 2.80±0.55 2.63±0.59 4.812 0.0902

Autonomy 2.49±0.67 2.67±0.68 2.52±0.62 4.091 0.1293

Belief in Service to the Public 2.30±0.53 2.23±0.53 2.11±0.60 5.124 0.0771

*p<0.05, chi-square with p-value based on Kruskal-Wallis Test

5-point Likert Scale (1=high degree of professionalism and 5= low degree of professionalism)

Baccalaureate degree nurses demonstrated greater mean professionalism scores in

all of the dimensions except for the autonomy dimension held by diploma nurses.

LaSala & Nelson (2005) assert that education serves to professionalize nursing and

to prepare nurses for practice in today‟s complex and highly technological environment.

Dutton (1984) in her descriptive study on professional attitudes of registered nurses relative

to selected variables using Hall‟s Professional Inventory to sample of (N=291) registered

nurses in hospital and community settings. The nurses in the study demonstrated higher

professionalism in their belief in self-regulation dimension and demonstrated the lowest

professionalism in the autonomy dimension. She concludes that the observed differences

among nurses could not be accounted for by basic nursing preparation, or length of work

experience. Table 14 presents the mean professionalism scale scores to each item statement

for the six professionalism dimensions by basic nursing degree.

As expected, the two dimensions demonstrating the majority of statistically

significant items were Belief in Continuing Competence followed by Professional

Organization as a Major Referent. In the dimension of Belief in Continuing Competence,

baccalaureate degree nurses more strongly disagreed that they could maintain an acceptable

practice without attending continuing education programs (p=0.0026), that daily practice is

all the continuing education they need (p=0.0011), and that continuing education is of little

importance to their practice (p=0.0080). Baccalaureate degree nurses more strongly agreed

that continuing education is essential for their work (p=0.0001). In the dimension of the

Professional Organization as a Major Referent, baccalaureate degree nurses more strongly

agreed that it important to read professional journals (p=0.0086), and that the professional

organization should be supported (p=0.0005). Baccalaureate degree nurses more strongly

disagreed that the professional organization doesn‟t really do much for the average member

(p=0.0050). In the dimensions that failed to demonstrate overall statistical significance

(Belief in Self-Regulation, Sense of Calling to the Field, Autonomy, Belief in Service to the

Public), there were a few item statements which demonstrated statistical significance. The

baccalaureate degree nurse more strongly agreed that the dedication of nurses is most

gratifying (p=0.0027) while they more strongly disagreed with there not being much
opportunity to judge another nurses competence (p=0.0493), not having much opportunity

to exercise their own judgment (p=0.0040), and that other professions are more vital to

society than nursing (p=0.0006). Concerning whether their own decisions are subject to

review (0.0366), baccalaureate and associate-prepared nurses reported neutrality while

diploma-prepared nurses reported stronger agreement.

Baccalaureate degree nurses reported lower mean professionalism scores

demonstrating a greater degree of professionalism in 22 of the 30 item statements (73.3%).

Associate degree nurses reported lower mean professionalism scores in 1 of the 30 item

statements (3.3%). Diploma degree nurses reported lower mean professionalism scores in 7

of the 30 items (23.3%). They reported higher mean professionalism scores to all of the

item statements in the dimensions of Professional Organization as a Major Referent and

Belief in Continuing Competence demonstrating a lower degree of professionalism. In the

dimension of Belief in Self-Regulation, diploma degree nurses reported a higher mean

professionalism score regarding their colleagues having a pretty good idea about each others

competence and pretty well knowing how well their colleagues do their work. In the

dimension of Sense of Calling, diploma degree nurses reported a higher mean

professionalism score to staying in the profession even if their incomes were reduced and

there being very few people who don‟t really believe in their work. In the dimension of

Autonomy, diploma degree nurses reported a higher mean professionalism score to their

decisions being subject to review and being their own boss in almost every work-related

situation. In the dimension Belief in Service to the Public, associate degree nurses reported

a higher mean professionalism score to the importance of the profession being over stressed

while diploma degree nurses reported a higher mean professionalism score to the
occupation being indispensible.

Multivariate linear regression analysis demonstrated that basic nursing degree was a

predictor for a weaker degree of professionalism by diploma degree nurses in the attitudinal

dimensions of Professional Organization as a Major Referent (β = .215, Wald Chi-square =

3.95, p=0.0469) and Belief in Continuing Competence (β = .479, Wald Chi-square = 13.58,

p=0.0002).
Table 14
Mean Professionalism Scores to Item Statements in each Dimension by Basic Nursing Degree
ITEM STATEMENTS DIPLOMA ASSOCIATE BSN p-value
(N=37) (n=94) (N=113)
Professional Association as a Major Referent Factor
1. I believe it important to systematically read the 2.59±1.07 2.06±0.84 2.04±0.80 0.0086*
professional journals.
3.03±1.01 2.99±1.01 2.80±1.03 0.2242
2. I am committed to regularly attend professional meetings
at the local level. 2.54±0.80 2.22±0.75 1.98±0.72 0.0005*
3. I believe that the professional organization(s) should be 2.78±0.98 2.87±0.87 2.44±0.98 0.0050*
supported.
2.59±1.12 2.41±0.97 2.27±0.90 0.2647
4. The professional organization doesn‟t really do much for
the average member.
5. Although I would like to, I don‟t think it is a priority to
read the journals too often.
Belief in Continuing Competence
1. I can maintain an acceptable standard of practice without 2.89±1.26 2.26±1.05 2.12±1.05 0.0026*
attending continuing education programs.
2.32±0.97 2.00±0.84 1.69±0.78 0.0001*
2. Continuing education such as self-study or seminars
is essential for my work. 2.49±1.10 1.90±0.70 1.82±0.85 0.0011*
3. My daily practice is all the continuing education I need. 2.27±1.12 1.80±0.67 1.69±0.78 0.0080*
4. Continuing education is of little importance to my practice.
2.35±1.09 2.28±0.87 2.14±1.00 0.2898
5. My practice would suffer if I did not attend
continuing education programs.
Belief in Self-Regulation Factor
1. My fellow professionals have a pretty good idea about 2.22±0.92 2.36±0.91 2.27±0.82 0.6486
each other‟s competence.
2.38±0.86 2.34±0.89 2.21±0.84 0.3959
2. A problem in this profession is that no one really knows
what his/her colleagues are doing. 2.30±0.97 2.19±0.85 2.01±0.80 0.1264
3. We really have no way of judging each other‟s competence. 2.41±0.90 2.30±0.80 2.09±0.81 0.0493*
4. There is not much opportunity to judge how another person
2.16±0.80 2.45±0.89 2.38±0.97 0.2061
his/her works.
5. My colleagues pretty well know how well we all do our work.
Sense of Calling to the Field Factor
1. People in this profession have a real “calling” for their work. 2.22±0.95 2.39±0.95 2.15±0.88 0.1642
2. The dedication of people in this field is most gratifying.
2.65±1.06 2.41±0.80 2.14±0.81 0.0027*
3. It is encouraging to see the high level of idealism which
is maintained by people in this field 2.51±0.80 2.66±0.73 2.50±0.93 0.2946
4. Most people would stay in the profession even if 3.46±0.99 3.71±0.99 3.68±1.03 0.3930
their incomes were reduced.
2.62±0.83 2.80±0.85 2.68±0.95 0.5531
5. There are very few people who don‟t really believe in
their work.
Autonomy Factor
1. I make my own decisions in regard to what is to be done in 2.03±0.76 2.09±1.03 1.97±0.86 0.8275
my work.
2.35±1.11 2.14±0.95 1.79±0.69 0.0040*
2. I don‟t have much opportunity to exercise my own judgment.
3. My own decisions are subject to review. 2.84±1.01 3.36±1.00 3.19±1.10 0.0366*
4. I am my own boss in almost every work-related situation. 2.46±0.87 2.85±1.11 2.93±1.11 0.0739
5. Most of my decisions are reviewed by other people.
2.78±0.92 2.91±0.97 2.71±1.06 0.2781
Belief in Service to the Public Factor
1. Other professions are actually more vital to society than mine. 2.27±0.90 2.04±0.83 1.74±0.78 0.0006*
2. I think that my profession, more than any other, is
2.05±0.88 2.11±0.90 1.96±0.99 0.2734
essential for society.
3. The importance of my profession is sometimes over stressed. 2.49±1.02 2.12±0.90 2.16±1.00 0.1105
4. Some other occupations are actually more important to 2.35±0.89 2.29±0.88 2.14±0.98 0.2336
society than is mine.
2.35±1.09 2.62±1.35 2.54±1.50 0.6019
5. If ever an occupation is indispensible, it is this one.
* p<0.05, p-value based on Kruskal-Wallis Test
5-point Likert Scale (1=strongly agree and 5 strongly disagree and reversed with negatively worded items)
Second Hypothesis

The hypothesis that degree of professionalism will significantly differ by basic

nursing degree among practicing registered nurses in South Texas when controlled for by

age was supported. Baccalaureate degree nurses under the age of 50 reported a higher

degree of professionalism within all six of the attitude dimensions. In those nurses over the

age of 50, baccalaureate and associate degree nurses reported fairly equal mean

professionalism scores by three dimensions each. This finding can be indicative of a lack of

correlation between increasing age and greater professionalism. Those nurses with a basic

nursing degree at the baccalaureate level may be more professional in the attitudes and

behaviors than associate and diploma degree nurses.

Table 15 displays the overall mean professionalism scale responses by age to the six

professionalism dimensions. There were no nurses under 20 years of age. Sense of Calling

to the Field (p=0.0495) and Autonomy (p=0.0440) demonstrated statistical significance to

age. Nurses between the ages of 31 to 60 reported Belief in Continuing Competence

as their strongest professionalism dimension and Sense of Calling to the Field as their

weakest professionalism dimension.

Nurses between the ages of 21 - 30 also reported Belief in Continuing Competence

as their strongest professionalism dimension however reported Autonomy as their weakest

professionalism dimension. Nurses >60 reported Belief in Self-Regulation as their

strongest professionalism dimension and Autonomy as their weakest professionalism

dimension.
Table 15
Overall Mean Professionalism Scores to Age

PROFESSIONALISM <20 21 – 30 31 - 40 41 to 50 51 to 60 > 60 χ2 p-value

DIMENSIONS (N=20) (N=22) (N=53) (N=82) (N=73) (N=14)

Professional - 2.54±0.69 2.46±0.56 2.52±0.59 2.36±0.69 2.26±0.77 3.423 0.4897

Organization as a
Major Referent

Belief in Continuing - 1.95±0.74 2.06±0.62 2.05±0.75 2.02±0.72 2.16±0.73 0.941 0.9186

Competence

Belief in Self- - 2.39±0.67 2.30±0.64 2.26±0.58 2.25±0.59 1.91±0.84 6.611 0.1579

Regulation

Sense of Calling to the - 2.77±0.58 2.74±0.55 2.69±0.52 2.77±0.65 2.21±0.61 9.511 0.0495*
Field

Autonomy - 2.95±0.65 2.57±0.61 2.57±0.67 2.51±0.67 2.33±0.44 9.797 0.0440*

Belief in Service to the - 2.28±0.54 2.20±0.82 2.14±0.54 2.18±0.66 2.29±0.42 2.392 0.6641
Public
* p<0.05, chi-square with p-value based on Kruskal-Wallis Test
5-point Likert Scale (1=high degree of professionalism and 5= low degree of professionalism)

Table 15a displays age and professionalism factors by basic nursing degree.

Baccalaureate degree nurses reported a higher degree of professionalism across all

dimensions and within age groups. Baccalaureate degree nurses within the age groups of 21

- 30 and 41 - 50 reported a higher degree of professionalism in all six dimensions. Because

of missing age groups and varied data, it was necessary to collapse the groups into <40

years old, 41 – 50 years old, and >50 years old for further regression analysis.

Table 15b displays the regression of gender and the six professionalism dimensions

by basic nursing degree. Baccalaureate degree nurses under the age of 50 report greater

mean professionalism scores in all attitude dimensions. Baccalaureate degree nurses over

the age of 50 only reported close yet greater mean professionalism scores in the dimensions

of Professional Organization as a Major Referent and Belief in Service to the Public and
Sense of Calling to the Field to associate degree nurses. Associate degree nurses reported

higher mean scores in the dimension of Belief in Continuing Competence and sharing the

same mean professionalism scores with baccalaureate degree nurses in the other two

dimensions. Diploma degree nurses over the age of 50 reported higher mean

professionalism scores in the dimensions of Sense of Calling, Autonomy, and Belief in Self-

Regulation while those under the age of 40 reported lesser mean professionalism scores.

Although univariate linear regression analysis demonstrated that the attitudinal

dimensions of Sense of Calling and Autonomy were statistically significant to age, the

results of the multivariate linear regression analysis demonstrated that age by basic nursing

degree was not a strong predictor for degree of professionalism.

Table 15a
Overall Professionalism Scores by Basic Nursing Degree to Age
PROFESSIONALISM Age DIPLOMA ASSOCIATE BACCALAUREATE
DIMENSION (N=37) (N=94) (N=113)

Professional <20 - - -
Organization as a 21-30 - 2.60±0.74 2.49±0.69
Major Referent 31-40 3.20±1.13 2.57±0.44 2.30±0.51
41-50 2.71±0.60 2.66±0.62 2.33±0.53
51-60 2.75±0.75 2.36±0.60 2.22±0.68
>60 2.50±0.79 1.80±0.49 2.20±1.13

Belief in Continuing <20 - - -

Competence 21-30 - 2.02±0.66 1.89±0.81
31-40 2.80±1.13 2.12±0.53 1.93±0.65
41-50 2.33±0.91 2.16±.074 1.86±0.65
51-60 2.55±0.92 1.90±0.55 1.90±0.68
>60 2.48±0.79 1.65±0.41 1.90±0.14

Belief in Self- <20 - - -

Regulation 21-30 - 2.47±0.65 2.34±0.70
31-40 3.00±1.41 2.32±0.61 2.22±0.60
41-50 2.39±0.62 2.40±.062 2.11±0.50
51-60 2.34±0.70 2.23±0.62 2.24±0.54
>60 1.88±0.38 2.10±0.12 1.70±0.42

Sense of Calling to <20 - - -

the Field 21-30 - 2.84±0.44 2.72±0.68
31-40 3.20±1.13 2.78±0.55 2.65±0.50
41-50 2.81±0.47 2.85±0.58 2.52±0.44
51-60 2.82±0.64 2.78±0.54 2.75±0.73
>60 2.15±0.53 2.45±0.90 2.00±0.28

Autonomy <20 - - -
21-30 - 3.29±0.39 2.71±0.70
31-40 3.00±1.41 2.61±0.59 2.60±0.59
41-50 2.63±0.71 2.68±0.69 2.46±0.64
51-60 2.38±0.63 2.54±0.76 2.54±0.62
>60 2.30±0.48 2.40±0.54 2.30±0.14

Belief in <20 - - -
Service to the Public 21-30 - 2.49±0.41 2.14±0.58
31-40 2.70±0.99 2.17±0.55 2.19±0.46
41-50 2.19±0.57 2.16±0.74 2.02±0.54
51-60 2.37±0.49 2.13±0.57 2.15±0.77
>60 2.30±0.44 2.50±0.26 1.60±0.28

5-point Likert Scale (1=high degree of professionalism and 5= low degree of professionalism)
Table 15b
Relationship of Class/Level for Mean Professionalism Scores by Basic Nursing Degree to
Age
PROFESSIONALISM Class/Level <40 years* 41 – 50 years** >50 years*** p-value
DIMENSION (N=75) (N=82) (N=87)

* **
Professional Diplomaa 3.20±1.13 2.71±0.60 2.68±0.76 0.3876 0.8319
* **
Organization as a Associateb 2.58±0.52 2.66±0.62 2.28±0.61 0.4547 0.2000
Major Referent Baccalaureatec 2.36±0.57 2.33±0.53 2.22±0.69

* **
Belief in Continuing Diplomaa 2.80±1.13 2.33±0.91 2.52±0.85 0.6138 0.5900
* **
Competence Associateb 2.10±0.56 2.16±0.74 1.87±0.53 0.3485 0.1514
Baccalaureatec 1.92±0.69 1.86±0.65 1.90±0.66

* **
Belief in Self- Diplomaa 3.00±1.41 2.39±0.62 2.16±0.63 0.0820 0.1734
* **
Regulation Associateb 2.36±0.62 2.40±0.62 2.21±0.57 0. 6368 0.1503
Baccalaureatec 2.26±0.63 2.11±0.50 2.21±0.55
* **
Sense of Calling to the Diplomaa 3.20±1.13 2.81±0.47 2.56±0.67 0.1292 0.0610
* **
Field Associateb 2.80±0.52 2.85±0.58 2.73±0.59 0.5961 0.1139
Baccalaureatec 2.67±0.56 2.52±0.44 2.71±0.73

* **
Autonomy Diplomaa 3.00±1.41 2.63±0.71 2.35±0.57 0.2278 0.1971
* **
Associateb 2.78±0.62 2.68±0.69 2.52±0.73 0.3375 0.3182
Baccalaureatec 2.57±0.63 2.46±0.64 2.52±0.61

* **
Belief in Diplomaa 2.70±0.99 2.19±0.57 2.34±0.46 0.4601 0.8521
* **
Service to the Public Associateb 2.25±0.53 2.27±0.52 2.18±0.55 0.8596 0.2982
Baccalaureatec 2.17±0.49 2.01±0.54 2.14±0.75

p<0.05
5-point Likert Scale (1=high degree of professionalism and 5= low degree of professionalism)
Note: cBaccalaureate and ***>50 years utilized as controls
a
Diploma versus Baccalaureate
b
Associate versus Baccalaureate
*<40 years versus >50 years
**
41 – 50 years versus >50 years
 Third Hypothesis

The hypothesis that basic nursing degree is a predictor of the degree of

professionalism when correlated with: gender, employment status, professional organization

membership, role in organization, continuing education hours, salary, expressed degree of

satisfaction, and mentoring was supported. Basic nursing degree as a predictor of degree of

professionalism when correlated to: shift worked, professional journal subscription,

professional certification, practice years, and practice setting was not supported.

Baccalaureate degree nurses exhibited the strongest attitudes toward professionalism

overall. Multivariate regression analysis demonstrated that basic nursing degree was a

predictor of weaker attitudes toward professionalism only for diploma degree nurses in the

attitudinal dimensions of Professional Organization as a Major Referent (β = .215, Wald

Chi-square = 3.95, p=0.0469, ) and Continuing Competence (β = .479, Wald Chi-square =

13.53, p=0.0002).

Table 16 displays the overall mean professionalism scale scores of the six

professionalism dimensions by gender. Professional Organization As a Major Referent

(p=0.0009) demonstrated statistical significance to gender. Male and female nurses reported

Belief in Continuing Competence as their strongest professionalism dimension and Sense of

Calling to the Field as their weakest professionalism dimension. Sherrod, Sherrod & Rasch

(2005) in their work to identify strategies to recruit and retain men in nursing reported that

females will certainly dominate the profession for years to come but suggest that efforts must

be made to acculturate more men into the profession of nursing (p. 51).
Table 16
Overall Mean Professionalism Scores to Gender
PROFESSIONALISM MALE FEMALE χ2 p-value
DIMENSIONS (N=45) (N=199)

Professional Organization as a Major 2.73±0.63 2.38±0.61 11.106 0.0009*

Referent

Belief in Continuing Competence 2.16±0.81 2.01±0.68 1.2902 0.2560

Belief in Self-Regulation 2.29±0.71 2.25±0.57 0.117 0.7323

Sense of Calling to the Field 2.84±0.51 2.67±0.59 2.621 0.1054

Autonomy 2.53±.0.66 2.58±0.65 0.444 0.5052

Belief in Service to the Public 2.22±0.52 2.18±0.58 0.028 0.8671

*p<0.05, chi-square with p-value based on Kruskal-Wallis Test

5-point Lik0ert Scale (1=high degree of professionalism and 5= low degree of professionalism)

Dixon (2006) surveyed male nurses (N = 500) determining that men enter the

nursing profession for essentially the same reasons that female nurses enter the profession

and highlighting that approximately 40% of the respondents indicated that the primary

reason that many men do not choose nursing as a profession was due to the feminine image

of nursing.

Table 16a displays the regression of gender and the six professionalism dimensions

by basic nursing degree. In the attitudinal dimension of Belief in Self-Regulation

(p=0.0117), statistical significance was found between male diploma and baccalaureate

degree nurses. Baccalaureate degree male nurses demonstrated a higher degree of

professionalism (2.17). In the attitudinal dimension of Sense of Calling to the Field

(p=0.0201), statistical significance was found between male diploma and baccalaureate

degree nurses. Baccalaureate degree male nurses demonstrated a higher degree of

professionalism (2.61).
Table 16a
Relationship of Class/Level for Mean Professionalism Scores by Basic Nursing Degree to
Gender
PROFESSIONALISM Class/Level MALE* FEMALE** p-value
DIMENSIONS (N=45) (N=199)
*
Professional Diplomaa 3.22±0.66 2.54±0.65 0.1201
*
Organization Associateb 2.67±0.62 2.46±0.58 0.8978
as a Major Referent Baccalaureatec 2.51±0.49 2.28±0.61
*
Belief in Continuing Diplomaa 2.91±1.01 2.32±0.78 0.0628
*
Competence Associateb 2.04±0.59 2.05±0.63 0.9797
Baccalaureatec 1.89±0.73 1.89±0.66
*
Belief in Self- Diplomaa 2.80±0.84 2.13±0.54 0.0117
*
Regulation Associateb 2.15±0.61 2.38±0.59 0.3528
Baccalaureatec 2.17±0.66 2.20±0.55
*
Sense of Calling to the Diplomaa 3.16±0.65 2.54±0.56 0.0201
*
Field Associateb 2.85±0.55 2.78±0.56 0.6507
Baccalaureatec 2.61±0.49 2.63±0.60

*
Autonomy Diplomaa 2.71±0.79 2.42±0.63 0.1110
*
Associateb 2.58±0.63 2.70±0.69 0.7244
Baccalaureatec 2.34±0.62 2.54±0.62
*
Belief in Diplomaa 2.91±1.01 2.22±0.52 0.1232
*
Service to the Public Associateb 2.19±0.57 2.25±0.52 0.9237
Baccalaureatec 2.04±0.34 2.12±0.63

p<0.05
5-point Likert Scale (1=high degree of professionalism and 5= low degree of professionalism)
Note: cBaccalaureate is utilized as a control
a
Diploma versus Baccalaureate
b
Associate versus Baccalaureate

Multivariate linear regression analysis demonstrated gender to be a predictor for a

weaker degree of professionalism in male diploma nurses (3.22) in the attitudinal dimension

of Professional Organization as a Major Referent (β = .227. Wald Chi-square = 6.38,

p=0.0115).

Table 17 displays the overall mean professionalism scale scores of the six

professionalism dimensions and shift worked. No statistically significant difference was

found between shift worked and the professionalism dimensions. The day and evening shift
 nurses reported Belief in Continuing Competence as their strongest attitudinal dimension

and Sense of Calling to the Field as their weakest attitudinal dimension. Reporting the same

strongest dimension to be Belief in Continuing Competence, night shift nurses differed with

Sense of Calling and Autonomy essentially equal as their weakest attitudinal dimension.

Table 17
Overall Mean Professionalism Scores to Shift Worked
PROFESSIONALISM NIGHT DAY EVENING χ2 p-value
DIMENSIONS SHIFT SHIFT SHIFT
(N=51) (N=174) (N=19)

Professional Organization as a Major 2.58±0.68 2.39±0.60 2.58±0.72 3.915 0.1412

Referent

Belief in Continuing Competence 2.15±0.76 2.01±0.70 2.02±0.67 2.217 0.3300

Belief in Self-Regulation 2.19±0.55 2.27±0.59 2.35±0.75 0.862 0.6497

Sense of Calling to the Field 2.71±0.63 2.69±0.57 2.86±0.64 1.258 0.5330

Autonomy 2.72±0.64 2.52±0.65 2.69±0.65 3.934 0.1398

Belief in Service to the Public 2.27±0.58 2.17±0.57 2.15±0.48 1.936 0.3797

p<0.05, chi-square with p-value based on Kruskal-Wallis Test

5-point Likert Scale (1=high degree of professionalism and 5= low degree of professionalism)

Table 17a displays the regression of shift worked and the six professionalism

dimensions by basic nursing degree. In the attitudinal dimension of Professional

Organization as a Major Referent (p=0.0465) significance was demonstrated between night

and evening shifts compared to diploma and baccalaureate degree nurses. Evening shift

diploma nurses (2.30) reported a higher degree of professionalism compared to night shift

baccalaureate nurses (2.43). In the professionalism dimension of Belief in Continuing

Competence (p=0.0463) significance was demonstrated between day and evening shifts

compared to diploma and baccalaureate degree nurses. Evening shift baccalaureate degree

nurses (1.74) reported a higher degree of professionalism compared to nurses on the day

shift (1.84).
Table 17a
Relationship of Class/Level for Mean Professionalism Scores by Basic Nursing Degree to
Shift Worked
PROFESSIONALISM Class/Level NIGHT* DAY** EVENING*** p-value
DIMESIONS (N=51) (N=174) (N=19)

* **
Professional Diplomaa 3.24±0.61 2.55±0.57 2.30±1.84 0.0465 0.2641
* **
Organization as a Associateb 2.44±0.51 2.50±0.59 2.77±0.75 0.4830 0.9844
Major Referent Baccalaureatec 2.43±0.65 2.22±0.58 2.50±0.47

* **
Belief in Continuing Diplomaa 2.69±0.91 2.32±0.83 3.30±0.99 0.1071 0.0463
* **
Competence Associateb 1.98±0.34 2.05±0.65 2.06±0.55 0.3409 0.7720
Baccalaureatec 2.05±0.76 1.84±0.64 1.74±0.37

* **
Belief in Self- Diplomaa 2.51±0.89 2.15±0.55 3.10±0.71 0.3558 0.0641
* **
Regulation Associateb 2.00±0.28 2.37±0.61 2.23±0.80 0.7804 0.4530
Baccalaureatec 2.15±0.46 2.20±0.58 2.28±0.71
* **
Sense of Calling to the Diplomaa 3.11±0.66 2.55±0.53 2.70±1.27 0.1226 0.7455
* **
Field Associateb 2.80±0.78 2.79±0.53 2.83±0.63 0.3701 0.3665
Baccalaureatec 2.58±0.54 2.62±0.60 2.92±0.61

* **
Autonomy Diplomaa 2.62±0.89 2.40±0.58 3.10±0.42 0.2351 0.3109
* **
Associateb 2.69±0.54 2.66±0.70 2.74±0.73 0.5668 0.7649
Baccalaureatec 2.75±0.60 2.40±0.61 2.58±0.64

* **
Belief in Diplomaa 2.47±0.44 2.23±0.56 2.50±0.14 0.6149 0.3974
* **
Service to the Public Associateb 2.36±0.36 2.22±0.54 2.29±0.69 0.6892 0.5298
Baccalaureatec 2.19±0.65 1.84±0.64 1.98±0.27

p<0.05
5-point Likert Scale (1=high degree of professionalism and 5= low degree of professionalism)
Note: ***Evening and cBaccalaureate utilized as controls
a
Diploma versus cBaccalaureate
b
Associate versus cBaccalaureate
*Night versus Evening
**
Day versus Evening

In the univariate linear regression analysis, Professional Organization as a Major

Referent and Belief in Continuing Competence demonstrated statistical significance to shift

worked however, multivariate linear regression analysis demonstrated that shift worked by

basic nursing degree was not a predictor of degree of professionalism. Admi, et al., (2008)

found that gender, age, and weight were more determinant of nurse‟s well-being than shift
work. They concluded that shift work by itself was not found to be a risk factor for nurse‟s

sleep, performance, health and organizational outcomes.

Table 18 displays the overall mean professionalism scale scores of the six

professionalism dimensions by employment status. No statistically significant difference

was demonstrated between professionalism dimensions and employment status. Full time

and part time nurses reported Belief in Continuing Competence as their strongest

professionalism dimension and Sense of Calling to the Field as their weakest

professionalism dimension.

Table 18
Overall Mean Professionalism Scores to Employment Status
PROFESSIONALISM FULL TIME PART TIME χ2 p-value
DIMENSIONS (N =216) (N=28)

Professional Organization as a Major Referent 2.45±0.63 2.44±0.64 0.0177 0.8942

Belief in Continuing Competence 2.04±0.71 2.01±0.70 0.0369 0.8476

Belief in Self-Regulation 2.28±0.60 2.12±0.53 2.1704 0.1407

Sense of Calling to the Field 2.72±0.57 2.59±0.67 1.4953 0.2214

Autonomy 2.59±0.67 2.41±0.45 1.6306 0.2016

Belief in Service to the Public 2.20±0.58 2.09±0.43 1.1560 0.2823

p<0.05, chi-square with p-value based on Kruskal-Wallis Test

5-point Likert Scale (1=high degree of professionalism and 5= low degree of professionalism)

Table 18a displays the regression of employment status to the six the

professionalism dimensions and basic nursing degree. In the professionalism dimension of

Professional Organization as a Major Referent (p=0.0045) significance was found between

part time diploma and baccalaureate degree nurses. Part time diploma nurses demonstrated

the higher degree of professionalism (2.20) just marginally above that of full time

baccalaureate degree nurses (2.29).

Table 18a
Relationship of Class/Level for Mean Professionalism Scores by Basic Nursing Degree to
Employment Status
PROFESSIONAISM Class/Level FULL TIME* PART TIME** p-value
DIMENSIONS (N=216) (N=28)
**
Professional Diplomaa 2.85±0.68 2.20±0.59 0.0045
**
Organization as a Associateb 2.51±0.58 2.56±0.74 0.5198
Major Referent Baccalaureatec 2.29±0.60 2.52±0.60

**
Belief in Continuing Diplomaa 2.59±0.89 2.03±0.64 0.2315
**
Competence Associateb 2.02±0.60 2.24±0.75 0.2529
Baccalaureatec 1.90±0.67 1.76±0.67

**
Belief in Self- Diplomaa 2.35±0.75 2.08±0.28 0.9446
**
Regulation Associateb 2.33±0.61 2.32±0.61 0.3722
Baccalaureatec 2.22±0.55 1.96±0.59
**
Sense of Calling to Diplomaa 2.79±0.61 2.35±0.61 0.1559
**
the Field Associateb 2.80±0.54 2.74±0.69 0.8552
Baccalaureatec 2.63±0.58 2.62±0.70

**
Autonomy Diplomaa 2.51±0.74 2.43±0.29 0.9497
**
Associateb 2.71±0.69 2.36±0.46 0.3509
Baccalaureatec 2.52±0.63 2.46±0.57

**
Belief in Diplomaa 2.28±0.57 2.37±0.31 0.2647
**
Service to the Public Associateb 2.26±0.53 2.04±0.53 0.9606
Baccalaureatec 2.13±0.62 1.90±0.29

p<0.05
5-point Likert Scale (1=high degree of professionalism and 5= low degree of professionalism)
Note: cBaccalaureate utilized as a control
a
Diploma versus Baccalaureate
b
Associate versus Baccalaureate

Multivariate linear regression analysis demonstrated that employment status was a

predictor of a weaker degree of professionalism for full time diploma and associate degree

nurses in the attitudinal dimensions of Belief in Service to the Public (β = .000, Wald Chi-

square = 4.23, p=0.0398), Belief in Self-Regulation (β = .000, Wald Chi-square = 6.92,

p=0.0085) and for associate degree nurses in the attitudinal dimension of Autonomy (β =

.000, Wald Chi-square = 5.42, p=0.0199).

 Table 19 displays the overall mean professionalism scale scores for the six

professionalism dimensions by professional organization membership. Professional

Organization as a Major Referent (p=<0.0001) and Belief in Continuing Competence

(p=0.0041) demonstrated statistical significance to professional organization membership.

Member and non member nurses reported Belief in Continuing Competence as their

strongest professionalism dimension and Sense of Calling to the Field as their

Table 19
Overall Mean Professionalism Scores to Professional Organization Membership
PROFESSIONALISM MEMBER NON-MEMBER χ2 p-value
DIMENSIONS (N=82) (N=162)

Professional Organization as a Major 2.12±0.56 2.61±0.60 32.154 <0.0001*

Referent

Belief in Continuing Competence 1.84±0.60 2.14±0.74 8.222 0.0041*

Belief in Self-Regulation 2.15±0.48 2.32±0.64 2.360 0.1245

Sense of Calling to the Field 2.60±0.56 2.76±0.60 2.921 0.0874

Autonomy 2.51±0.59 2.60±0.68 0.789 0.3742

Belief in Service to the Public 2.14±0.60 2.21±0.55 1.085 0.2975

*p<0.05, chi-square with p-value based on Kruskal-Wallis Test

5-point Likert Scale (1=high degree of professionalism and 5= low degree of professionalism)

weakest professionalism dimension.

Table 19a displays the regression of professional organization membership to the six

the professionalism dimensions and basic nursing degree. Members of professional

organizations reported greater mean professionalism scores in every dimension except

Autonomy, where associate degree non members reported a greater yet close mean

professionalism score (2.67) and baccalaureate degree non members in Belief in Service to

the Public (2.07). Baccalaureate degree members reported greater mean professionalism

scores in Professional Organization as a Major Referent (2.05) and Belief in Continuing

Competence (1.80) as well as non members in Belief in Service to the Public (2.07).

Diploma degree nurses reported greater mean professionalism scores in the dimensions of

Belief in Self-Regulation (2.00), Sense of Calling to the Field (2.44), and Autonomy (2.24).

Multivariate linear regression analysis demonstrated that professional organization

membership was a predictor of a greater degree of professionalism for baccalaureate degree

nurses (2.05) who are members of professional organizations in the attitudinal dimension of

Professional Organization as a Major Referent (β = .315, Wald Chi-square = 14.26,

p=0.0002).

DeLeskey (2003) writes that although nursing comprises the largest number of

health care workers in the country, fewer and fewer nurses are joining professional

organizations. In her study of current and former members of ASPAN, she found that the

variables most strongly influencing members and nonmembers to join APSPAN were self-

improvement, education, new ideas, programs, professionalism, validation of ideas,

improvement of the profession, improvement of work, and maintenance of professional

standards.
Table 19a
Relationship of Class/Level for Mean Professionalism Scores by Basic Nursing Degree to
Professional Organization Membership
PROFESSIONALISM Class/Level MEMBER* NON-MEMBER** p-value
DIMENSIONS (N=82) (N=162)

**
Professional Diplomaa 2.24±0.75 2.88±0.62 0.5156
**
Organization as a Associateb 2.26±0.54 2.57±0.60 0.3597
Major Referent Baccalaureatec 2.05±0.53 2.54±0.57

**
Belief in Continuing Diplomaa 2.06±0.65 2.61±0.90 0.1712
**
Competence Associateb 1.83±0.36 2.10±0.66 0.6831
Baccalaureatec 1.80±0.65 1.98±0.67

**
Belief in Self- Diplomaa 2.00±0.37 2.40±0.74 0.1770
**
Regulation Associateb 2.20±0.44 2.36±0.63 0.6479
Baccalaureatec 2.16±0.51 2.23±0.60

**
Sense of Calling to the Diplomaa 2.44±0.44 2.79±0.67 0.3260
**
Field Associateb 2.78±0.39 2.80±0.59 0.6336
Baccalaureatec 2.57±0.60 2.68±0.58

**
Autonomy Diplomaa 2.24±0.54 2.59±0.70 0.2371
**
Associateb 2.69±0.53 2.67±0.71 0.8042
Baccalaureatec 2.50±0.60 2.53±0.64

**
Belief in Diplomaa 2.16±0.42 2.35±0.56 0.2330
**
Service to the Public Associateb 2.11±0.50 2.26±0.54 0.1960
Baccalaureatec 2.15±0.67 2.07±0.54

p<0.05
5-point Likert Scale (1=high degree of professionalism and 5= low degree of professionalism)
Note: cBaccalaureate utilized as a control
a
Diploma versus Baccalaureate
b
Associate versus Baccalaureate

Table 20 displays the overall mean professionalism scale scores to the six

professionalism dimensions by professional certification. Professional Organization as a

Major Referent (p=<0.0001) and Belief in Continuing Competence (p=0.0030)

demonstrated statistical significance to professional certification. Certified and non

certified nurses reported Belief in Continuing Competence as their strongest

 professionalism dimension and Sense of Calling to the Field as their weakest

professionalism dimension.

Table 20
Overall Mean Professionalism Scores to Professional Certification
PROFESSIONALISM CERTIFIED NOT CERTIFIED χ2 p-value
DIMENSION (N=69) (N=175)

Professional Organization As a Major 2.21±0.64 2.54±0.60 16.160 <0.0001*

Referent

Belief in Continuing Competence 1.84±0.68 2.12±0.71 8.814 0.0030*

Belief in Self-Regulation 2.19±0.61 2.29±0.59 0.540 0.4624

Sense of Calling To The Field 2.63±0.56 2.73±0.59 1.805 0.1790

Autonomy 2.50±0.63 2.60±0.66 0.813 0.3672

Belief in Service To The Public 2.12±0.65 2.21±0.53 2.406 0.1208

*p<0.05, chi-square with p-value based on Kruskal-Wallis Test

5-point Likert Scale (1=high degree of professionalism and 5= low degree of professionalism)

Table 20a displays the regression of professional certification to the six the

professionalism dimensions and basic nursing degree. In the professionalism dimensions

of Belief in Self-Regulation (p=0.0458) and Sense of Calling to the Field (p=0.0263)

statistical significance was found between non certified baccalaureate and associate degree

nurses. In those dimensions, non certified baccalaureate degree nurses demonstrated

weaker mean professionalism scores compared to greater scores reported by certified

diploma degree nurses. Certified and non certified baccalaureate degree nurses

demonstrated greater mean professionalism scores in the dimensions Professional

Organization as a Major Referent (2.09/2.45), Belief in Continuing Competence (1.75/1.98),

and Sense of Calling to the Field (2.04/2.15). In the Autonomy dimension, certified and

non certified diploma degree nurses demonstrated a greater mean professionalism scores.
Table 20a
Relationship of Class/Level for Mean Professionalism Scores by Basic Nursing Degree to
Professional Certification
PROFESSIONALISM Class/Level CERTIFIED* NOT CERTIFIED** p-value
DIMENSIONS (N=69) (N=175)

**
Professional Diplomaa 2.30±0.76 2.82±0.66 0.5410
**
Organization as a Associateb 2.48±0.73 2.52±0.57 0.0989
Major Referent Baccalaureatec 2.09±0.56 2.45±0.58

**
Belief in Continuing Diplomaa 2.40±0.90 2.48±0.87 0.6144
**
Competence Associateb 1.81±0.47 2.10±0.64 0.8062
Baccalaureatec 1.75±0.67 1.98±0.65

**
Belief in Self- Diplomaa 1.90±0.48 2.40±0.69 0.0458
**
Regulation Associateb 2.28±0.54 2.34±0.62 0.7008
Baccalaureatec 2.20±0.64 2.19±0.50
**
Sense of Calling to the Diplomaa 2.25±0.40 2.81±0.63 0.0263
**
Field Associateb 2.79±0.43 2.80±0.58 0.9616
Baccalaureatec 2.63±0.61 2.63±0.58

**
Autonomy Diplomaa 2.30±0.64 2.54±0.68 0.7781
**
Associateb 2.80±0.49 2.64±0.71 0.1285
Baccalaureatec 2.42±0.64 2.58±0.61

**
Belief in Diplomaa 2.05±0.51 2.37±0.52 0.3947
**
Service to the Public Associateb 2.36±0.51 2.21±0.54 0.1378
Baccalaureatec 2.04±0.70 2.15±0.53

p<0.05
5-point Likert Scale (1=high degree of professionalism and 5= low degree of professionalism)
Note: cBaccalaureate utilized as a control
a
Diploma versus Baccalaureate
b
Associate versus Baccalaureate

Although in the univariate linear regression analysis the attitudinal dimensions of

Belief in Self-Regulation and Sense of Calling to the Field were statistically significant to

professional certification, multivariate linear regression analysis demonstrated that

professional certification was not a predictor by basic nursing degree of degree of

professionalism.
 Table 21 displays the overall mean professionalism scale scores to the six

professionalism dimensions by organizational role. Professional Organization as a Major

Referent (p=0.0001) and Belief in Continuing Competence (p=0.0015) demonstrated

statistical significance to organizational role. Nurses in all organizational roles reported

Belief in Continuing Competence as their strongest attitude dimension and Sense of Calling

to the Field as their weakest attitude dimension. Flight nursing (N=1) reported the strongest

attitude dimension as Belief in Continuing Competence and the weakest attitude dimension

as Autonomy which might possibly be due to the importance of staying abreast clinically

and technically but possibly not having control in their practice environment. Table 21a

displays the regression of the six the professionalism dimensions and organizational role by

basic nursing degree. Due to the wide range of nursing roles outside of the staff nurse role

and missing categories, the nurses were collapsed into two groups (staff nurses and others)

for further analysis in Table 21b. Baccalaureate degree nurses in the staff nurse role

reported greater mean professionalism scores in 5 of the 6 attitude dimensions while

diploma degree nurses in the others role reported greater mean scores in only 2 dimensions.

Multivariate linear regression analysis demonstrated that role in the organization

was a predictor of a weaker degree of professionalism for diploma degree staff nurses (2.80)

in the attitudinal dimension of Professional Organization as a Major Referent (β = .000,

Wald Chi-square = 4.18, p=0.0408).

 202

Table 21
Overall Mean Professionalism Scores to Organizational Role
PROFESSIONALISM Staff Nurse Supervisor Admin Instructor/ Advanced School Researcher Flight χ2 p-value
DIMENSIONS Educator Practice Office Nurse / Nursing
Nurse Consultant
(N=156) (N=34) (N=12) (N=12) (N=3) (N=19) (N=1)
(N=5)

Professional Organization As 2.58 ±0.60 2.27±0.70 2.17±0.54 1.92±0.54 2.20±0.55 2.48 ±0.53 1.80±0.32 1.80 - 31.192 0.0001*
A Major Referent

Belief in Continuing 2.15±0.74 1.99±0.70 1.78±0.42 1.50±0.35 1.44±0.38 2.05±0.52 1.56±0.41 1.00 - 23.342 0.0015*
Competence

Belief in Self-Regulation 2.30±0.63 2.18±0.55 2.15±0.39 1.97±0.52 2.0±0.70 2.47±0.53 2.20±0.32 1.20 - 9.863 0.1965

Sense Of Calling To The 2.75±0.59 2.58±0.60 2.48±0.65 2.88±0.54 2.76±0.26 2.64±0.54 2.64±0.59 1.60 - 8.456 0.2941
Field

Autonomy 2.65±0.65 2.50±0.69 2.45±0.62 2.32±0.64 2.64±0.78 2.35±0.64 2.44±0.64 2.40 - 7.660 0.3636

Belief in Service To The 2.25±0.53 2.13±0.56 2.15±0.53 1.92±0.55 1.84±0.67 2.14±0.61 2.08±0.63 1.20 - 9.663 0.2085
Public

*p<0.05, chi-square with p-value based on Kruskal-Wallis Test

5-point Likert Scale (1=high degree of professionalism and 5= low degree of professionalism)
 203

Table 21a
Overall Mean Professionalism Scores by Basic Nursing Degree to Organizational Role
PROFESSIONALISM ROLE DIPLOMA ASSOCIATE BACCALAUREATE
DIMENSIONS (N=37) (N=94) (N=113)
Professional Staff Nurse 2.80±0.70 2.59±0.53 2.46±0.59
Organization as a Supervisor/HN 2.13±0.83 2.47±0.75 1.90±0.40
Major Referent Administrative 2.40 2.33±0.50 1.92±0.59
Instructor/Educator - 1.30±0.14 2.04±0.51
Advance Practice - - 2.20±0.55
School/Office 2.30±0.42 2.57±0.48 2.46±0.60
Research/Consultant - 2.20 1.70±0.26
Belief in Continuing Infection Control - - 1.60
Competence Staff Nurse 2.55±0.89 2.12±0.61 1.99±0.72
Supervisor/HN 1.67±0.31 2.06±.074 1.94±0.60
Administrative 2.00 1.87±0.27 1.64±0.59
Instructor/Educator - 1.20±0.00 1.56±0.35
Advance Practice - - 1.44±0.38
School/Office 2.50±0.99 1.86±0.51 2.10±0.41
Belief in Self- Research/Consultant - 2.00 1.45±0.38
Regulation Infection Control - - 1.00
Staff Nurse 2.36±0.71 2.31±0.66 2.26±0.56
Supervisor/HN 1.87±0.12 2.32±0.59 1.98±0.45
Administrative 2.00 2.20±0.33 2.12±0.52
Instructor/Educator - 2.30±0.14 1.90±0.54
Advance Practice - - 2.08±0.70
School/Office 2.00±0.00 2.60±0.52 2.48±0.56
Sense of Calling to Research/Consultant - 2.40 2.15±0.34
the Field Infection Control - - 1.20
Staff Nurse 2.72±0.67 2.86±0.56 2.67±0.56
Supervisor/HN 2.67±0.50 2.73±0.65 2.22±0.61
Administrative 2.40 2.40±0.59 2.60±0.84
Instructor/Educator - 3.00±0.28 2.86±0.59
Advance Practice - - 2.76±0.26
Autonomy School/Office 2.50±0.14 2.80±0.52 2.56±0.62
Research/Consultant - 2.40 2.70±0.65
Infection Control - - 1.60
Staff Nurse 2.59±0.69 2.74±0.66 2.60±0.62
Supervisor/HN 1.93±0.12 2.57±0.77 2.52±0.54
Administrative 2.00 2.33±0.52 2.66±0.78
Instructor/Educator - 3.10±0.71 2.16±0.53
Advance Practice - - 2.64±0.78
Belief in Service to School/Office 2.10±0.14 2.51±0.68 2.28±0.67
the Public Research/Consultant - 3.20 2.25±0.55
Infection Control - - 2.40
Staff Nurse 2.34±0.56 2.29±0.53 2.17±0.52
Supervisor/HN 2.07±0.31 2.13±0.55 2.14±0.95
Administrative 2.00 2.27±0.43 2.04±0.71
Instructor/Educator - 2.10±0.71 1.88±0.55
Advance Practice - - 1.84±0.67
School/Office 2.30±0.42 1.94±0.51 2.24±0.72
Research/Consultant - 3.00 1.85±0.41
Infection Control - - 1.20
5-point Likert Scale (1=high degree of professionalism and 5= low degree of professionalism)
Table 21b
Relationship of Class/Level for Mean Professionalism Scores by Basic Nursing Degree to
Organizational Role
PROFESSIONALISM Class/Level STAFF NURSE* OTHERS** p-value
DIMENSIONS (N=156) (N=88)

**
Professional Diplomaa 2.80±0.70 2.23±0.57 0.5375
**
Organization as a Associateb 2.59±0.53 2.39±0.68 0.2433
Major Referent Baccalaureatec 2.46±0.59 2.07±0.53

**
Belief in Continuing Diplomaa 2.55±0.89 2.00±0.63 0.3563
**
Competence Associateb 2.12±0.61 1.94±0.63 0.6699
Baccalaureatec 1.99±0.72 1.74±0.54

**
Belief in Self- Diplomaa 2.36±0.72 1.93±0.10 0.3429
**
Regulation Associateb 2.31±0.66 2.36±0.52 0.2178
Baccalaureatec 2.26±0.58 2.10±0.55

**
Sense of Calling to the Diplomaa 2.72±0.67 2.57±0.34 0.8726
**
Field Associateb 2.86±0.56 2.70±0.54 0.7254
Baccalaureatec 2.67±0.56 2.57±0.63

**
Autonomy Diplomaa 2.59±0.69 2.00±0.13 0.2246
**
Associateb 2.74±0.66 2.57±0.70 0.8148
Baccalaureatec 2.60±0.62 2.39±0.61

**
Belief in Diplomaa 2.34±0.56 2.13±0.30 0.8764
**
Service to the Public Associateb 2.29±0.53 2.14±0.53 0.9698
Baccalaureatec 2.17±0.52 2.01±0.70

p<0.05
5-point Likert Scale (1=high degree of professionalism and 5= low degree of professionalism)
c
Baccalaureate utilized as a control
a
Diploma versus Baccalaureate
b
Associate versus Baccalaureate

Table 22 displays the overall mean scale professionalism scores to the six

professionalism dimensions by practice setting. No statistical significance was

demonstrated between practice setting and the six professionalism dimensions. The

hospital, outpatient clinic, school, agency/pool, home health, flight, and other type nurses
reported Belief in Continuing Competence as their strongest professionalism dimension

and Sense of Calling to the Field as their weakest professionalism dimension. Military

installation and nursing home nurses reported Belief in Self-Regulation as their strongest

professionalism dimension and Sense of Calling to the Field as their weakest

professionalism dimension. The health department and industrial setting nurses reported

Belief in Continuing Competence as their strongest professionalism dimension and

Autonomy as their weakest professionalism dimension. Nurses in doctor‟s offices

reported Belief in Continuing Competence as their strongest professionalism dimension

and Professional Organization as a Major Referent as their weakest professionalism

dimension. The correctional medicine nurse (N=1) reported both the Professional

Organization as a Major Referent and Belief in Continuing Competence as the strongest

professionalism dimension and Belief in Service to the Public as the weakest

professionalism dimension. Table 22a displays the six professionalism dimensions and

practice setting by basic nursing degree. Due to the distribution and wide range of

nursing practice setting and distribution, nurses were collapsed into three groups

(hospital, outpatient clinic, others) for further analysis.

Table 22b displays the regression of practice setting and the six professionalism

dimensions by basic nursing degree. In the attitude dimension of Professional

Organization as a Major Referent (p=0.0521) significance was found between hospital

and other nurse compared to diploma and baccalaureate degree nurses. Baccalaureate

degree nurses in both groups demonstrated greater mean professionalism scores. In the

attitude dimension of Belief in Continuing Competence (p=0.0070/p=0.0089)

significance was found between hospital and other nurses compared to diploma and

baccalaureate degree nurses as well as between outpatient clinics and other nurses
 207

Table 22
Overall Mean Professionalism Scores to Practice Setting

Home Health (N = 12)

Doctor‟s Office (N = 7)

Emergency Center

Self/ Employed/Private
(N = 12) Outpatient Clinic

Flight Nursing (N = 1)
Military Installation

Agency/Nursing Pool (N =

Medicine (N =
PROFESSIONALISM

Health Department

Industrial Setting
Nursing Home
Hospital (N = 156)
DIMENSIONS

(N = 20)

Other (N = 4)

p-value
School10)

χ2
1)
Correctional
(N = 11)

(N = 1)
(N = 2)

(N = 7)
Professional
Organization 2.43±0.65 2.57±0.52 2.10±0.37 2.37±0.48 2.53±0.65 2.20 2.48±0.56 3.02±0.55 2.60±0.59 - 2.07±0.57 - 2.20 2.48 2.30±0.42 14.850 .2497
As a Major
Referent

Belief in 2.08±0.74 2.10±0.75 1.80±0.85 1.51±0.41 2.00±0.61 2.00 1.99±0.58 2.44±0.88 2.06±0.49 - 1.82±0.54 - 2.20 1.60 1.50±0.35 12.684 .3924
Continuing
Competence

Belief in 2.23±0.62 2.52±2.55 2.10±0.42 2.00±0.33 2.22±0.58 2.40 2.40±0.59 2.50±0.80 2.23±0.48 - 2.07±0.25 - 2.40 3.20 2.30±0.48 14.340 .2798
Self-
Regulation

Sense Of 2.71±0.58 2.85±0.69 2.10±0.14 2.69±0.30 2.56±0.57 2.40 2.70±0.60 3.12±0.61 2.40±0.28 - 2.52±0.51 - 2.40 3.40 2.75±1.02 14.748 .2555
Calling To
The Field

Autonomy 2.66±0.68 2.40±0.51 3.30±0.42 2.46±0.70 2.35±0.61 3.20 2.35±0.52 2.560.67 2.43±0.52 - 2.22±0.35 - 2.60 3.20 2.45±0.81 16.447 .1716

Belief in 2.21±0.58 2.83±0.57 2.60±0.28 1.86±0.63 2.50±0.30 3.00 2.05±0.64 2.34±0.47 2.17±0.34 - 2.25±0.60 - 2.80 2.00 2.15±0.57 11.649 .4742
Service To
The Public

p<0.05, chi-square with p-value based on Kruskal-Wallis Test

5-point Likert Scale (1=high degree of professionalism and 5= low degree of professionalism)
 208

Table 22a
Overall Mean Professionalism Scores by Basic Nursing Degree to Practice Setting
PROFESSIONALIM PRACTICE SETTING DIPLOMA ASSOCIATE BACCALAUREATE
DIMENSIONS (N=37) (N=94) (N=113)

Professional Hospital 2.81±0.75 2.48±0.60 2.27±0.61

Organization as a Outpatient Clinic 2.80±0.53 2.80±0.43 2.24±0.50
Major Referent Health Department - 2.10±0.71 -
Military Installation 2.60 2.80 2.24±0.52
Nursing Home 2.40 2.68±0.71 2.00±0.00
Industrial Setting - 2.20 -
School 2.30±0.42 2.63±0.48 2.42±0.64
Agency/Nursing Pool 3.20±0.57 2.85±0.62 3.10±0.58
Doctors Office - 2.73±0.76 2.50±0.53
Home Health 2.00±0.69 2.14±0.63 1.90±0.42
Correctional Medicine - - 2.20
Flight Nurse - 2.40 -
Other 2.40 - 2.27

Belief in Continuing
Competence Hospital 2.73±0.91 2.04±0.59 1.89±0.68
Outpatient Clinic 1.93±0.12 2.85±0.66 1.60±0.57
Health Department - 1.80±0.85 -
Military Installation 1.60 2.00 1.40±0.42
Nursing Home 1.40 2.10±0.68 1.90±0.14
Industrial Setting - 2.20 -
School 2.50±0.99 1.77±0.45 2.04±0.57
Agency/Nursing Pool 2.50±0.71 2.60±0.71 2.25±1.26
Doctors Office - 1.87±0.61 2.20±0.40
Home Health 1.87±0.23 1.74±0.61 2.00±0.85
Correctional Medicine - - 2.20
Flight Nurse - 1.60 -
Other 1.40 - 1.53
Belief in Self-
Regulation
Hospital 2.39±0.81 2.27±0.64 2.15±0.53
Outpatient Clinic 2.27±0.23 2.60±0.59 2.60±0.69
Health Department - 2.10±0.42 -
Military Installation 2.20 2.00 1.96±0.38
Nursing Home 1.80 2.35±0.63 1.90±0.14
Industrial Setting - 2.40 -
School 2.00±0.00 2.54±0.51 2.38±0.67
Agency/Nursing Pool 2.50±0.14 2.45±0.96 2.55±100
Doctors Office - 2.60±0.53 1.95±0.19
Home Health 1.87±0.12 2.20±0.23 1.90±0.14
Correctional Medicine - - 2.40
Flight Nurse - 3.20 -
Other 2.00 - 2.40 ±0.53

5-point Likert Scale (1=high degree of professionalism and 5= low degree of professionalism)
Table 22a
Overall Mean Professionalism Scores by Basic Nursing Degree to Practice Setting
(cont‟d)
PROFESSIONALISM PRACTICE SETTING DIPLOMA ASSOCIATE BACCALAUREATE
DIMENSIONS (N=37) (N=94) (N=113)

Sense of Calling to Hospital 2.73±0.68 2.84±0.53 2.61±0.58

the Field Outpatient Clinic 2.53±0.42 3.25±0.50 2.72±0.88
Health Department - 2.10±0.14 -
Military Installation 2.60 2.20 2.76±0.28
Nursing Home 3.20 2.55±0.56 2.30±0.71
Industrial Setting - 2.40 -
School 2.50±0.14 2.83±0.50 2.65±0.71
Agency/Nursing Pool 3.30±0.42 3.25±0.77 2.90±0.58
Doctors Office - 2.60±0.20 2.25±0.25
Home Health 2.53±0.42 2.49±0.60 2.60±0.57
Correctional Medicine - - 2.40
Flight Nurse - 3.40 -
Other 1.40 - 3.20±0.60

Autonomy Hospital 2.59±0.74 2.76±0.73 2.60±0.61

Outpatient Clinic 2.40±0.40 2.20±0.52 2.56±0.61
Health Department - 3.30±0.42 -
Military Installation 3.60 2.00 2.32±0.58
Nursing Home 2.00 2.53±0.62 1.80±0.28
Industrial Setting - 3.20 -
School 2.10±0.14 2.43±0.65 2.35±0.68
Agency/Nursing Pool 2.00±0.00 2.75±0.55 2.65±0.89
Doctors Office - 2.80±0.53 2.15±0.34
Home Health 2.07±0.31 2.31±0.40 2.10±0.14
Correctional Medicine - - 2.60
Flight Nurse - 3.20 -
Other 2.80 - 2.33±0.95

Belief in Service to Hospital 2.36±0.55 2.25±0.56 2.14±0.60

the Public Outpatient Clinic 2.27±0.31 2.15±0.34 1.80±0.80
Health Department - 2.60±0.28 -
Military Installation 1.00 2.00 2.00±0.62
Nursing Home 2.00 2.10±0.34 1.90±0.14
Industrial Setting - 3.00 -
School 2.30±0.42 2.00±0.57 2.04±0.75
Agency/Nursing Pool 2.60±0.28 2.35±0.66 2.20±0.37
Doctors Office - 2.20±0.20 2.15±0.44
Home Health 2.13±0.42 2.37±0.66 2.00±0.85
Correctional Medicine - .- 2.80
Flight Nurse - 2.00 -
Other 2.60 - 2.00±0.60

5-point Likert Scale (1=high degree of professionalism and 5= low degree of professionalism)
Table 22b
Relationship of Class/Level for Mean Professionalism Scores by Basic Nursing Degree to
Practice Setting
PROFESSIONALSIM Class/Level HOSPITAL* OUTPT CLINIC** OTHER*** p-value
DIMENSIONS (N=156) (N=12) (N=76)

* **
Professional Diplomaa 2.81±0.75 2.80±0.53 2.44±0.60 0.0521 0.2853
* **
Organization as a Associateb 2.48±0.60 2.80±.043 2.53±0.61 0.6206 0.3116
Major Referent Baccalaureatec 2.27±0.61 2.24±0.50 2.41±0.59

* **
Belief in Continuing Diplomaa 2.73±0.91 1.93±0.12 2.00±0.63 0. 0070 0.6198
* **
Competence Associateb 2.04±0.59 2.85±0.66 1.96±0.61 0. 5428 0.0089
Baccalaureatec 1.89±0.68 1.60±0.57 1.93±0.65

* **
Belief in Self- Diplomaa 2.39±0.81 2.27±0.23 2.06±0.27 0. 1082 0.7233
* **
Regulation Associateb 2.27±0.64 2.60±0.59 2.39±0.54 0. 7602 0.6849
Baccalaureatec 2.15±0.53 2.60±0.69 2.23±0.59

* **
Sense of Calling to Diplomaa 2.73±0.68 2.53±0.42 2.66±0.61 0. 6181 0.7033
* **
the Field Associateb 2.84±0.53 3.25±0.50 2.66±0.58 0.1730 0.1921
Baccalaureatec 2.61±0.58 2.72±0.88 2.67±0.57

* **
Autonomy Diplomaa 2.59±0.74 2.40±0.40 2.28±0.54 0. 9373 0.8053
* **
Associateb 2.76±0.73 2.20±0.52 2.58±0.57 0. 5482 0.1647
Baccalaureatec 2.60±0.61 2.56±0.61 2.31±0.62

* **
Belief in Diplomaa 2.36±0.55 2.27±0.31 2.18±0.54 0.6515 0.4260
* **
Service to the Public Associateb 2.25±0.56 2.15±0.34 2.22±0.51 0.7813 0.6129
Baccalaureatec 2.14±0.60 1.80±0.80 1.93±0.65

p<0.05
5-point Likert Scale (1=high degree of professionalism and 5= low degree of professionalism)
Note: ***Other and cBaccalaureate are utilized as controls
a
Diploma versus Baccalaureate
b
Associate versus Baccalaureate
*
Hospital versus Other
**
Outpatient Clinic versus Other

compared to associate and baccalaureate degree nurses. Hospital, outpatient clinic and

other baccalaureate degree nurses demonstrated greater mean professionalism scores.

Univariate linear regression analysis demonstrated statistical significance between

practice setting and the attitudinal dimensions of Professional Organization as a Major

Referent and Belief in Continuing Competence while multivariate linear regression

analysis demonstrated that practice setting was not a predictor by basic nursing degree of

degree of professionalism.

Table 23 displays the overall mean professionalism scale scores to the six

professionalism dimensions by nursing practice years. Nursing practice years

demonstrated statistical significance to Autonomy (p=0.0099). Nurses with practice

years in the ranges of 6 - 10, 11 - 15, and 21 - 35 reported Belief in Continuing

Competence as their strongest professionalism dimension and Sense of Calling to the

Field as their weakest professionalism dimension. Nurses with less <5 years of practice

reported Belief in Continuing Competence as their strongest professionalism dimension

however reported Autonomy as their weakest professionalism dimension. Nurses with 16

- 20 practice years reported Belief in Service to the Public as their strongest

professionalism dimension and reported Autonomy along with Sense of Calling to the

Field as their weakest professionalism dimension. Nurses with >36 years reported Belief

in Self-Regulation as their strongest professionalism dimension however reported

Professional Organization as a Major Referent as their weakest professionalism

dimension. Table 23a displays nursing practice years and the six professionalism

dimensions by basic nursing degree. Due to the distribution and wide range of nursing

practice years, the groups were collapsed into three year groups (1 - 15, 16 - 25, and >

26) for further analysis.

Table 23b displays the regression analysis of nursing practice years and the six

professionalism dimensions by basic nursing degree. In the attitude dimension of Belief

in Continuing Competence (p=0.0485) statistical significance was demonstrated between

16 - 25 and >26 years of practice nurses compared to diploma and baccalaureate degree

nurses. Baccalaureate degree nurses with over 16 years of practice reported higher mean

professionalism scores. In the attitude dimension Sense of Calling to the Field

(p=0.0474/p=0.0049) significance was found between 1 - 25 and >26 years of practice

nurses compared to diploma and baccalaureate degree nurses. Baccalaureate degree

nurses with 1 – 25 years and diploma nurses with >26 years demonstrated higher mean

professionalism scores. In the attitude dimension of Autonomy (p=0.0182) significance

was found between nurses with 1 to 25 and >26 practice year compared to associate and

baccalaureate degree nurses. Baccalaureate degree nurses with 1 – 15 years

demonstrated a higher mean professionalism score as well as associate degree nurses with

>26 years.

Although univariate linear regression analysis demonstrated statistical

significance between practice years and the attitudinal dimensions of Belief in

Continuing Competence and Sense of Calling to the Field, multivariate linear regression

analysis demonstrated that practice years was not a predictor by basic nursing degree of

degree of professionalism.
 213

Table 23
Overall Mean Professionalism Scores to Nursing Practice Years
PROFESSIONALISM <5 6 - 10 11 – 15 16 – 25 21 – 25 26 - 30 31 - 35 >36 χ2 p-value
DIMENSIONS (N=28) (N=38) (N=48) (N=35) (N=49) (N=30) (N=12) (N=4)

Professional Organization as 2.60±0.60 2.28±0.51 2.52±0.61 2.53±0.70 2.38±0.66 2.41±0.70 2.28±0.54 2.90±0.60 8.5739 0.2847
a Major Referent

Belief in Continuing 2.10±0.70 1.85±0.53 2.02±0.67 2.21±0.85 1.93±0.70 2.25±0.77 1.87±0.59 2.45±0.90 9.0867 0.2465
Competence

Belief in Self-Regulation 2.32±0.51 2.33±0.65 2.24±0.58 2.35±0.62 2.14±0.57 2.25±0.66 2.33±0.61 1.85±0.34 6.4842 0.4845

Sense Of Calling To The 2.73±0.55 2.67±0.60 2.84±0.56 2.65±0.51 2.67±0.59 2.69±0.69 2.83±0.77 2.00±0.52 9.8861 0.1951
Field

Autonomy 2.96±0.53 2.58±0.60 2.59±0.67 2.66±0.70 2.36±0.62 2.51±0.70 2.35±0.58 2.50±0.68 18.4999 0.0099*

Belief in Service To The 2.37±0.48 2.07±0.51 2.20±0.50 2.19±0.54 2.17±0.56 2.26±0.71 1.92±0.84 2.30±0.53 9.7502 0.2032
Public
p<0.05, chi-square with p-value based on Kruskal-Wallis Test
5-point Likert Scale (1=high degree of professionalism and 5= low degree of professionalism)
 214

Table 23a
Overall Mean Professionalism Scores by Basic Nursing Degree to Practice Years
PROFESSIONAL PRACTICE DIPLOMA ASSOCIATE BACCALAUREATE
DIMENSIONS YEARS (N=37) (N=94) (N=113)
Professional Organization as a Major <5 - 2.68±0.59 2.50±0.63
Referent 6 - 10 - 2.36±0.40 2.24±0.57
11 - 15 2.83±0.70 2.65±0.62 2.27±0.50
16 - 20 2.30±0.43 2.65±0.71 2.47±0.80
21 - 25 2.83±0.71 2.18±0.57 2.22±0.55
26 - 30 2.68±0.91 2.50±0.51 2.21±0.64
31 - 35 - 2.15±0.41 2.35±0.60
> 36 2.80±0.69 - 3.204
Belief in Continuing Competence <5 - 2.04±0.40 2.08±0.94
6 - 10 - 1.94±0.55 1.79±0.52
11 - 15 2.57±0.97 2.09±0.61 1.77±0.52
16 - 20 1.90±0.60 2.24±0.88 2.33±0.93
21 - 25 2.39±0.85 1.80±0.55 1.71±0.54
26 - 30 2.95±0.84 2.23±0.51 1.87±0.60
31 - 35 - 1.85±0.47 1.88±0.68
> 36 2.47±1.10 - 2.40
Belief in Self-Regulation <5 - 2.35±0.56 2.28±0.44
6 - 10 - 2.39±0.63 2.29±0.67
11 - 15 2.33±0.85 2.32±0.61 2.13±0.47
16 - 20 2.17±0.43 2.44±0.71 2.33±0.59
21 - 25 2.44±0.74 2.15±0.23 1.95±0.52
26 - 30 2.30±0.70 2.45±0.82 2.11±0.54
31 - 35 - 1.95±0.66 2.53±0.51
> 36 1.73±0.31 - 2.20
Sense of Calling to the Field <5 - 2.86±0.45 2.55±0.64
6 - 10 - 2.61±0.49 2.70±0.55
11 - 15 2.87±0.78 3.00±0.57 2.65±0.43
16 - 20 2.60±0.33 2.68±0.64 2.62±0.39
21 - 25 2.91±0.56 2.78±0.36 2.44±0.66
26 - 30 2.58±0.65 2.83±0.87 2.67±0.65
31 - 35 - 2.50±0.26 3.00±0.89
> 36 1.80±0.40 - 2.60
Autonomy <5 - 3.04±0.51 2.87±0.57
6 - 10 - 2.67±0.60 2.53±0.60
11 - 15 2.63±0.82 2.75±0.71 2.39±0.56
16 - 20 2.47±0.68 2.72±0.67 2.67±0.78
21 - 25 2.39±0.71 2.43±.068 2.31±0.55
26 - 30 2.58±0.56 2.33±0.74 2.59±0.78
31 - 35 - 2.00±0.63 2.53±0.50
> 36 2.53±0.83 - 2.40
Belief in Service to the Public <5 - 2.40±0.37 2.33±0.62
6 - 10 - 2.04±0.62 2.08±0.45
11 - 15 2.43±0.57 2.29±0.53 2.03±0.40
16 - 20 1.93±0.64 2.28±0.48 2.18±0.60
21 - 25 2.36±0.49 2.02±0.57 2.15±0.58
26 - 30 2.45±0.45 2.47±0.41 2.03±0.90
31 - 35 - 1.95±0.85 1.90±0.89
> 36 2.13±0.50 - 2.80
5-point Likert Scale (1=high degree of professionalism and 5= low degree of professionalism)
Table 23b
Relationship of Class/Level for Mean Professionalism Scores by Basic Nursing Degree to
Practice Years
PROFESSIONALISM Class/Level 1 – 15* 16 - 25** >26*** p-value
DIMENSIONS (114) (N=84) (N=46)

* **
Professional Diplomaa 2.83±0.70 2.67±0.67 2.71±0.82 0.7236 0.8851
* **
Organization as a Associateb 2.58±0.56 2.45±0.68 2.38±0.49 0.4291 0.8154
Major Referent Baccalaureatec 2.31±0.56 2.31±0.65 2.30±0.63

* **
Belief in Continuing Diplomaa 257±0.97 2.24±0.80 2.82±0.89 0.5548 0.0485
* **
Competence Associateb 2.03±0.55 2.05±0.77 2.10±0.51 0.8899 0.7655
Baccalaureatec 1.87±0.64 1.93±0.75 1.60±0.61

* **
Belief in Self- Diplomaa 2.33±0.85 2.36±0.66 2.15±0.66 0.5143 0.1483
* **
Regulation Associateb 2.35±0.59 2.31±0.57 2.28±0.78 0.7006 0.4154
Baccalaureatec 2.23±0.56 2.08±0.57 2.26±0.54
*
Sense of Calling to Diplomaa 2.87±0.78 2.82±0.51 2.36±0.68 0.0474 **
0.0049
the Field Associateb 2.85±0.53 2.73±0.53 2.72±0.73 *0.2404 **
0.2364
Baccalaureatec 2.65±0.52 2.50±0.65 2.78±0.73

* **
Autonomy Diplomaa 2.63±0.82 2.41±0.68 2.56±0.60 0.8391 0.9119
* **
Associateb 2.82±0.63 2.59±0.69 2.22±0.70 0.0182 0.0711
Baccalaureatec 2.55±0.60 2.44±0.65 2.56±0.66

* **
Belief in Diplomaa 2.43±0.57 2.23±0.56 2.36±0.46 0.9222 0.2862
* **
Service to the Public Associateb 2.26±0.52 2.17±0.52 2.30±0.61 0.5272 0.2579
Baccalaureatec 2.12±0.48 2.16±0.58 2.02±0.87

p<0.05
5-point Likert Scale (1=high degree of professionalism and 5= low degree of professionalism)
Note: ***>26 years and cBaccalaureate utilized as controls
a
Diploma versus Baccalaureate
b
Associate versus Baccalaureate
*1 – 15 years versus >26 years
**
16 – 25 years versus >26 years

Table 24 displays the overall mean professionalism scale scores to the six

professionalism dimensions by continuing education. Professional Organization as a

Major Referent (p=<0.0001) and Belief in Continuing Competence (p=<0.0001)

demonstrated statistical significance to continuing education hours. Nurses reported

Belief in Continuing Competence as their strongest professionalism dimension and

 reported Sense of Calling to the Field as their weakest professionalism dimension. Table

24a displays continuing education and the six professionalism dimensions by basic

nursing degree. Due to the distribution of nursing continuing education hours and taking

into account the mandatory 20 hour minimum for registered nurse licensure in the state of

Texas, the nurses were collapsed into two groups (<20 hours, >20 hours) for further

analysis. Table 24b displays the regression analysis of continuing education and the six

professionalism dimensions by basic nursing degree. In the attitude dimension

Professional Organization as a Major Referent (p=0.0446), significance was found

between associate and baccalaureate degree nurses attaining 20 or greater continuing

education hours. Baccalaureate degree nurses demonstrated higher mean professionalism

scores.

Table 24
Overall Mean Professionalism Scores to Continuing Education Hours
PROFESSIONALISM < 20 21 – 40 41 -60 > 61 χ2 p-value
DIMENSIONS (N=108) (N=104) (N=27) (N=5)

Professional Organization as a 2.64±0.57 2.37±0.65 2.08±0.53 1.88±0.50 24.182 <0.0001*

Major Referent

Belief in Continuing 2.20±0.69 2.01±0.71 1.54±0.46 1.84±0.68 21.650 <0.0001*

Competence

Belief in Self-Regulation 2.36±0.60 2.18±0.60 2.19±0.54 2.00±0.47 5.770 0.1233

Sense of Calling to the Field 2.72±0.50 2.69±0.64 2.73±0.66 2.54±0.77 0.647 0.8854

Autonomy 2.68±0.64 2.53±0.68 2.36±0.55 2.36±0.33 6.479 0.0905

Belief in Service to the Public 2.26±0.49 2.16±0.62 2.02±0.61 2.16±0.79 2.727 0.1256

*p<0.05, chi-square with p-value based on Kruskal-Wallis Test

5-point Likert Scale (1=high degree of professionalism and 5= low degree of professionalism)
Table 24a
Overall Mean Professionalism Scores by Basic Nursing Degree to Continuing Education
Hours
PROFESSIONALISM HOURS DIPLOMA ASSOCIATE BACCALAUREATE
DIMENSIONS (N=37) (N=94) (N=113)

Professional < 20 2.81±0.67 2.58±0.53 2.60±0.54

Organization as a 21 - 40 2.53±0.77 2.52±0.67 2.22±0.58
Major Referent 41- 60 3.00 2.25±0.62 1.96±0.48
> 60 - 2.07±0.58 1.60±0.28

Belief in Continuing < 20 2.56±0.86 2.10±0.58 2.12±0.67

Competence 21 - 40 2.34±0.92 2.07±0.69 1.87±0.64
41- 60 2.00 1.68±0.43 1.46±0.47
> 60 - 1.93±0.64 1.70±0.99

Belief in Self- < 20 2.38±0.61 2.35±0.65 2.36±0.55

Regulation 21 - 40 2.14±0.80 2.35±0.61 2.08±0.52
41- 60 2.40 2.13±0.45 2.21±0.59
> 60 - 2.27±0.12 1.60±0.57

Sense of Calling to < 20 2.77±0.56 2.72±0.50 2.70±0.47

the Field 21 - 40 2.54±0.74 2.94±061 2.54±0.59
41- 60 3.00 2.50±0.32 2.81±0.77
> 60 - 2.87±0.76 2.00±0.57

Autonomy < 20 2.55±0.64 2.80±0.64 2.61±0.64

21 - 40 2.40±0.75 2.58±0.75 2.52±0.62
41- 60 2.40 2038±0.51 2.34±0.60
> 60 - 2.53±0.12 2.10±0.42

Belief in Service to < 20 2.28±0.50 2.34±0.48 2.16±0.48

the Public 21 - 40 2.31±0.60 2.12±0.52 2.14±0.69
41- 60 2.60 2.05±0.72 1.98±0.58
> 60 - 2.67±0.50 1.40±0.28
5-point Likert Scale (1=high degree of professionalism and 5= low degree of professionalism)

Multivariate linear regression analysis demonstrated that basic nursing degree was

a predictor of a weaker degree of professionalism for diploma degree nurses (2.81)

receiving <20 hours of continuing education in the attitudinal dimension of Professional

Organization as a Major Referent (β = .000, Wald Chi-square = 4.33, p=0.0375).

Table 24b
Relationship of Class/Level for Mean Professionalism Scores by Basic Nursing Degree to
Continuing Education Hours
PROFESSIONALISM Class/Level <20 hours* ≥20 hours** p-value
DIMENSIONS (N=108) (N=136)
**
Professional Diplomaa 2.81±0.67 2.56±0.75 0.3349
**
Organization as a Associateb 2.58±0.53 2.45±0.65 0.0446
Major Referent Baccalaureatec 2.60±0.54 2.14±0.56

**
Belief in Continuing Diplomaa 2.56±0.86 2.32±0.89 0.6500
**
Competence Associateb 2.10±0.58 2.00±0.66 0.1649
Baccalaureatec 2.12±0.67 1076±0.63

**
Belief in Self- Diplomaa 2.38±0.61 2.16±0.78 0.8530
**
Regulation Associateb 2.35±0.65 2.31±0.57 0.1875
Baccalaureatec 2.36±0.55 2.10±0.54

**
Sense of Calling to the Diplomaa 2.77±0.58 2.57±0.72 0.6660
**
Field Associateb 2.72±0.50 2.87±0.60 0.1289
Baccalaureatec 2.70±0.47 2.59±0.65

**
Autonomy Diplomaa 2.55±0.64 2.40±0.73 0.9632
**
Associateb 2.80±0.64 2.55±0.69 0.5300
Baccalaureatec 2.61±0.64 2.47±0.61

**
Belief in Diplomaa 2.28±0.50 2.33±0.58 0.5409
**
Service to the Public Associateb 2.34±0.48 2.14±0.56 0.4537
Baccalaureatec 2.16±0.48 2.08±0.66

p<0.05
5-point Likert Scale (1=high degree of professionalism and 5= low degree of professionalism)
Note: cBaccalaureate utilized as a control
a
Diploma versus Baccalaureate
b
Associate versus Baccalaureate

Table 25 displays the overall mean scale professionalism scores to the six

professionalism dimensions by annual salary. Professional Organization as a Major

Referent (p=<0.0197) and Belief in Self-Regulation (p=0.0372) demonstrated statistical

significance to annual salary. Nurses earning annual salaries between <20,999 and

>$40,000 reported Belief in Continuing Competence as their strongest professionalism

dimension and reported Sense of Calling to the Field as their lowest professionalism

dimension as in the two salary ranges ( $70,000 - $79,999 and $90,000 - $99,999).

Nurses earning between $30,000 - $39,999 reported Belief in Continuing Competence as

their strongest professionalism dimension and Autonomy as their lowest professionalism

dimension. Table 25a displays annual salary and the six professionalism dimensions to

basic nursing degree. Due to the distribution of annual salaries, the nurses were

collapsed into three groups (<$40,000, $40,000 - $79,999, >80,000) for further analysis.

Table 25b displays that regression of annual salary to professionalism failed to

demonstrate statistically significance differences by basic nursing degree.

While univariate linear regression analysis demonstrated statistical significance

between salary and the attitude dimensions of Professional Organization as a Major

Referent and Belief in Self-Regulation, multivariate regression analysis demonstrated that

salary was a predictor of a weaker degree of professionalism for associate degree nurses

(2.90) earning <$40,000 annual salary in the attitude dimension of Belief in Self-

Regulation (β = .489, Wald Chi-square = 7.14, p=0.0075).

 220

Table 25
Overall Mean Professionalism Scores to Annual Salary

χ2
< $20,999

> $100,000
$21,000 - $29,999

$70,000 - $79,9999

$80,000 - $89,000

$90,000 - $99,999
$30,000 - $39,999

$40,000 - $49,000

$60,000 - $69,999
$50,000 - $59,999
PROFESSIONALISM
DIMENSIONS

Professional
Organization As a 2.40 - 2.45±0.10 2.35±0.45 2.71±0.57 2.56±0.64 2.43±0.65 2.32±0.65 2.40±0.65 2.13±0.50 2.12±0.65 19.725 0.0197*
Major Referent

Belief in
1.40 - 2.20±0.75 1.82±0.49 2.21±0.72 2.10±0.76 2.09±0.76 1.95±0.66 1.83±0.70 1.93±0.71 1.78±0.38 9.192 0.4197
Continuing
Competence
2.12±0.52
Belief in Self- 2.00 - 2.45±0.66 2.51±0.73 2.45±0.67 2.28±0.62 2.25±0.57 1.94±0.46 2.42±0.46 2.16±0.50 17.826 0.0372
Regulation

Sense of Calling 1.40 - 2.70±0.35 2.69±0.60 2.76±0.64 2.71±0.53 2.81±0.58 2.64±0.61 2.58±0.48 2.80±0.71 2.46±0.59 8.224 0.5117
To The Field

Autonomy 2.80 – 2.35±0.19 2.91±0.73 2.69±0.70 2.54±0.66 2.45±0.60 2.64±0.69 2.43±0.66 2.80±0.60 2.42±0.50 9.018 0.4356

Belief in Service 2.60 - 2.10±0.76 2.47±0.45 2.24±0.51 2.16±0.51 2.18±0.62 2.14±0.53 2.03±0.57 2.31±0.89 2.16±0.74 7.555 0.4197
To The Public
n =1 n=4 n = 11 n = 46 n = 50 n = 51 n = 39 n = 23 n=9 n = 10
*p<0.05, chi-square with p-value based on Kruskal-Wallis Test
5-point Likert Scale (1=high degree of professionalism and 5= low degree of professionalism)
Table 25a
Overall Mean Professionalism Scores by Basic Nursing Degree to Annual Salary

Professionalism Diploma Associate Baccalaureate ANNUAL Diploma Associate Baccalaureate

Factors (N=37) (N=94) (N=113) SALARY (N=37) (N=94) (N=113)

Professional 2.40 - - < 20,000 1.40 - - Sense Of

Organization As 2.50±0.14 2.40±0.00 - 20,000-29,999 2.70±0.42 2.70±0.42 - Calling To
a Major 2.00±0.00 2.25±0.55 2.56±0.38 30,000-39,999 2.20±0.57 2.90±0.82 2.72±0.39 The Field
Referent 3.03±0.45 2.77±0.50 2.56±0.62 40,000-49,999 3.07±0.58 2.85±0.68 2.58±0.61
2.72±0.67 2.59±0.52 2.42±0.75 50,000-59,999 2.70±0.61 2.80±0.40 2.60±0.63
3.20±0.57 2.33±0.61 2.19±0.44 60,000-69,999 2.98±0.67 2.78±0.65 2.77±0.43
2.16±0.77 2.48±0.77 2.26±0.56 70,000-79,999 2.36±0.36 2.75±0.59 2.64±0.67
1.90±0.99 2.45±0.91 2.24±0.58 80,000-89,999 2.20±0.00 2.75±0.34 2.59±0.52
- 2.20±0.28 2.11±0.56 90,000-99,999 - 2.80±0.28 2.80±0.82
- 2.55±0.57 1.83±0.56 >100,000 - 2.70±0.38 2.30±0.68

Belief in 1.40 - - < 20,000 2.80 - - Autonomy

Continuing 2.60±0.85 1.80±0.57 - 20,000-29,999 2.30±0.14 2.40±0.28 -
Competence 1.90±0.14 1.60±0.63 1.96±0.46 30,000-39,999 2.30±0.42 3.35±0.50 2.80±0.84
2.77±0.91 2.21±0.63 2.06±0.70 40,000-49,999 2.77±0.78 2.91±0.63 2.47±0.70
2.30±0.74 2.08±0.58 2.00±0.97 50,000-59,999 2.48±0.67 2.62±0.69 2.46±0.63
2.82±1.12 1.97±0.66 1.89±0.41 60,000-69,999 2.51±0.81 2.41±0.63 2.46±0.48
2.16±0.59 2.17±0.75 1.79±0.60 70,000-79,999 2.28±0.69 2.77±0.80 2.65±0.62
2.50±1.27 1.95±0.53 1.73±0.67 80,000-89,999 2.40±0.85 2.60±0.78 2.40±0.66
- 1.70±0.14 2.00±0.80 90,000-99,999 - 2.60±0.00 2.86±0.68
- 2.00±0.40 1.63±0.32 >100,000 - 2.60±0.63 2.30±0.41

Belief in Self- 2.00 - - < 20,000 2.60 - - Belief in

Regulation 1.90±0.14 3.00±0.28 - 20,000-29,999 2.60±0.00 1.60±0.85 - Service To
1.90±0.14 2.85±0.87 2.48±0.67 30,000-39,999 2.20±0.28 2.70±0.35 2.40±0.55 The Public
2.57±0.81 2.47±0.64 2.40±0.68 40,000-49,999 2.37±0.39 2.36±0.45 2.10±0.57
2.32±0.73 2.37±0.58 2.12±0.60 50,000-59,999 2.26±0.60 2.26±0.46 1.98±0.49
2.42±0.88 2.14±0.52 2.29±0.44 60,000-69,999 2.29±0.75 2.04±0.58 2.31±0.59
2.04±0.33 2.17±0.66 2.11±0.48 70,000-79,999 2.16±0.26 2.25±0.58 2.08±0.55
2.30±0.71 2.05±0.25 1.87±0.48 80,000-89,999 2.40±0.85 2.10±0.38 1.98±0.60
- 2.60±0.28 2.37±0.51 90,000-99,999 - 2.00±0.57 2.40±0.98
- 2.25±0.70 2.10±0.37 >100,000 - 2.65±0.55 1.83±0.69
 222

Table 25b
Relationship of Class/Level for Mean Professionalism Scores by Basic Nursing Degree to
Annual Salary
PROFESSIONALISM Class/Level <$40,000* $40,000 – $79.999** >$80,000*** p-value
DIMENSIONS (N=16) (N=186) (N=42)

* **
Professional Diplomaa 2.28±0.27 2.83±0.69 1.90±0.99 0.9261 0.1216
* **
Organization as a Associateb 2.30±0.43 2.54±0.60 2.44±0.64 0.1728 0.5725
Major Referent Baccalaureatec 2.56±0.38 2.36±0.61 2.13±0.57

* **
Belief in Continuing Diplomaa 2.08±0.67 2.53±0.89 2.50±1.27 0.3491 0.7940
* **
Competence Associateb 1.67±0.56 2.09±0.64 1.92±0.40 0.3535 0.9633
Baccalaureatec 1.96±0.46 1.93±0.68 1.77±0.64

* **
Belief in Self- Diplomaa 1.92±0.11 2.35±0.73 2.30±0.71 0.1378 0.7339
* **
Regulation Associateb 2.90±0.69 2.29±0.59 2.24±0.49 0.6008 0.5206
Baccalaureatec 2.48±0.67 2.24±0.56 2.03±0.50
* **
Sense of Calling to Diplomaa 2.24±0.64 2.80±0.61 2.20±0.00 0.8564 0.2202
* **
the Field Associateb 2.83±0.67 2.80±0.57 2.74±0.31 0.9081 0.9785
Baccalaureatec 2.72±0.39 2.65±0.59 2.58±0.63

* **
Autonomy Diplomaa 2.40±0.32 2.51±0.72 2.40±0.85 0.6142 0.8587
* **
Associateb 3.03±0.64 2.65±0.65 2.60±0.58 0.7920 0.9220
Baccalaureatec 2.80±0.84 2.51±0.61 2.49±0.64

* **
Belief in Diplomaa 2.44±0.26 2.27±0.55 2.40±0.85 0.5608 0.6453
* **
Service to the Public Associateb 2.33±0.73 2.22±0.52 2.30±0.53 0.4170 0.4977
Baccalaureatec 2.40±0.55 2.12±0.56 2.05±0.72
p<0.05
5-point Likert Scale (1=high degree of professionalism and 5= low degree of professionalism)
Note: cBaccalaureate and ***>$80,000 utilized as controls
a
Diploma versus Baccalaureate
b
Associate versus Baccalaureate
*<$40,000 versus >$80,000
**
$40,000 - $79,000 versus >$80,000

Table 26 displays the overall mean scale responses to the six professionalism

dimensions by expressed degree of satisfaction in current nursing role. Professional

Organization as a Major Referent (p=0.0001), Belief in Continuing Competence

(p=<0.0074), Belief in Self Regulation (p=0.0002), Sense of Calling to the Field

(p=<0.0001), and Autonomy (p=0.0231) demonstrated statistical significance to

expressed degree of satisfaction.

Table 26
Overall Mean Professionalism Scores to Expressed Degree of Satisfaction with Current
Role
PROFESSIONALISM Very Satisfied Satisfied Marginally Dissatisfied Intent to χ2 p-value
DIMENSIONS Satisfied leave
(N= 66) (N=130) (N= 32) (N= 9) (N=7)

Professional 2.22±0.64 2.45±0.55 2.55±0.57 3.38±0.78 2.86±0.72 23.267 0.0001*

Organization As a
Major Referent

Belief in Continuing 1.84±0.59 2.05±0.69 2.11±0.65 3.00±1.02 2.11±0.90 13.969 0.0074*

Competence

Belief in Self- 2.06±0.53 2.23±0.51 2.54±0.63 3.07±0.94 2.37±0.84 22.243 0.0002*

Regulation

Sense of Calling to the 2.45±0.55 2.68±0.53 2.99±0.51 3.31±0.68 3.43±0.51 38.638 <0.0001*
Field

Autonomy 2.44±0.68 2.54±0.58 2.81±0.59 3.16±0.94 2.54±0.95 11.330 0.0231*

Belief in Service To 2.04±0.62 2.20±0.51 2.39±0.58 2.38±0.57 2.09±0.70 7.230 0.1242

The Public

*p<0.05, chi-square with p-value based on Kruskal-Wallis Test

5-point Likert Scale (1=high degree of professionalism and 5= low degree of professionalism)

Very satisfied, satisfied, and marginally satisfied nurses reported Belief in

Continuing Competence as their strongest professionalism dimension and reported Sense

of Calling to the Field as their lowest professionalism dimension. Dissatisfied nurses

reported Belief in Service to the Public as their strongest professionalism dimension and

remained fairly neutral throughout with Professional Organization as a Major Referent as

their lowest professionalism dimension. Nurses expressing intent to leave their current

role reported Belief in Service to the Public as their strongest professionalism dimension

and Sense of Calling to the Field as their lowest professionalism dimension. Table 26a

displays annual salary and the six professionalism dimensions to basic nursing degree.
Due to the distribution within degree of satisfaction, the nurses were collapsed into two

groups (satisfied and dissatisfied) for further analysis. Table 26b displays the regression

of expressed degree of satisfaction to professionalism and attitudes toward

professionalism by basic nursing degree.

While univariate linear regression analysis demonstrated statistical significance

between expressed degree of satisfaction with role in nursing in the attitudinal

dimensions of Professional Organization As a Major Referent, Belief in Continuing

Competence, Belief in Self-Regulation, Sense of Calling to the Field, and Autonomy,

multivariate linear regression analysis demonstrated that expressed degree of satisfaction

was a predictor of a greater degree of professionalism for satisfied baccalaureate degree

nurses in the attitude dimension of Professional Organization as a Major Referent (β =

.496, Wald Chi-square = 12.11, p=0.0005) and a predictor of a weaker degree of

professionalism for dissatisfied diploma degree nurses in the attitude dimension of Belief

in Continuing Competence (β = .400, Wald Chi-square = 5.46, p=0.0194), Belief in Self-

Regulation (β = .510, Wald Chi-square = 11.80, p=0.0006) and Sense of Calling to the

Field (β = .653, Wald Chi-square = 19.23, p=<0.0001).

Table 26a
Overall Mean Professionalism Scores by Basic Nursing Degree to Expressed Degree of
Satisfaction with Current Role
PROFESSIONAISM EXPRESSED DIPLOMA ASSOCIATE BACCALAUREATE
FACTORS SATISFACTION (N=37) (N=94) (N=113)

Professional Very Satisfied 2.40±0.71 2.30±0.67 2.12±0.60

Organization as a Satisfied 2.66±0.61 2.48±0.48 2.35±0.57
Major Referent Marginally Satisfied 2.95±0.75 2.72±0.38 2.37±0.56
Dissatisfied 3.33±0.99 3.40±0.76 -
Intent to Leave 3.60 2.40±0.52 3.40±0.57

Belief in Continuing Very Satisfied 2.11±0.81 1.83±0.49 1.76±0.59

Competence Satisfied 2.44±0.76 2.07±0.57 1.91±0.71
Marginally Satisfied 3.00±1.15 2.04±0.30 1.96±0.52
Dissatisfied 2.80±1.39 3.10±0.93 -
Intent to Leave 3.00 1.60±0.49 2.70±1.27
Belief in Self-
Regulation Very Satisfied 1.76±0.22 2.10±0.49 2.11±0.60
Satisfied 2.42±0.59 2.27±0.44 2.14±0.52
Marginally Satisfied 2.00±0.28 2.90±0.69 2.46±0.58
Dissatisfied 3.33±1.15 2.93±0.90 -
Intent to Leave 2.60 2.10±1.09 2.80±0.00
Sense of Calling to
the Field Very Satisfied 2.22±0.49 2.58±0.53 2.42±0.57
Satisfied 2.70±0.49 2.74±0.47 2.63±0.59
Marginally Satisfied 2.80±0.71 3.16±0.51 2.94±0.46
Dissatisfied 3.60±0.69 3.17±0.95 -
Intent to Leave 3.60 3.40±0.69 3.40±0.28
Autonomy
Very Satisfied 2.22±0.60 2.38±0.61 2.55±0.76
Satisfied 2.48±0.61 2.65±0.59 2.45±0.56
Marginally Satisfied 2.60±0.49 3.24±0.46 2.62±0.57
Dissatisfied 3.40±1.04 3.03±0.96 -
Intent to Leave 2.00 2.35±1.17 3.20±0.00
Belief in Service to
the Public Very Satisfied 2.09±0.43 2.19±0.60 1.91±0.66
Satisfied 2.36±0.57 2.24±0.49 2.12±0.50
Marginally Satisfied 2.30±0.38 2.44±0.39 2.39±0.71
Dissatisfied 2.53±0.81 2.30±0.49 -
Intent to Leave 2.40 1.80±0.85 2.50±0.14

5-point Likert Scale (1=high degree of professionalism and 5= low degree of professionalism)
Table 26b
Relationship of Class/Level for Mean Professionalism Scores by Basic Nursing Degree to
Expressed Degree of Satisfaction with Current Role
PROFESSIONALISM Class/Level SATISFIED* DISSATISFIED** p-value
DIMENSIONS (N=228) (N=16)

**
Professional Diplomaa 2.62±0.66 3.40±0.82 0.5162
**
Organization as a Associateb 2.45±0.54 3.00±0.82 0.2181
Major Referent Baccalaureatec 2.29±0.58 3.40±0.57

**
Belief in Continuing Diplomaa 2.42±0.84 2.85±1.14 0.5087
**
Competence Associateb 1.99±0.53 2.50±1.08 0.5476
Baccalaureatec 1.88±0.65 2.70±1.27

**
Belief in Self- Diplomaa 2.19±0.57 3.15±1.01 0.5001
**
Regulation Associateb 2.30±0.54 2.60±1.02 0.4889
Baccalaureatec 2.18±0.56 2.80±0.00
**
Sense of Calling to the Diplomaa 2.58±0.55 3.60±0.57 0.6305
**
Field Associateb 2.74±0.52 3.26±0.66 0.5468
Baccalaureatec 2.62±0.58 3.40±0.28

**
Autonomy Diplomaa 2.42±0.59 3.05±1.10 0.9049
**
Associateb 2.66±0.63 2.76±1.04 0.2395
Baccalaureatec 2.51±0.62 3.20±0.00

**
Belief in Diplomaa 2.28±0.51 2.50±0.66 0.7224
**
Service to the Public Associateb 2.25±0.52 2.10±0.66 0.2132
Baccalaureatec 2.10±0.60 2.50±0.14

p<0.05
5-point Likert Scale (1=high degree of professionalism and 5= low degree of professionalism)
Note: cBaccalaureate utilized as a control
a
Diploma versus Baccalaureate
b
Associate versus Baccalaureate

Table 27 displays the overall mean professionalism scale scores to mentorship.

Professional Organization as a Major Referent (p=0.0243), Belief in Continuing

Competence (p=<0.0001), Belief in Self Regulation (p=<0.0001), and Autonomy

(p=0.0066) demonstrated statistical significance to mentorship. Mentored and non-

mentored nurses reported Belief in Continuing Competence as their strongest

professionalism dimension and Sense of Calling to the Field as their lowest

Table 27
Overall Mean Professionalism Scores to Mentorship
PROFESSIONALISM MENTOR NO MENTOR χ2 p-value
DIMENSIONS (N=58) (N=186)

Professional Organization As a Major 2.29±0.61 2.49±0.63 5.073 0.0243*

Referent

Belief in Continuing Competence 1.77±0.69 2.12±0.70 14.646 0.0001*

Belief in Self-Regulation 2.03±0.59 2.33±0.58 16.753 <0.0001*

Sense of Calling to the Field 2.62±0.59 2.73±0.58 1.363 0.2430

Autonomy 2.38±0.64 2.63±0.65 7.366 0.0066*

Belief in Service To The Public 2.09±0.52 2.22±0.58 3.364 0.0666

*p<0.05, chi-square with p-value based on Kruskal-Wallis Test

5-point Likert Scale (1=high degree of professionalism and 5= low degree of professionalism)

professionalism dimension.

Table 27a and 27b display the number of reported nursing mentor or non nursing

mentor relationships to the six professionalism dimensions by basic nursing degree. Due

to the variation of mentor relationships and missing categories, nurses were collapsed

into two groups (mentored and non mentored) for further analysis. Table 27c displays the

regression of mentorship to attitudes toward professionalism by basic nursing degree. In

the attitude dimension Autonomy (p=0.0247), significance was found between non

mentored associate and baccalaureate degree nurses. Non mentored baccalaureate degree

nurses demonstrated greater mean professionalism scores compared to associate degree

nurses. Mentored baccalaureate degree nurses demonstrated greater mean

professionalism scores in 4 of the 6 dimensions.

Multivariate regression analysis demonstrated that mentorship was a predictor of

a weaker degree of professionalism for non mentored diploma nurses in the dimensions

of Professional Organization as a Major Referent (β = .200, Wald Chi-square = 5.85,

p=0.0156), Belief in Continuing Competence (β =.351, Wald Chi-square = 12.50,

p=0.0004), Belief in Self-Regulation (β = .330, Wald Chi-square = 14.73, p=0.0001) and

a predictor of a weaker degree of professionalism for non mentored associate degree

nurses in the dimension of Autonomy (β = .256, Wald Chi-square = 7.01, p=0.0081).

Nurses who do not find it important to read professional journals, participate in

professional organizations, seek out continuing education opportunities, or act in an

independent manner when making work decisions could surely benefit from the gift of

mentoring at any position in their nursing career. For those seeking to enter the

profession, stay and grow in the profession or leave it, mentoring is a vehicle which can

be utilized to facilitate either. Dwyer (2008) reports that a priority exists for more

nursing organizational workplace and educational support in making the commitment to

mentoring as a norm and an expectation for nurses at all levels and that socialization to

the roles of mentee and mentor allow nurses at all levels to participate in the mentoring

relationship and helps renew the zest for the profession (p. 90).
 229

Table 27a
Overall Mean Professionalism Scores to Nursing Mentor Relationship by Basic Nursing
Degree
PROFESSIONALISM NUMBER of DIPLOMA ASSOCIATE BACCALAUREATE
DIMENSIONS MENTORS (N=10) (N=18) (N=28)
WITHIN NURSING

Professional 0 3.20 3.20 2.80±0.53

Organization as a 1 2.53±0.48 2.66±0.51 2.05±0.53
Major Referent 2 1.20 1.93±0.46 2.08±0.77
3 - 2.00 -
4 - - 2.20
6 - - 2.00

Belief in Continuing 0 1.80 1.80 1.60±0.53

Competence 1 2.08±0.86 2.05±0.69 1.54±0.50
2 1.60 1.33±0.23 1.72±1.01
3 - 2.20 -
4 - - 1.20
6 - - 2.00
Belief in Self-
Regulation 0 2.40 2.40 2.73±1.30
1 1.88±0.10 2.25±0.67 2.00±0.60
2 1.80 2.07±0.12 1.80±0.41
3 - 1.40 -
4 - - 1.60
6 - - 2.00
Sense of Calling to the
Field 0 2.40 2.40 2.73±0.99
1 2.63±0.45 2.89±0.53 2.52±0.62
2 2.20 2.47±0.42 2.68±0.65
3 - 3.00 -
4 - - 2.40
6 - - 1.40

Autonomy
0 2.80 2.80 1.73±0.81
1 2.23±0.62 2.78±0.54 2.02±0.49
2 1.80 2.33±0.76 2.40±0.73
3 - 3.60 -
4 - - 2.00
6 - - 2.60
Belief in Service to the
Public 0 2.20 2.20 1.80±0.72
1 2.08±0.24 2.37±0.59 1.96±0.56
2 1.80 2.33±0.76 1.98±0.38
3 - 2.20 -
4 - - 1.60
6 - - 2.80

5-point Likert Scale (1=high degree of professionalism and 5= low degree of professionalism)
Table 27b
Overall Mean Professionalism Scores to Non Nursing Mentor Relationship by Basic Nursing
Degree
PROFESSIONALISM NUMBER of DIPLOMA ASSOCIATE BACCALAUREATE
DIMENSIONS MENTORS OUTSIDE (N=10) ((N=18) (N=30)
of NURSING

Professional 0 3.20 2.52±0.88 2.20±0.71

Organization as a 1 2.63±0.41 2.56±0.47 2.31±0.63
Major Referent 2 1.50±0.42 2.13±0.12 1.77±0.35
3 - 2.40 -
6 - - 1.80±0.57

Belief in Continuing 0 1.80 2.00±0.66 1.68±0.63

Competence 1 2.20±0.85 2.00±0.77 1.79±0.74
2 1.40±0.20 1.73±0.46 1.23±0.29
3 - 1.60 -
6 - - 1.20±0.00

Belief in Self- 0 1.80 1.76±0.43 1.96±0.90

Regulation 1 1.97±0.21 2.31±0.63 2.23±0.65
2 1.80±0.00 1.80±0.35 1.63±0.35
3 - 3.20 -
6 - - 1.70±0.14

0 2.40 3.00±0.24 2.44±0.82

Sense of Calling to the 1 2.63±0.48 2.84±0.52 2.60±0.69
Field 2 2.40±0.28 2.07±0.12 2.60±0.59
3 - 3.40 -
6 - - 2.10±0.42

0 1.80 3.08±0.48 2.36±0.67

Autonomy 1 2.46±0.59 2.64±0.66 2.38±0.62
2 1.70±0.14 2.20±0.20 1.74±0.40
3 - 3.20 -
6 - - 2.30±0.42

0 2.60 2.48±0.58 1.72±0.41

Belief in Service to the 1 2.06±0.10 2.40±0.66 2.18±0.55
Public 2 1.80±0.00 1087±0.23 1.65±0.35
3 - 2.00 -
6 - - 2.00

5-point Likert Scale (1=high degree of professionalism and 5= low degree of professionalism)
Table 27c
Relationship of Class/Level for Mean Professionalism Scores by Basic Nursing Degree to
Mentorship
PROFESSIONALISM Class/Level MENTORED* NOT MENTORED* p-value
DIMENSIONS (N=58) (N=186)
**
Professional Diplomaa 2.46±0.65 2.80±0.71 0.6846
**
Organization as a Associateb 2.47±0.56 2.52±0.61 0.3815
Major Referent Baccalaureatec 2.13±0.61 2.37±0.58

**
Belief in Continuing Diplomaa 2.00±0.78 2.64±0.85 0.3942
**
Competence Associateb 1.93±0.65 2.07±0.61 0.2471
Baccalaureatec 1.60±0.65 2.00±0.64

**
Belief in Self- Diplomaa 1.92±0.19 2.43±0.74 0.2985
**
Regulation Associateb 2.12±0.63 2.38±0.59 0.9979
Baccalaureatec 2.01±0.65 2.26±0.51
**
Sense of Calling to the Diplomaa 2.56±0.42 2.74±0.69 0.8213
**
Field Associateb 2.79±0.52 2.80±0.57 0.5498
Baccalaureatec 2.54±0.65 2.67±0.56

**
Autonomy Diplomaa 2.24±0.59 2.59±0.68 0.7945
**
Associateb 2.72±0.61 2.66±0.70 0.0247
Baccalaureatec 2.21±0.61 2.63±0.59

**
Belief in Diplomaa 2.06±0.23 2.39±0.58 0.5603
**
Service to the Public Associateb 1.93±0.65 2.22±0.52 0.1211
Baccalaureatec 1.97±0.53 2.00±0.64

p<0.05
5-point Likert Scale (1=high degree of professionalism and 5= low degree of professionalism)
Note: cBaccalaureate utilized as a control
a
Diploma versus Baccalaureate
b
Associate versus Baccalaureate

Variables and the Attitudes That Follow

This sample of currently practicing registered nurses in South Texas identify with

Belief in Continuing Competence as their strongest professionalism attitude and Sense of

Calling to the Field as their weakest professionalism attitude. Univariate and multivariate

linear regression analysis demonstrated statistically significant predictor variables

within the dimensions: Professional Organization as a Major Referent, Belief in Continuing

Competence, Belief in Self-Regulation, and Autonomy by basic nursing degree.

Surprising, basic nursing degree was found to be significant within only two attitude

dimensions. Diploma degree nurses demonstrated a weaker degree of professionalism within

the attitude dimensions of Professional Organization as a Major Referent and Belief in

Continuing Competence.

Mentoring was found to be significant in four attitude dimensions. Non mentored

diploma degree nurses demonstrated a lower degree of professionalism within the dimensions

of Professional Organization as a Major Referent, Belief in Self-Regulation, Autonomy, and

Belief in Continuing Competence while associate degree nurses demonstrated a lower degree

of professionalism in the dimension of Autonomy.

Expressed degree of satisfaction was also found to be significant in four attitude

dimensions. Satisfied baccalaureate degree nurses demonstrated a higher degree of

professionalism in the dimension of Professional Organization as a Major Referent, while

dissatisfied diploma degree nurses demonstrated a lower degree of professionalism in the

dimensions of Belief in Self-Regulation, Sense of Calling, and Belief in Continuing

Competence.

Employment status was found to be significant in three attitude dimensions. Full

time diploma and associate degree nurses demonstrated a lower degree of professionalism in

Belief in Service to the Public and Belief in Self-Regulation while only associate degree

nurses demonstrated a lower degree of professionalism in Autonomy.

The following variables were found to be significant in only one attitude dimension.

Professional organization membership was found to be significant for a higher degree of

professionalism in baccalaureate degree nurses who are members of professional

organizations. Salary was found to be significant for a lower degree of professionalism in

associate degree nurses who earn less than $40,000 annually. Gender was found to be

significant for a lower degree of professionalism in male diploma nurses. Role in the

organization was found to be significant for a lower degree of professionalism in diploma

staff nurses. Continuing education hours was found to be significant for a lower degree of

professionalism in diploma degree nurses receiving less than 20 hours.

Basic nursing degree is not the sole variable which influences attitudes toward

professionalism. Degree of satisfaction was found to be the strongest predictor in the

attitudinal dimensions of Professional Organization as a Major Referent, Belief in Self-

Regulation, and Sense of Calling to the Field. Basic nursing degree was found to be the

strongest predicator in the attitude dimension of Belief in Continuing Competence.

Employment status, organizational role, and continuing education hours were found to be the

weaker predictors in the attitudinal dimensions of Professional Organization as a Major

Referent, Belief in Self-Regulation, Autonomy, and Belief in Service to the Public. Salary

was a strong predictor of professionalism in the attitudinal dimension of Belief in Self

Regulation. Salary was found to be a strong predictor of professionalism in the attitude

dimension of Belief in Self Regulation.

Table 28 displays the predictor variables of significance by both univariate and

multivariate linear regression analysis for the six professionalism dimensions. Logistic

regression was used as the statistical technique to make predictions when the dependent

variable was dichotomous and the independent variable(s) were continuous and/or discrete.

The dependent variable “professionalism” was dichotomized whereby <2.5 represented

Table 28
Professionalism Dimensions with Initial and Final Variables of Significance
Initial Variables of Significance Professionalism Final Variables of Significance
by Basic Nursing Degree after Dimensions by Basic Nursing Degree after
Generalized Univariate Generalized Multivariate Linear
Linear Regression Regression

Basic Nursing Degree Professional Basic Nursing Degree

Gender
Professional Organization
Professional Certification
Expressed Degree of Satisfaction
Role in Organization
Continuing Education
Salary
Organization As a Gender
Major Referent Professional Organization
Expressed Degree of Satisfaction
Role in Organization
Continuing Education
Mentorship

Basic Nursing Degree Belief in Basic Nursing Degree

Professional Organization Continuing Expressed Degree of Satisfaction
Professional Certification Competence Mentorship
Expressed Degree of Satisfaction
Role in Organization
Continuing Education

Expressed Degree of Satisfaction Belief in Self- Expressed Degree of Satisfaction

Salary Regulation Mentorship
Employment Status
Salary

Age Sense of Calling to Expressed Degree of Satisfaction

Expressed Degree of Satisfaction the Field

Age Autonomy Mentorship

Expressed Degree of Satisfaction Employment Status
Practice Years

None Belief in Public Employment Status

Service
greater professionalism and ≥2.5 represented lesser professionalism. Eleven variables were

retained as they were believed to be the most important predictor variables to be used for

further analysis. Table 29 displays those variables of significance after being subjected to

multiple linear regression analysis in the determination of the predictor variables within the

professionalism dimensions.

Table 29
Professionalism Dimensions and the Related Values for the Predictor Variables of
Significance
PROFESSIONALISM Predictor Coefficient Standard Wald p-value
DIMENSIONS Variables (β) Error χ2

Professional Nursing Degree - diploma .215 .108 3.95 0.0469

Organization as a Gender - male .227 .090 6.38 0.0115
Major Referent Member of Prof. Org. - no .315 .083 14.26 0.0002
Degree of Satisfaction - not .496† .143 12.11 0.0005
Role in Org. – staff nurse .000 .000 4.18 0.0408
Continuing Edu. - <20 hrs .000 .000 4.33 0.0375
Mentor Relationship - no .200 .083 5.85 0.0156

Belief in Nursing Degree - diploma .479† .130 13.53 0.0002

Continuing Degree of Satisfaction - not .400† .171 5.46 0.0194
Competence Mentor Relationship - no .351 .100 12.50 0.0004

Belief in Self – Salary - <$40,000/year .489† .183 7.14 0.0075

Regulation Degree of Satisfaction - not .510† .148 11.80 0.0006
Mentor Relationship - no .331 .086 14.73 0.0001
Employment Status – FT .000 .000 6.92 0.0085

Sense of Calling Degree of Satisfaction - not .653† .150 19.23 <0.0001

to the Field

Autonomy Mentor Relationship - no .256 .097 7.01 0.0081

Employment Status - FT .000 .000 5.42 0.0199

Belief in Service Employment Status - FT .000 .000 4.23 0.0398

to the Public
Note: † is the beta value greater than .4 which represents the higher impact of the predictor variable (IV). If an
independent variable has a beta weight of .4, this means that when other independent variables are held
constant, the dependent variable will increase by .4 of a standard deviation.
Logistic Regression Analysis

Table 30 displays the results of the logistic regression analysis for the

professionalism dimensions and the values for the predictor variables of significance. The

analysis of the interactional affects on the independent variables from highest to least was:

degree of satisfaction, nursing degree, and mentor relationship. This suggests that degree of

satisfaction, nursing degree and mentor relationship have more important effects on

attitudes toward professionalism.

Professional Organization as a Major Referent

In the attitudinal dimension of Professional Organization as a Major Referent, there

were 3 significant interactions. The Odds Ratio (OR) for GENDER (female vs. male) was

2.47 (95% CI 1.14-5.36). This suggests that female nurses are almost 2.5 times more likely

to have a greater degree of professionalism than male nurses. The OR for the PROFORG

(yes vs. no) was 2.07 (95% CI 1.03-4.15). This suggests that nurses who are members of

professional organizations are 2 times more likely to have greater professionalism than non-

members. The OR for MENTOR (yes vs. no) was 2.53 (95% CI 1.23-5.18). This suggests

that nurses who have a mentor relationship in their nursing career are 2.5 times more likely

to have greater professionalism than those who have not.

Belief in Continuing Competence

In the attitudinal dimension of Belief in Continuing Competence, there were 2

significant interactions. The OR for DEGREE (associate vs. diploma) was 6.35 (95% CI

2.15-18.73). This suggests that the associate degree nurses are almost 6 times more likely to

have greater professionalism than the diploma degree nurses. Upon second analysis when

adding the variables of DEGREE and SATISFIED for associate and baccalaureate degree
nurses, no significance was demonstrated as with DEGREE and GENDER for associate and

baccalaureate degree nurses. The OR for SATISFIED (yes vs. no) was 4.50 (95% CI 1.31-

15.41). This suggests that nurses satisfied in their current roles are almost 5 times more

likely to have greater professionalism than those who are not.

Belief in Self-Regulation

In the attitudinal dimension of Belief in Self-Regulation, there were 2 significant

interactions. The OR for SATISFIED (yes vs. no) was 4.90 (95% CI 1.56-15.41). This

suggests that those nurses who are satisfied in their current role are almost 5 times more

likely to have greater professionalism than those who are not. The OR for MENTOR (yes

vs. no) was 3.00 (95% CI 1.23-6.93). This suggests nurses who have had a mentor

relationship in their nursing career are 3 times more likely to have greater professionalism

than those who have not.

Sense of Calling to the Field

In the attitude dimension of Sense of Calling to the Field, there were 3 significant

interactions. The OR SATISFIED (yes vs. no) was 9.43 (95% CI 1.16-76.58). This

suggests that nurses who are satisfied in their current role are almost 9 times more likely to

have a greater degree of professionalism than those who are not. The OR MENTOR (yes vs.

no) was 1.95 (95% CI 1.01-3.77). This suggests that nurses who have a mentor relationship

in their nursing career are 2 times more likely to have greater professionalism than those

who have not. The OR FULLTIME (no vs. yes) was 3.23 (95% CI 1.22-8.54). This

suggests that part-time nurses are 3 times more likely to have greater professionalism than

full-time nurses.
Autonomy

In the attitude dimension of Autonomy, there was 1 significant interaction. The OR

FULLTIME (yes vs. no) was 0.355 (95% CI .133-.951). This suggests that full-time nurses

are .4 times more likely to have greater professionalism than part-time nurses.

Belief in Service to the Public

There were no significant interactions in this attitudinal dimension. The other

coefficient variables have become insignificant. This is due to the correlation between the

other variables. This does not suggest that the other variables are not important in the

prediction of attitudes toward professionalism in this dimension; but the degree of

significance changed when analyzed with the entire grouping of independent variables.

Since the other independent variables are either insignificantly different from zero or

continuous, interpretation of there magnitude has little meaning in logistic regression.

Table 30
Logistic Regression Analysis of Professionalism Dimensions and the Values for the
Predictor Variables of Significance
Professionalism Predictor OR 95% CI for p
Dimensions Variables the OR

Professional Gender - female 2.47 1.14,5.36 0.0222

Organization as Professional Org - member 2.07 1.03,4.15 0.0409
a Major Mentor Relationship - yes 2.53† 1.23,5.18 0.0115
Referent

Belief in Nursing Degree - associate 6.35† 2.15,18.7 0.0084

Continuing Degree of Satisfaction - yes 4.50 1.31,15.4 0.0169
Competence

Belief in Self – Degree of Satisfaction - yes 4.91† 1.57,15.41 0.0064

Regulation Mentor relationship - yes 3.00 1.30,6.93 0.0101

Sense of Calling Degree of Satisfaction - yes 9.43† 1.16 ,6.58 0.0358

to the Field Mentor Relationship - yes 1.95 1.01,3.77 0.0462
Employment Status – part-time 3.23 1.22,8.54 0.0184

Autonomy Employment Status – full-time 0.356 0.13,0.95 0.0394

Belief in None .
Service to the
Public

Note: † is the odds ratio value which represents the predictor variable (IV) which is more likely to have the
greater degree of professionalism in the attitude dimension (DV). Highest rankings relative to value of the IVs
are: degree of satisfaction, nursing degree, and mentor relationship.
 CHAPTER V

DISCUSSION AND IMPLICATIONS

Discussion

The objective of this study was to assess registered nurses attitudes and factors

associated with practice behaviors. This study was specifically designed to extend

existing research findings relevant to professionalism in nursing and explore variables

which may influence professional attitudes. The findings of this research provide for

nursing some insight into member reported attitudes of professionalism. An opportunity

has been afforded to address the variation and differences in professional attitudes and

behaviors among relevant variables.

The following research questions are proposed based upon two major research

assumptions: (a) there is a difference in the perception of the degree of professionalism

between the various levels of practicing registered nurses, as manifested within work

environments, and (b) there are other variables which exert an influence upon attitudes

toward professionalism.

1. Will baccalaureate-prepared practicing registered nurses report a higher

degree of professionalism within all dimensions as compared to associate and diploma-

prepared practicing registered nurses in South Texas?

2. Will baccalaureate-prepared practicing registered nurses in South Texas

report a higher degree of professionalism within all dimensions regardless of age?

3. Is there a positive correlation with degree of professionalism of actively

practicing registered nurses prepared at the baccalaureate level to: age, gender, shift

worked, employment status, professional organization membership, professional journal

240
 241

subscription, professional certification, role in organization, practice years,

practice setting, continuing education hours, salary, expressed degree of satisfaction, and

mentorship? Which of these variables has the greater effect or are more strongly

associated with professionalism?

Hall‟s Professionalism Scale (1968) revised by Snizek (1972) and Schack &

Helper (1979) was used to survey (N=244) currently practicing registered nurses in South

Texas. A total of 788 surveys were mailed. A 59% return rate was achieved with a final

response rate of 35% used for data analysis. The scale consisted of six attitudinal

dimensions containing five item statements in each dimension:

1. Use of the Professional Organization as a Major Referent

2. Belief in Service to the Public

3. Belief in Self-Regulation

4. Sense of Calling to the Field

5. Autonomy

6. Belief in Continuing Competence

Influence of Variables on Attitudes Toward Professionalism

Many of the results of this study refute and support those of previous

investigators indicating that registered nurses in South Texas differed in their attitudes

toward professionalism between basic nursing degrees programs, age, and amidst varied

predictors of degree of professionalism. The overall average mean professionalism

scores ranged from 2.15 (strongest association) for Belief in Continuing Competence to

2.70 (weakest association) for Sense of Calling to the Field. This nurse group exhibits a

modest degree of professionalism. When evaluated by basic nursing degree, the same
was found to be true for associate and baccalaureate degree nurses while diploma degree

nurses reported Belief in Self-Regulation as their highest average mean professionalism

score and Professional Organization as a Major Referent as their lowest average mean

professionalism score. Basic nursing degree program had no specific influence in four of

the six dimensions (Belief in Service to the Public, Belief in Self-Regulation, Sense of

Calling to the Field, Autonomy). Baccalaureate degree nurses demonstrated an overall

higher degree of professionalism and age was not a predictor. In the attitude dimension

of Professional Organization as a Major Referent, their higher educational attainment was

found to be correlate with a stronger degree of professionalism as demonstrated by

membership in professional organizations and satisfaction in their current roles.

However, basic nursing degree was a predictor of a weaker degree of

professionalism for diploma degree nurses and was consistently demonstrated in the

attitude dimensions of Professional Organization as a Major Referent and Continuing

Competence. It appears that early on, individual differences during the socialization

process matter and perhaps a confounder is that higher educational levels attained since

graduation from the basic nursing program influence professional behaviors and therefore

overall professionalism.

The objective of this study was to add to the collective understanding of factors

likely to influence attitudes toward professionalism in order to target, identify, and

increase the degree of professionalism throughout the profession. This will need to be

occur over time in practice with astute assessment of changing roles and responsibilities

within the myriad of practice environments. This study confirms the importance of basic

nursing degree and the influence it exerts over time on a nurse‟s degree of
professionalism. Wooley (1978) understood that resocialization is the key to successful

change and occurs by taking on of new attitudes, concepts and roles occurs and not

merely the accretion of new knowledge. Therefore, it is imperative that variables thought

to influence attitudes toward professionalism be identified and their implications be

diligently addressed. By embracing lessons learned, nursing as a profession can raise the

bar by continuously growing a cadre of professional nurses.

This study sought to determine whether registered nurses educated in three basic

nursing programs differed in their attitudes toward professionalism utilizing Hall‟s

Professionalism Scale (1968) as modified by Snizek (1972) and Schack and Hepler

(1979) and to highlight the importance of developing strategies to attract, retain, and

increase the professional attributes of currently practicing registered nurses. Based upon

the findings, I encourage others to examine these findings through more rigorous research

designs, comparatively, and across different professions. First, how can nurses become

more intentional and effective in increasing/enhancing their own professional attitudes

and behaviors? Secondly, can a more deliberate approach be taken to provide

opportunities and creative strategies for the widest dissemination to enhance the practice

of professional behaviors in and outside of the work environment?

Eleven variables (basic nursing degree, age, gender, employment status,

organizational role, salary, professional certification, professional organization

membership, degree of satisfaction, mentorship, and continuing education) were

considered to be important predictors of degree of professionalism and were selected for

further regression analysis in assessment of their influence on the six attitude dimensions.
Research Question 1

Baccalaureate-prepared practicing registered nurses reported a higher degree of

professionalism within all six attitude dimensions as compared to associate and diploma-

prepared practicing registered nurses in South Texas.

Education

Education was a predictor of professionalism in only two attitude dimensions.

The Texas Board of Nurse Examiners reports the highest degree attained by nurses in

2008 has changed slightly from the data in 2006. The percentage of diploma degree

nurses has decreased from 11% to 10% which is probably reflective of retirements. The

percentage of associate degree nurses has increased from 39% to 40% probably due to the

proliferation of second career job seekers and the influx of nurses into the profession.

The percentage of baccalaureate degree nurses has increased from 36% to 37% probably

due to an influx of nurses into the profession and suggestive of the limitations placed on

enrollments by instructor shortages and retirements. The state of Texas enacted

legislation committing funds to help infuse more nurses into the health care system

through scholarships, loan forgiveness programs, expansion of nursing education

programs and the increase of faculty and/or physical facilities (American Nurses

Association – Nursing Education, 2008). There was no intent to determine whether

nurses had obtained higher degrees since graduation from their basic educational

program. Thos sample population was however a strong representation of the overall

population percentages reported in both of those years: diploma nurses (15%), associate

degree nurse (39%), baccalaureate degree nurses (46%).

Although basic nursing degree was not a predictor of degree of professionalism

for associate and baccalaureate degree nurses, there were implications for diploma degree

nurses (37). They represented the older population of nurses with a significantly weaker

degree of professionalism in the two attitude scales of Professional Organization as a

Major Referent and Belief in Continuing Competence. As their training was received

more through an apprenticeship style of learning within a hospital based program it is not

surprising that they do not regard the professional organization or membership, journal

subscription, or mentorship as a means to continued competence. Many were staff nurses

(27) over the age of forty (35) with only 3 holding the position of manager and 1 in an

administrative position. They were full time (29) day shift (26) staff nurses (24) starting

at 11 years of practice with a salary ranging from $50,000 - $69,999, receiving less than

20 hours of continuing education and who are satisfied with their current role.

Duffield, Pallas, & Aitken (2004) who studied nurses who had left the profession

to investigate why they became a nurse, how long they stayed in nursing, and the reasons

for eventually leaving. Altruistic reasons were given as the most important followed by

default and stepping stone. Those with higher educational qualifications on entry to the

profession had shorter tenure in nursing, while higher educational attainment after initial

entry was associated with longer tenure as was holding a more senior nursing position.

Generally, a higher degree of professionalism lines up with a positive attitude for

continuing competence and professional organization membership producing a set of

common beliefs followed by active intentions to perform a variety of behaviors as

demonstrated by baccalaureate degree nurses. Professional community affiliation refers

to the extent which a person is actively involved in the professional community and uses

professional institutions as a major referent (Hall, 1968). Conversely, diploma degree

nurses have experienced the many changes within nursing history, policies and practices.

These nurses may very well be the mentors to some of the newest nurses in the

profession sharing organizational knowledge that can only be gained from within. Maude

& Manias (2006) report that nurses with long tenure are likely to have more power to

change the environment in accordance with their role preferences due to a long-earned

recognition for their work and organizational an negotiating skills acquired (p. 752).

They may also be the nurses nearing the realization of their retirement goal at this current

time. It cannot be ignored that individuals who stay closely affiliated with their

professional community by engaging in activities such as reading journals and attending

conferences should be more strongly influenced by standards of the profession (Snizek,

1979). Fletcher (2001) declares that the increasing complexity of the nursing practice

role, particularly without adequate preparation may cause some nurses to leave their

positions for other, less demanding jobs or even other professions.

Monnig (1978) found that nurses with a master‟s degree exhibited a higher

degree of professionalism in the dimension of Professional Organization as a Major

Referent than baccalaureate and diploma degree nurses. She also found that diploma

degree nurses exhibited the highest degree of professionalism in all of the dimensions

except that of Autonomy compared to baccalaureate degree nurses.

Nelson (2002) reports interestingly enough that over the past forty years since the

ANA proposal for the baccalaureate degree to be the entry point into professional

practice this has been learned:

1. The current nursing shortage should not be used as an excuse for postponing
action to raise educational standards.
2. Educational standards influence perceptions about nursing as a career choice.
3. It is no longer feasible to try to differentiate practice along current educational
 points of entry as the distinction between professional and technical nursing roles
has not been translated into differentiated practice expectations in work settings.
4. Any successful plan for changing nursing education must be inclusive as access
based upon financial, gender, age, location and cultural barriers are real.
5. Agreement about BSN requirements for entry into practice should disenfranchise
no one.
6. Employers will not make the decision about entry into practice for nursing.

Although diploma degree nurses may engage in professional development to

further enhance their professionalism, due to many factors, they may not exemplify the

behavior or professional characteristic of such accomplishment. A necessary precursor

for both autonomy and power is competence, which has its foundation in educational

preparation as power is maintained through knowledge development acquired through

education (Manojlovich, 2007). It is not surprising that associate degree nurses were 6

times more likely to exhibit greater professionalism in the attitude dimension of Belief in

Continuing Competence since their educational foundations are highly technical in

nature. Basic nursing education signifies where a nurse has begun their professional

journey but cannot define the destination or the limit the discovery along the way.

Obtaining information on current degree status, years and age between initial degree and

current degree could be used to determine if there is any value in further exploration of

comparative degrees of professionalism.

Research Question 2

Baccalaureate-prepared practicing registered nurses in South Texas reported a

higher degree of professionalism within all dimensions regardless of age.

Age

Although age was not found to be a significant predictor of the degree in

professionalism, there was no indication that an increasing of age in these nurses was
related to an increased in mean professionalism scores. Sherman (2006) purports that

nursing leaders should anticipate that the nursing workforce will continue to be age-

diverse for many years to come while during the foreseeable future, the nursing

workforce will be driven increasingly by the swelling number of older RNs and the

forces that determined their decision to participate in the nursing workforce (Norman,

Donelan, Bauerhaus, Willis, Wiliams, Ulirich & Dittus, 2005).

Diploma nurses under the age of 40 demonstrated a weaker degree of

professionalism in the attitude dimension of Sense of Calling to the Field and Autonomy

while those nurses over the age of 50 demonstrated a greater degree of professionalism in

those dimensions. This speaks volumes to the fact that baccalaureate and associate

degree nurses who have recently entered into the profession must share in the creation of

both professional environments and behaviors. Nuerhaus, Auerbach & Staiger (2007)

found that the majority of nurses are employed within hospitals and that much of the

employment growth of registered nurses in hospitals has been in nurses over age 50.

The Texas Board of Nursing (2008) reports a 3% decrease in the female age group of 45

– 54 and a 1% decrease in the age group 35 – 44 since 2006. Interestingly enough, there

has been a 2% increase in the age group 55 – 64 since 2006. The average age of nursing

faculty in baccalaureate degree programs is 51.5 years and the retirement rate exceeds the

rate of replacement (Tanner, 2006). Here lies the challenge for organizations to offer

educational incentives for retention purposes and for nurse educators for years to come.

Norman et al. (2005) found that younger and older RNs differed in their

perception of the main reason for the nursing shortage as being: (a) more career options

for women, (b) salary and benefits, (c) undesirable hours, (d) nursing not seen as a
rewarding career. Regardless of age, 8 of 10 RNs agreed that improved working

environments would help a great deal in improving the nursing shortage.

Age may not be a determining factor for degree of professionalism however, other

factors such as role in organization, salary, and degree of satisfaction may have a greater

impact for nurses who lack a sense of calling to the field or who possess a greater sense

of autonomy. Further research of age, basic nursing degree and current nursing degree

could determine if there is any significance to further explore.

Research Question 3

There is a positive correlation with degree of professionalism of actively

practicing registered nurses prepared at the baccalaureate level to membership in the

professional organization and expressed degree of satisfaction. There is no correlation

with degree of professionalism of actively practicing registered nurses to age, shift

worked, professional journal subscription, professional certification, practice years, and

practice setting. There is a negative correlation with degree of professionalism of

actively practicing registered nurses prepared at the associate degree level to mentor

relationship, salary, and employment status. There is also a negative correlation with

degree of professionalism of actively practicing registered nurses prepared at the diploma

degree level to mentor relationship, employment status, gender, role in organization,

continuing education hours, expressed degree of satisfaction, and basic nursing degree.

The variables that were strong predictors of professionalism were: expressed degree of

satisfaction, salary, mentorship, and basic nursing degree.

Gender

Gender was found to be a predictor of professionalism in only one attitude

dimension. Female nurses have consistently dominated the profession however, Mee

(2003) reports that fewer people are entering nursing because other professions are doing

a better job of attracting a new generation of workers men and women alike (p. 51) and

Andrews (2005) reports that women have become less interested in nursing as a career,

and men continue without interest in nursing.

The Texas Board of Nursing reports 90% female to 10% male nurses in 2006 and

also in the most current 2008 statistics. This sample of nurse respondents was 82%

female and 18% male. Gender was a predictor for a weaker degree of professionalism in

the attitude dimension of Professional Organization as a Major Referent for male diploma

nurses (9). Both male and female nurses reported the Professional Organization as the

Major Referent as their strongest professionalism dimension however, female nurses

were almost 2.5 times more likely to have a greater degree of professionalism than male

nurses. It would not be uncommon for males to be less represented in professional

organizations of a predominantly female populated profession. This is however a major

area to address based upon the necessity to have the nursing profession be representative

of the population for which they serve. A larger sample of male nurses would have been

preferable however; it is evident that these males do not subscribe to professional

organization participation or the reading of professional journals. While nursing remains

a female dominated profession with the same challenges as many other professions

dominated by males, this is not the issue that keeps us from attaining a greater degree of

professionalism among our members but gives rise to the notion that males can be a part
of this problem and also a part of the solution. Su-Mei (1997) poignantly writes that

there are limitations in the development of full professionalism to include gender

discrimination, divisiveness and disempowerment, and bureaucratic structures that limit

the positive effect of education in raising professionalism in nursing.

Boughn (2001) after a two year study of men and women nursing students at all

levels writes that women expressed an interest in empowering patients, while men were

more inclined to empower the profession as a whole and themselves as professionals.

Noting that men and women are both attracted to professions where they can expect to be

empowered, enjoy financial rewards,, and favorable working conditions for their efforts,

he concludes that the latter attitude is a significant indicator of the will and potential of

nurses in the profession to work to improve the conditions for nurses within the health

care industry (pp.17– 18).

While a balance may never be reached among male and female nurses, further

research into the attitude dimension of sense of calling and whether gender is a predictor

related to age, salary, and current nursing degree may define the path of least resistance

to increasing professionalism among male and female gendered nurses.

Employment Status

Employment status was a predictor of professionalism in three attitude

dimensions. Eighty nine percent (216) of the nurses worked full time and employment

status was the second highest predictor of professionalism. Employment status was a

strong predictor of a weaker degree of professionalism for full time associate and

diploma nurses in the attitude dimensions of Belief in Self Regulation, Belief in Service

to the Public, and a predictor of a weaker degree of professionalism for full time associate
degree nurses in the attitude dimension of Autonomy. It appears that the relationship

between these nurses working full time and their commitment to service to the public,

autonomy, and self-regulation does not seem to be reflective of strong professional

beliefs. Surprisingly, part-time nurses were 3 times more likely to have greater

professionalism than full-time nurses in the attitudinal dimension of Sense of Calling to

the Field, whereas full-time nurses were .4 times more likely to have greater

professionalism in the attitude dimension of Autonomy. Autonomy represents one kind

of power nurses need, and has been defined as “the freedom to act on what one knows”,

and is an attribute that the nursing profession must cultivate among its members in order

to practice more autonomously, raise their status, define their area of expertise, and

influence others (Manojlovich, 2007).

Those nurses finding themselves immersed in the practice area generally work on

the day shift generally working a full time schedule and are likely to experience most of

the organizational and professional challenges. These challenges are experienced in

different ways by those who work on a part time basis or on the evening and night shifts.

Hall (1968) was timely in his statement that belief in social obligation or commitment

requires an individual to recognize the importance of their work to society, and the fact

that their work benefits not only the organization and the individual, but the public as

well. Personal and professional ideologies, values, and attitudes are those very necessary

elements that must be tapped into daily when practicing in the work environment. It is

outside of the work environment where additional resources such as the professional

organizations and continuing education opportunities can fuel the fire.

Dealy and Bass (1995) found that full time nurse‟s ranked the following items as
highly influential motivating factors: to keep up to date professionally, to obtain practical

benefit, to secure professional advancement, and to meet formal requirements.

Differentiating between nurses, they also make the point that this may reflect a full time

nurse‟s commitment to nursing as a profession, while a part time nurse may have other

outside activities and may not be seeking professional advancement this does not

necessarily mean that they are less committed (p. 32H). An explanation offered for the

responses from this population of associate and diploma degree nurses who work full

time but not from baccalaureate degree nurses is perhaps found in their higher degree of

professionalism for the very dimension of Professional Organization as a Major Referent.

Strong indictors of the benefits gained from the professional organization such as reading

professional journals and the degree of satisfaction with their current role is evident.

Lindqvist, Duncan, Shepstone, Watts & Pearce (2005) reported that each individual

acquires a range of attitudes throughout life, and these attitudes influence their choice of

profession and probably their approach to interprofessional working while Levett-Jones

(2005) concur that education not only increases clinical skills and knowledge but also

enhances behaviors and attitudes necessary in the changing health care environment.

Baccalaureate degree nurses represented the majority holding professional

organization memberships and were satisfied to very satisfied in their current role. While

employment status was a predictor of three attitude dimensions for full time nurses, it is

feasible that the exploration of shift work whether 8 or 12 hour shifts, weekday, weekend

days of the week and role in organization can yield further results as the majority of these

nurses work in facilities with 24 hour daily functioning units.

Role in the Organization

Role in the organization was found to be a predictor of professionalism in only

one attitude dimension. The staff nurse role is generally represented by a greater number

of nurses. The Texas Board of Nursing statistics of registered nurses employed in

nursing by clinical area has not changed much in the 2006 to 2008 data; Community

Public Health Nurses (3%), Medical/Surgical Nurses (15%), Emergency Nurses (6%),

Home Health Nurses (5% to 6%), and Operating Room/Recovery Care (8%). The

increase in home health is directly attributed to the practice of earlier discharges with

greater resources devoted to caring for patients in the home instead of the high costs of

acute care beds. Role in the organization was a strong predictor of a lower level of

professionalism among diploma staff nurses in the attitude dimension of Professional

Organization as a Major Referent. Although diploma nurses (N=37) represented the

smallest group of nurses, 83% were staff nurses, older, and probably with the most work

experience. In spite of this, Griscti & Jacono (2006) report that direct-care personnel

shortages have conspired to make life-long learning a difficult undertaking in nursing

however, in spite of this, growing numbers of diploma trained nurses go on to obtain a

degree, and the increasing number of new, university trained nurses, suggest that a thirst

for knowledge, thus quality healthcare delivery, continue to exist in the nursing

profession (p. 454). While diploma nurses may not take the time or make a priority of

systematically reading professional journals, attend professional meetings at the local

level, or support professional organization(s), they may not take advantage of hospital in-

services either as 59% received less than the twenty hours of the required continuing

education hours. Evans, Krause, & Anfossi (2006) state that central to professionalism is:
understanding professional roles and norms, working with others, managing oneself and

contributing (pp 219-220) whereas Takas, Maude & Manias (2006) believe that while

experienced nurses continuously engage in professional development to enhance their

professionalism, heavy workload or other organizational factors may prevent nurses from

achieving their ideal practice.

Buckenham (1988) surveyed student nurses and staff nurses to identify the

developing perception of the staff nurse role finding that first-year student nurses hold

perceptions of the importance of the functions of the staff nurse role while second-year

students gave the same responses as staff nurses. On the other hand, third-year student

nurses perception of the staff nurse role did not differ significantly from that of the staff

nurse except for the clinical experience. Parker, Ford & Fox (2003) found that nursing

roles were predictive of nurse‟s professional identification with the profession of nursing

while Hopkins (2001) found that 33% of nurses under the age of 30 plans to leave their

nursing position within the year and 54% would not recommend their profession to

others.

Perhaps capturing greater numbers to represent the other roles in which nurse‟s

serve will provide a deeper understanding of where an impact can be made in the

assessment of role conception along with professional attitudes and behaviors.

Salary

Salary was a predictor of professionalism in only one attitude dimension. There

were fairly diverse salary ranges among respondents. Salary was found to be a predictor

for a lower degree of professionalism in the attitude dimension of Belief in Self-

Regulation for associate degree nurses earning less than $40,000 annual salary (16).
Self-regulation is the belief that laypersons are not qualified to judge the quality of the

professional‟s work, making it necessary for professionals judges their colleagues (Hall,

1968). Salary made a greater impact on these nurses compared to other associate degree

nurses who earned greater that $90,000 annual salary (6) making it very clear that other

factors possibly have influence here. These nurses may also be the younger or older

nurses in varied settings who work part-time on any shift, may not possess the ability to

demand the earning power due to their organizational role, and don‟t have a good idea

about other‟s competence or how another nurse does his/her work. Stechmiller &

Yarandi (1992) surveyed female critical care nurses and concluded that the four most

significant effects on job satisfaction were: opportunities for advancement,

meaningfulness of work, salary, and supervisory staff.

Duffield, Aiken, O‟Brien, & Wise (2004) when exploring positions that nurses

transitioned to after they left nursing found that nurses are well qualified, skilled, and

capable of making the transition to a varied number of careers and positions if and when

they decide to leave the nursing profession. Money is a motivator to many and has

diminishing returns for others. Key to the assessment of professional attitudes is the

understanding of the value nurses place upon variables which significantly influence their

perception of pay as it relates to role responsibilities, accountability, livelihood,

opportunity for advancement and behavior. Perhaps greater understanding will emerge

with a more representative sample of nurse roles, current nursing degree type and

employment interests relative to nursing degree. Males still represent less than 10% of

the nursing population.

Professional Certification

Attainment of professional certification was not a predictor of degree of

professionalism between basic nursing degree programs. Many professional

certifications were held by respondents. The listing of the professional certifications held

by this sample of nurses (Appendix L) gave some insight into the roles which were

represented. Certifications can be driven by personal or professional goals for financial

gain, recognition, or career mobility but may not be tied to an attitude of say excellence

or progressive behavior. Schmalenberg & Kramer (2007) found that within a large group

of nurses surveyed who possessed certification; nurses demonstrated the lowest

perception in the item “certification is a mark of clinical excellence.” This was

concerning due to the fact that specialization is so important to harmonious work

environments even more important among nurses engaged in continuous development.

Interestingly, certified diploma nurses and non-certified baccalaureate degree nurses

demonstrated higher professional attitudes in the dimension of Belief in Self-Regulation

and Sense of Calling to the Field. An association can be made between the two types of

nurses in the sample and the two attitude dimensions in relation to the “what” that has

been gained since graduation from the basic nursing program.

More importantly, certification as a mark of excellence should be highly

associated with the attitude dimension of Professional Organization as a Major Referent,

Autonomy, Belief in Self-Regulation, and Belief in Continuing Competence. Today,

with the movement toward “Magnet Status” as a mark of excellence for nursing as a

profession in hospitals, it would be interesting to assess whether there is a relationship

between certification and magnet status and the six attitude dimension of professionalism
within a wider population. Schmalenberg & Kramer (2007) generated grounded theories

to measure 8 attributes which were found to represent essential environmental attributes

by staff nurses in magnet hospitals: working with clinically competent peers,

collegial/collaborative relationships between nurses and physicians, clinical autonomy,

nurse manager support, control over nursing practice, perception that staffing is adequate,

support for education, and a culture of concern for the patient. These results in part

indicated that baccalaureate educated nurses prepare to avail themselves of opportunities

which meet individual, organizational and professional standards and behavior.

Professional Organization Membership

Professional organization membership was a predictor of professionalism in only

one attitude dimension. Not surprisingly, professional organization membership was a

strong predictor in the attitude dimension of Professional Organization as a Major

Referent for baccalaureate degree nurses. It was the first of two variables in which there

was a strong positive predictor of a higher degree of professionalism for baccalaureate

degree nurses only. Nurses who were members of professional organizations were 2

times more likely to have greater professionalism than non-members. Perhaps the higher

the educational level, the greater the affiliation with the professional organization for

ideals of professional identity, competency and professional attitudes.

Only eighty two (34%) of respondents reported membership in professional

organizations and baccalaureate degree nurses (54) were in the majority with diploma

degree nurses (10) having the least. Those nurses who reported membership also

reported lower mean professionalism scores. Nurses who seek out opportunities such as

attending professional seminars, conferences, and reading journals also avail themselves
to increasing their professional skill sets. Surprisingly, this variable was not related to the

attitude dimensions of Belief in Continuing Competence, Autonomy, and Belief in Self-

Regulation which are also believed to be fostered as an outcome of professional

organization membership. Perhaps those non members are lacking in the opportunity to

develop a community among their peers, or feel that they have the right to participate in

decision making activities in regard to the work that they do or the independence that is

derived from those actions. Varied professional organization membership was reported

by respondents (Appendix J). The organization membership listings offered some insight

into the roles which were represented by the sample. Wynd (2003) assessed

professionalism utilizing Hall‟s Professionalism scale for five dimensions among a

random sample of registered nurses (N=774). She examined differences and

relationships among levels of nursing professionalism, experience, educational degree,

organizational membership, and specialty certification. She found that professionalism

was related significantly to years of experience as a RN, higher educational degree in

nursing, membership in organizations, service as an officer in the organization, and

specialty certification. As would be expected, members of professional organizations

reported a higher mean score in all the attitude dimensions. In the study of

professionalism in associate degree nurses, Fetzer (2003) discovered that professionalism

is not the exclusive purview of the baccalaureate graduate (p. 143).

Since the survey did not seek to identify the respondent‟s current nursing degree,

future research should be undertaken to determine if there is a correlation between a

wider distribution of nurses who maintain professional organization membership,

certification, and current nursing degree to the six attitudinal dimensions of

professionalism.

Expressed Degree of Satisfaction

Satisfaction was a strong predictor of professionalism in 4 attitude dimensions.

It was the second variable in which there was a strong positive predictor of a higher

degree of professionalism for baccalaureate degree nurses only in the attitude dimension

of Professional Organization as a Major Referent. A healthy work environment enables

nurses to meet organizational objectives as well as achieve personal and professional

satisfaction. Dissatisfied diploma degree nurses demonstrated a weaker degree of

professionalism in the attitude dimensions of Belief in Continuing Competence, Belief in

Self-Regulation, and Sense of Calling to the Field, and. These nurses are generally older,

and have been in the profession longer having seen much change in practice, increasing

technological demands, and are possibly considering retirement. On the other hand, in

the attitude dimension of Belief in Continuing Competence, nurses who were satisfied in

their current roles were almost 5 times more likely to have greater professionalism than

those who are not. In the attitude dimension of Belief in Self-Regulation, nurses who

were satisfied in their current role were almost 5 times more likely to have greater

professionalism than those who are not. In the attitude dimension of Sense of Calling to

the Field, nurses who were satisfied in their current role were almost 9 times more likely

to have a greater degree of professionalism than those who are not.

In contrast to this, when considering all aspects of the job, Schmalenberg &

Kramer (2007) discovered that ICU nurses scored moderately high when asked about

their overall job satisfaction with their current nursing job. They explored satisfaction as

a multidimensional construct and used multivariate logistic regression to analyze the

relationship between age and satisfaction with being a nurse controlling for race, marital

status, education, wages, union membership, health status, work setting and position,

resulting in increasing age as a high predictor of satisfaction with being a nurse.

Norman (2005) also discovered that older registered nurses expressed greater

satisfaction with their jobs and with nursing as a career choice. Ingersoll et al. (2002) in

their study of nurses‟ job satisfaction, organizational commitment and career intent

found job satisfaction to be a predictor of nurses‟ intent to remain. These results are

understandable not only for the diploma degree nurse but consider that there are certainly

other factors already mentioned that influence attitudes toward professionalism for many

nurses. Weiss & Cropanzano (1996) reported that job satisfaction is an attitude rather

than an emotional experience and the evaluation of the job is not necessarily entirely

affective but can also have a cognitive component as well mediated by the fact that

satisfaction can lead to many different behaviors just as dissatisfaction.

Jones & Gates (2007) discussed how the totality of costs and benefits of turnover

and retention of nurses are interrelated, and in some cases may be appropriate to assume

that the benefits of retention are the costs of nurse turnover avoided. They give examples

of nurse turnover costs (orientation and training, poor work environment and culture,

dissatisfaction, distrust, loss of organizational knowledge and additional turnover),nurse

turnover benefits (replacement nurses who bring new ideas, creativity, innovations,

knowledge of competitors, and elimination of poor performers), nurse retention benefits

(improved work environment and culture, increased satisfaction, increased trust and

accountability), and nurse retention costs (adequate nurse staffing, promotion and career
advancement opportunities, ongoing education and learning, rewards and recognition,

and program costs such as mentorship).

In this sample, there were (N=9) dissatisfied diploma nurses. Future research

should focus on current nursing degree to determine if the is a relationship to age, salary,

retention, satisfaction and mentorship among a larger population. Given the reality

of the nursing shortage, worker satisfaction, retention, and turnover, these findings will

be useful to those who understand that motivation is the breakfast of champions and

commitment to this effort will become a lifeline to the growth of nursing as a profession.

Mentor Relationship

Mentorship was a strong predictor of professionalism in 4 attitude dimensions. It

was a predictor of a weaker degree of professionalism for non-mentored diploma degree

nurses in the attitude dimensions of Professional Organization as a Major Referent, Belief

in Self-Regulation, and Belief in Continuing Competence. Those nurses reported less

association with the reading of professional journals, professional organization

membership, attending continuing education programs, and knowing and judging each

others competence. In the dimension of Professional Organization as a Major Referent,

nurses who have had a mentor relationship in their nursing career were 2.5 times more

likely to have greater professionalism than those who have not. Blythe, Baumann,

Zeytinoglu & Denton (2008) found that retention might be improved due to the

professional commitment and regard for education of younger nurses along with

mentorship and encouragement to reach professional goals. It was also a predictor of a

weaker degree of professionalism for non mentored associate degree nurses in the attitude

dimension of Autonomy. They reported less association with making their own decisions
and exercising their own judgment in work situations. Interestingly, a correlation can be

made here in regard to the degree of autonomy exercised in practice as it was found that

those nurses who were mentored were 3 times more likely to have greater

professionalism in the attitude dimension of Belief in Self-Regulation. The term

autonomy literally refers to regulation by oneself while self-regulation of nurses is the

exercising of social control over its members. Some ambiguity often surfaces in the

interpretation of these two terms. However, nurses believed that they as the members of

the profession should be the assessors of nursing competence and should be the judges of

those members not meeting professional standards.

Pinkerton (2001) suggests that many nurses have practiced with little or no

autonomy, and given the opportunity, some nurses prefer not to have autonomy in their

practice (p.130), while Moore (1970) suggests that at times such as these with the

looming nursing shortage, the profession and its members are offered the prime

opportunity to exhibit greater degrees of autonomy. Non-mentored nurses experience a

missed opportunity to have someone come along side of them at the right time to guide

them and support in career decisions when needed most.

There was no intent to determine length of mentor relationship but the inherent

value for nurses. This may be a crucial element to the success that nurses report in

weathering the early or current career challenges facing them. De Janasz, Sullivan, &

Whiting (2003) conclude what is applicable to most professions and especially nursing is

that in order to develop the knowing, who, how, and why competencies in an increasingly

complex and changing environment, individuals must develop relationships with multiple

mentors who can assist in different aspects of their careers and assist in their continuous
learning and development of new expertise (pp 83-84).

Greater worth might be placed on the inquiry of whether these nurses believe that

their careers, nursing degree, and professionalism might be at a different level with the

added benefits of a mentor, professional organization membership, and greater

professional development.

Continuing Education Hours

Continuing education was a predictor of professionalism in 1 attitude dimension.

It was a predictor for a weaker degree of professionalism for diploma nurses earning less

than twenty hours of continuing education in the attitude dimension of Professional

Organization as a Major Referent. Nursing as a profession has set the standard for the

minimal requirement to maintain clinical proficiency. Perhaps this is a sign that with the

availability of professional organizations, but without the attitude of professional

commitment, members will continuously lag in their accomplishment to seek out and

engage in continuous education opportunities. O‟Connor (1992) found that nurses rated

as their highest motivational factors for participating in continuing education as:

improving professional knowledge and skills while Turner (1991) reported that personal

satisfaction, joy of learning, increased technical knowledge and self-assurance were

benefits of continuing education for nurses.

Cullen (1998) agrees that nurses participate in continuing education programs to:

enhance professional knowledge, advance professionally, provide relief from routines,

comply with authority, acquire credentials, and improve social relations and skills.

Surprisingly, continuing education was not a predictor of professionalism in the

dimension of Continuing Competence. Failure of nurses to attain twenty hours a year of

continuing professional education hours can be indicative of a lower degree of

professionalism when related to the reading professional journals, professional

organization membership, and attending continuing education programs. Freeman (1994)

in his study of professionalism among selected practitioners of continuing education

found major significance on the academic degree preparation of practitioners. Those

holding doctoral degrees expressed significantly higher levels of professionalism on each

of the attitudinal dimensions than those holding Master‟s and Bachelor‟s Degrees and

those holding Masters degrees exceeded the levels expressed by those holding bachelor

degrees. The discipline in which the academic degree was held was found to be unrelated

to the level of attitudinal professionalism.

Perhaps greater emphasis placed on the monitoring and compliance with

continuing education hours would highlight on the radar those areas needing focus.

Boards of nursing as well as professional and employment organizations would reap a

tremendous return on investment at a time when it is needed the most.

Limitations of Study

Some limitations of this study should be noted. In order to realistically apply the

findings of this study to practice, consideration of the limitations is essential.

Quantitative studies don‟t offer as much richness to the information that can be obtained

when interviewing respondents for clarity of the topic of interest. While data was

collected by self-report, there were no objective verifications of satisfaction and other

measures. There was no intent to gain information about continued educational

development however that information would shed some additional light upon the overall

results. The representativeness of the population and generalizability by design, this

study was limited to a percentage of currently practicing registered nurses in South Texas

and their self reports to attributes of professionalism.

The primary limitation of this study is the low response rate and thereby lack of

control for non-respondents. Cross-sectional studies are especially appropriate for

describing the status of the phenomena at a fixed point in time (Polit, 1999). The cross-

sectional design prevents any causal conclusions from being drawn and it is impossible

infer causal relationships of any kind. Although important, self-perception is only one

aspect of assessing the adequacy of preparation of nurses for practice and measuring their

behaviors. Social desirability response effect bias is a limitation in any study where

participants rate their own behaviors.

Due to the expected variation in the characteristics of practicing nurses, it cannot

be assumed that differences in the reported attributes are solely a result of age, practice

level, social, or environmental factors. The information gained is applicable within this

South Texas population, however further generalizability can only be made when

utilizing study participants from the total population of Registered Nurses within Texas.

The mailed sample size was doubled in order to obtain adequate samples from each

group and to increase the obtaining of adequate returns. To minimize the number of non-

respondents, available resources were utilized as prescribed by Dillman (2000) in efforts

to increase the response rate. A greater than 50% response rate is the desired outcome.

Efforts inherent in this study are aimed to assure that the representative sample

specifically meet the inclusion criteria. The inclusion criterion was clearly stated

however there is no method for verification of the respondent‟s employment status.

All item statements in the attitude scale were utilized even when the Chronbach
Alpha for internal consistency was below >.40 lending itself to ambiguity of meaning for

respondent‟s. To my knowledge, this is the first professionalism study of this respective

population. This study suggests answers to phenomena which have been utilized to

assess professionalism in other populations such as Occupational Therapists, Physical

Therapists, Teachers, and Medical Doctors. Biases are inherent in self-report data,

although self-reporting represents a practical as will as powerful mechanism for obtaining

data. Researchers who use this approach should always be aware of the risk of response

bias – that is the tendency of some respondents to distort their responses (Polit, 1999);

possibly by replying in defense of their practice level instead of their attitudinal level.

Nethertheless, the results do suggest that important differences in associations

between professionalism and basic education program. Generalizability of the findings is

limited to the characteristics of the sample and the operational definition of

professionalism (Hall‟s Professionalism Scale, 1968, Schack & Hepler, 1979).

Recommendations

The findings of this study are both relevant and timely for the nursing profession

currently faced with a shortage of working nurses. The findings suggest the need for

further study related to professionalism and the relationship to basic nursing degree at the

national level to enhance the generalizability to the larger registered nurse population. It

is further suggested that the individuals‟ degree of professionalism is dependent on many

factors. As the profile of nursing becomes more diverse, the professional values of the

group might change to reflect the increased diversity of the profession (Martin, 2003).

The notion that developing trusting relationships among groups whose members each
have diverse interests, priorities, and motives is difficult (Ponte, Fay, Brown, .et al.,

1998) still holds true today.

Age limitations should be aligned with roles and/or practice settings however

should not be a limiting factor for admission into a baccalaureate degree program.

Nursing should continue on every front to elevate the view of nursing from an emerging

profession to full professional status and nurse‟s work diligently at upholding that

status by all means available.

The findings of this study endorse the findings that individual professionalism can

be developed or detoured after an individual enters the profession. The following are

recommendations when further explored can yield greater insight into behavioral and

attitudinal influences on professionalism:

Study of all relevant variables independently among homogeneous and

different groups and educational levels.

A longitudinal study can address attitudinal and behavioral aspects along the

socialization continuum from basic nursing degree to current nursing degree.

Replication of this study in other geographic regions and among other professions

for the purpose of comparison between degrees and roles within organizations can

be useful in understanding how professional attitudes and behaviors can be

infused into the practice environment.

Replicate this study utilizing a larger sample, different states or

comparison between like states.

Further targeted studies of variables not found to demonstrate statistical

significance to attitudes of professionalism.

 Cohort studies utilizing age and educational level to better understand specific

factors which influence attitudes toward professionalism along the socialization

continuum.

Utilize interviews as an objective measure of behavior to discover and validate

reported beliefs as well as ideals.

Evaluate whether to maintain the 6 attitudinal dimensions ideally measuring 30

items or whether to combine the dimensions with a resultant 3 dimension scale

and/or eliminate loadings of less than .03 or .04. to increase internal consistency.

Conclusions

Professionalism is an important principal to be introduced early in the nurses‟

career. Cultivate/enhance professionalism in all nurses, identify deficiencies and it may

be necessary to dismiss the rare nurse that cannot embody professionalism in the practice

environment.

This study contributed to the body of knowledge relating to the attitudinal

attributes of professionalism from a sample of registered nurses in South Texas. Findings

supported the assertion that an assessment of the degree of professionalism can be made

by asking nurses representative of all educational levels in the profession. Minimally,

findings from this study have the potential to create more open, honest, purposeful

dialogue among nurses interested and committed to improving nursing‟s professional

image and addressing the nursing shortage.

I stand in agreement with Campbell, Regan, Gruen, & Ferris (2007) who

surveyed physicians on attitudes and behaviors related to professionalism and pointed out

that their results do not provide a comprehensive assessment of the “professionalism” of

respondents but instead provide the basis for exploring factors that may influence

physicians behaviors related to professionalism (p. 796) along with Espeland (2006) who

asserted that nurses do not always use their potential as they may not be able to change

situations in the work environment, but they always have control over their thinking. That

notion is what has been suggested as a predictor of behavior. This leads to the overall

conclusion that degree of professional behaviors exhibited appears to be perfunctory and

depends largely on the conscious, deliberate professional development and socialization

not only into practice but while in practice. Currently practicing nurses stay in the

profession for a myriad of reasons however, Lynn (2005) asserts that intention to leave

nursing appears to be driven by nurses‟ lack of professional socialization, their disinterest

in working, and their need for higher salary when they are the breadwinner for their

family (p. 269) as well as the personal choice for that particular nurse.

Today‟s nursing workforce presents unique leadership challenges as staff and

nursing leaders from four generations representing different attitudes, beliefs, work

habits, and experiences, work together (Sherman, 2006). This effort to assess practicing

registered nurses in South Texas attitudes toward professionalism by their reported

conformance to professional behaviors has provided valuable insight. Professionalism is

a complex concept resultant of one‟s beliefs, life experiences, and socialization even

though Simpson (1979) believes that “socialization is individual change and cross-

sectional designs are inappropriate to fully study it” (p. 46). Longitudinal research is

needed to study and document over time the attitudinal attributes of professionalism and

its impact on not only those current members but those constantly entering the nursing

profession.
 Throughout the stages of professional socialization into nursing, professionalism

must be a core value for is members. It was found that attitudinal attributes of

professionalism are associated with behavior and do differ by educational level.

Promoting further exploration and integration of these research findings into basic

nursing curriculums, work environments, and into theoretical teachings can be a catalyst

to target attitudes in an effort to attain higher levels of professionalism aimed at attracting

and retaining more professional nurses. In an effort to create health care environments

that retain qualified nurses, the importance of professional satisfaction must be

recognized (Kotzer, Koepping, & Leduc, 2006) and also the understanding that an

individual may identify with an occupation and claim membership in it, but such

identification may not predict working (or staying) in an occupation unless it is coupled

with occupational commitment (Simpson 1979, p. 155).

For nurses to emerge unequivocally as a thriving profession, nurses must execute

and achieve the transformations required in a timely fashion. Nursing consequently
needs to be united in order to alter fragmented and variable beliefs in practice (Rutty,
1998). Hodges (2005) concludes that acknowledgement of professional attitudes and
behaviors can motivate positive change in nurses both inside and outside formal learning
environments serving to bring into view their professional behaviors and choices made.
An important growth oriented process in any profession is the development of
professional identity. In agreement with Garmon & Roehrs (1999) who reported that one
of the key factors found to contribute to professionalism among nursing students was in
understanding that activities beyond the bedside are important to developing a career in
nursing. Nurses as professionals must see themselves as change agents and contributors
to the shaping of their profession.
 The time has come for nurses who must also work together and be creative in

their approaches to resolve issues documented to drive so many colleagues from the field

and discourage others from entering it.

Stern (2006) writes for medical education that which is totally applicable to

nursing education so far as:

“while in pursuit of the highest ideals of professionalism in service to our

patients, as well as in our own self-interest, medical educators would be wise to take a
comprehensive view of the task at hand, setting clear expectations for behavior, designing
meaningful experiences that promote professional values, and insisting on the widest
possible application of robust behavioral outcome measures across the entire continuum
of medical education and practice” (p. 1799).

It appears that there is a difference in the professionalism of nurses by basic

nursing degree and basic nursing degree is not a strong predictor of professionalism. A

compelling finding of this study was that baccalaureate degree nurses demonstrated

overall higher mean professionalism scores and showed a positive relationship to degree

of satisfaction and professional organization membership as predictors of professionalism

in the attitude dimension of Professional Organization as a Major Referent. Associate

degree nurses demonstrated varying mean professionalism scores and showed a negative

relationship to mentorship, salary, and employment status as predictors of

professionalism in the attitude dimensions of Autonomy, and Belief in Self-Service.

Diploma degree nurses demonstrated overall lower mean professionalism scores and

showed a negative relationship to mentor relationship, employment status, gender, role in

organization, continuing education, degree of satisfaction with current role, and basic

nursing degree. The profession has its work cut out. Preparing not only new nurses, but

those currently in practice to respond to and cope with internal as well as external forces
inherent in the work environment which must be done through professional nursing skill

sets and personal and professional development. Nurses and nurse educators must

advocate for change which begins with each of them (us) through skills, behavior, and

attitudes to create the desired outcomes in work environments where the profession will

flourish by cultivating leadership, professional communication, competency, knowledge

and application, critical thinking, collaboration, collegiality, policy making, and

accountability.

Future studies should continue to explore the professionalism of nurses and

address the impact and importance that attitudes and behaviors exert in the shaping of the

profession today. Adaptation of higher professional attributes contributes to

strengthening the core values of the profession and the professionals it represents.

The continuing nursing shortage coupled with an aging workforce of experienced

nurses and instructors offers a great opportunity to direct efforts in addressing differences

in attitudes toward professionalism which might hinder or enhance commitment to

professional behaviors. These results may have far reaching implications for future

educational and socialization efforts by the nursing profession, healthcare organizations,

and individual nursing professionals. This study documents the individual characteristics

that may influence nurse‟s intent to stay in the profession as well as attractiveness of

nursing as a profession in various practice setting. Nursing as a profession as well as

healthcare organizations providing customer focused quality care can be proactive in

methods to enhance the professionalism among such a pivotal group. Historically, nurses

have had difficulty acknowledging their own power while this reluctance to use their

power explains many nurses inability to control their practice (Manojlovich, 2007). The
only way professionalism can be achieved is by a majority of nurses who understand the

importance of working together for the common goal.

The baccalaureate degree is the recognized minimum entry-level into practice for

many professions and remains at the heart of the RN professionalism issue due to the lack

of differentiation between an associate degree nurse, a diploma-prepared nurse, or a

baccalaureate-degree nurse (Kidder, 2006, p. 15). It is imperative that nursing as a

profession gain further understanding of how its members rate their professional

attributes and grow as professionals. Understanding that an image of competence and

professionalism must be conveyed within all areas of nursing practice in order care for

patients, nurses, and society, to enhance the appeal and attractiveness of nursing, and

retain registered nurses within the profession. Kidder (2006) is adamant that licensure is

often synonymous with professionalism because there is no professional distinction as all

levels take the same licensure examination (p. 16).

Based upon the results of this study, it professionalism cannot be mandated

however, discovering and exuding the best in ourselves will be the impetus for change.

This study indicated that the type of basic nursing program whether diploma, associate,

or baccalaureate is not the only variable of concern as nurses are indeed resocialized

throughout their career.

 REFERENCES

Adams, A. (1998). Attitude scales: Building a composite picture (healthcare assessment

tools). Nurse Researcher, 8(3), 51-62.

Adams, D., Miller, K. (1994). Developing professionalism in the practice setting.

Aspen’s Advisor for Nurse Executives, 10(1), 1-3.

Admi, H., Tzischinsky, O., Epstein, R., Herer, P., & Peretz, L. (2008). Shift work
in nursing: Is it really a risk factor for nurses‟ health and patients‟ safety?
Nursing Economics, 26(4), 250-257.

Ajzen, I., Fishbein, M. (1975). Belief, attitude, intention, and behavior: An introduction
to theory and research. Massachusetts: Addison-Wesley Publishing Co.

Ajzen, I., Fishbein, M. (1980). Understanding Attitudes and Predicting Social Behavior.
New Jersey: Prentice-Hall.

Ajzen, I., Madden, T. (1986). Prediction of goal-directed behavior: Attitudes, intentions,

and perceived behavioral control. Journal of Experimental Social Psychology,
22, 453-474.

Ajzen, I. (1988). Attitudes, personality, and behavior. Chicago: The Dorsey Press.

Ajzen, I., Fishbein, M. (2000). Attitudes and the attitude-behavior relation: Reasoned
and automatic processes. In European Review of Social Psychology (Ed).
Stroebe, W., Hewstone, H., England: Wiley Press.

Al‟Aitah, R., Cameron, S., Armstrong-Stassen, M., Horsburgh, M. (1999). Effect of

gender and education on the quality of nursing work life of Jordanian nurses.
Nursing & Health Care Perspective, 20(2), 88-94.
Allen, Linda. (2008). The nursing shortage continues as faculty shortage grows. Nursing
Economics, 26(1), 35-40.

Ali, P., Panther, W. (2008). Professional development and the role of mentorship.
Nursing Standard, 22(42), 35-39.

American Association of Colleges of Nursing. (1986). Essentials of college and

university education for professional nursing. Washington, DC.

American Association of Colleges of Nursing. (1998). The essentials of baccalaureate

education for professional nursing practice, Retrieved on April 7, 2006, from
http://www.aacn.nche.edu/Publications/pdf/DIFFMOD.PDF.

275
 276

American Association of Colleges of Nursing. (2000). The baccalaureate degree in

nursing as minimal preparation for professional practice. Journal of
Professional Nursing, 17(5), 267-269.

American Nurses Association. (2000). Scope and standards of professional practice for
nursing development. Retrieved on April 23, 2004, from http://www.ana.org.

American Nurses Association (2001). Code of Ethics: 2001 Approved Provisions.

Retrieved on December 21, 2008, from
http://nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/
EthicsStandards/CodeofEthics/2110Provisions.aspx.

American Nurses Association. (2008). Code of Ethics. Retrieved on November 1, 2008,

from http://nursingworld.org/ethics/code/protected_nwcoe813.htm.

American Nurses Association. (2008). Nursing Education. Retrieved on December 3,

2008, from
http://nursingworld.org/MainMenuCategories/ANAPoliticalPower/State/StateLeg
islature.

American Nurses Foundation. (2001). Nursing‟s agenda for the Future. Retrieved on
April 7, 2006, from http://www.NursingWorld.org/naf.

AMN Healthcare. (2008). Survey of Nurses 45 to 60 years old. Retrieved on November

10, 2008 from http://phx.corporate-ir.net/phoenix.zhtml?c=130589&p=irol-
contact.

Andrews, K. (2005). Perceptions of high school boys toward nursing as a career choice.
(Doctoral dissertation, University of Missouri, 2005). Missouri. 3167305

Andrews, M., Wallis, M., Wrexham, W. (1999). Mentorship in nursing: a literature

review. Journal of Advanced Nursing, 29(1), 201-207.

Anthony, A. (2004). Gender bias and discrimination in nursing education: can we change
it? Nurse Educator, 29(3), 121-125.

Apker, J., Ford, W., Fox, D. (2003). Predicting nurses‟ organizational an professional
identification: The effect of nursing roles, professional autonomy, and supportive
communication. Nursing Economics, 21(5), 226-232.

Auerbach, D., Buerhaus, P., Staiger, D. (2000). Associate degree graduates and the
rapidly aging RN workforce. Nursing Economics, 18(4), 178-184.

Babie, E. (2001). The practice of social research (9th ed.). Belmont, CA:
Wadsworth/Thomson Learning.
Bauerhaus, P.I. (2000). Implications of an aging registered nurse workforce. JAMA,
283(22), 2948-2954.

Bauerhaus, P. I. (2005). Is the shortage of hospital registered nurses getting better or

worse? Findings from two recent surveys of rns. Nursing Economics, 23(2), 61-
73.

Bauerhaus, P. I., Donelan, K., Ulricli, B.T., Norman, L., Dittus, R., (2006). State of the
registered nurse workforce in the United States. Nursing Economics, 23(1), 6-12.

Barondess, J. A. (2003). Medicine and professionalism. Archives of Internal Medicine,

163(2), 145-149.

Bell, C. (1998). Managers as mentors. San Francisco: Berrett-Koehler Publishers.

Bernice, J., Teixeira, R. (2002). Mentorship: A successful tool for recruitment,

recognition, and advancement. Clinical Leadership & Management
Review, 16(6), 386-390.

Bligh, J. (1999). Mentoring: An invisible support network. Medical Education, 33 (1), 2-

3.

Blythe, J., Baumann, A., Zeytinoglu, I., & Denton, M. (2008). Nursing generations in the
contemporary workplace. Public Personnel Management, 37(2), 137-159.

Board of Nurse Examiners for the State of Texas and the Texas Board of Vocational
Nurse Examiners. (2002). Differentiated entry level competencies of graduates of
Texas nursing programs. Austin, TX.

Board of Nurse Examiners for the State of Texas: Statewide plan to create innovative
models for nursing education to increase rn graduates in Texas professional
nursing education programs. Retrieved on April 17, 2007, from
ftp://www.bne.state.tx.us/educ-innovativemodels.pdf.

Board of Nurse Examiners for the State of Texas approved Professional Education
Programs, January (2007). Retrieved on April 17, 2007, from
ftp://www.bne.state.tx.us/rnschools.pdf.

Bonito, A. J. (1975). Effect of attitudinal content on formation of professional attitudes

in medical students. British Journal of Medical Education, 9(1), 22-26.

Boughn, S. (2001). Why women and men choose nursing. Nursing and Health Care
Perspectives, 22(1), 14-19.

Bourdieu, S. (1990). In S. Hesook (1983) The nature of theoretical thinking in nursing,

2nd ed. Connecticut: Appleton-Century Crofts.
Bradshaw, A. (1998). Defining competency in nursing (part II) an analytical review.
Journal of Clinical Nursing, 7(2), 103-111.

Brady, M., Sherrod, D. (2003). Retaining men in nursing programs designed for women.
Journal of Nursing Education, 42(4), 159-162.

Brooks, I. (2000). Nurse Retention: Moderating the ill-effects of shift work. Human
Resource Management Journal, 10(4), 16-31.

Brooks, I., Swailes, S. (2002). Analysis of the relationship between nurse influences over
flexible working and commitment to nursing. Journal of Advanced Nursing,
38(2), 117-126.

Brooks, K. L. (1992). Professionalism versus general critical thinking abilities of senior

nursing students in four types of nursing curricula. Journal of Professional
Nursing, 8(2), 87-95.

Broscio, M., Scherer, J. (2003). New ways of thinking about career success. Journal of
Healthcare Management, 48(1), 6-11.

Brown, R., Sr. Expecting something great in 2008. Resurrection Baptist Church,
Schertz, Texas, 28 September 2008.

Brush, B., Sochalski, J., Berger, A. (2004). Imported care: Recruiting foreign nurses to
U.S. health care facilities. Health Affairs, 23(3), 78-87.

Budge, C., Carryer, J., Wood, S. (2003). Health correlates of autonomy, control and
professional relationships in the nursing work environment. Journal of
Advanced Nursing, 42(3), 260-268.

Buckenham, M.A. (1988). Student nurse perception of the staff nurse role. Journal of
Advanced Nursing, 13, 662-670.

Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook,

2006 - 07 Edition, Registered Nurses. Retrieved on November 18, 2006, from
http://www.bls.gov/oco/ocos083.htm.

Burkhardt, M., Nathaniel, A. (2002). Ethics & issues in contemporary nursing (2nd Ed.).
New York: Delmar.

Cameron, S., Horsburgh, M. & Armstron-Strassen, M. (1994). Job satisfaction,

propensity to leave and burnout in rns and rnas: A multivariate perspective.
Canadian Journal of Nursing Administration, 7(5), 43-64.
Campbell, E., Regan, S., Gruen, R., Ferris, T., Sowmya, R., Cleary, P., & Blumenthal, D.
(2007). Professionalism in medicine: Results of a national survey of physicians.
Annals of Internal Medicine, 147(11), 795-802.

Carey, S. J. & Campbell, S. (1994). Preceptor, mentor, and sponsor roles: Creative
strategies for nurse retention. Journal of Nursing Administration, 24(12), 39-48.

Chan, A., Chan, E., Scott, D. (2007), Evaluation of hall‟s professionalism scale for
professionals in the construction industry. Psychological Reports, 100(2), 1201-
1217.

Chaska, N. (1978). The nursing profession: Views through the mist. New York:
McGraw-Hill.

Chisholm, M., Cobb, H., Duke, L., McDuffie, C. & Kenney, W. (2006). Development of
an instrument to measure professionalism, American Journal of Pharmaceutical
Education, 70(4), 1-6.

Clark, R., Harden, S., Johnson, W. (2000). Mentor relationships in clinical psychology
doctoral training: Results of a national survey. Teaching of Psychology, (27), 262-
268.

Cleland, V.S. (1975). Taft-Harley amended: implications for nursing – the professional
model. American Journal of Nursing, 25(2), 288-292.

Clouder, L. (2003). Becoming professional: Exploring complexities of professional

socialization in health and social care. In Cohen, J. (1988). Learning in
Health and Social Care, 2(4), 213-222. Statistical Power Analysis for the
Behavioral Sciences. Hillsdale, New Jersey.

Coffey-Love, M. (2001). Said another way: The nursing shortage: What is your role?
Nursing Forum, 36(2), 29-35.

Cohen, Jacob. (1988). Statistical Power Analysis for the Behavioral Sciences. Hillsdale,
New Jersey.

Collins, R. (1979). The credential society. New York: Academic Press.

Colyer, H. M. (2004). The construction and development of health professions: Where

will it end? Nursing and Health Care Management and Policy, 48(4), 406-412.

Cook, T. H. (2003). Beginning student's definitions of nursing: An inductive framework

of professional identity. Journal of Nursing Education, 42(7), 331-317.

Cooper, E. (2003). Pieces of the shortage puzzle: Aging and shift work. Nursing
Economics, 21(2), 75-79.
Coulon, L., Mok, M., Krause, K., Anderson, M. (1996). The pursuit of excellence in
nursing care: What does it mean? Journal of Advanced Nursing, 24(4), 817-826.

Cullen, C. (2000). Autonomy and the nurse practitioner. Nursing Standard, 14(21), 53-
56.

Cullen, P. (1998). Delaware RNs‟ reasons for nonparticipation in continuing education.

The Journal of Continuing Education in Nursing, 29, 228-233.

D‟Antonio, P. (2004). Women, nursing, and baccalaureate education in 20th century

America. Journal of Nursing Scholarship, 36(4), 379-384.

Dealy, M., Bass, M. (1995). Professional development: factors that motivate staff.
Nursing Management, 26(8), 32F-32I.

DeCenzo, D. (1997). Human Relations: Personal and Professional Development. New

Jersey: Prentice Hall.

DeLeskey, K. (2003). Factors affecting nurses‟ decisions to join and maintain

membership in professional associations. Journal of PeriAnesthesia
Nursing, 18(1), 8-17.

De Janasz, S., Sullivan, S., Whiting, V. (2003). Mentor networks and career success:
Lessons for turbulent times. In Turban, D., Dougherty, T. (1994). Role of protégé
personality in receipt of mentoring and career success. Academy of Management
Journal, 37(3), 688-702.

Dempster, J. (1994). Autonomy: a professional issue of concern for nurse practitioners.

Nurse Practitioner Forum, 5(4), 227-232.

Department of Health and Human Services. The registered nurse population.

(Washington D C: Government Printing Office, 2006).

Dixon, M. E. (2006). Feminine image of nursing persists. Advance News Magazine.

Retrieved on June 8, 2006, from
http://nursing.advanceweb.com/common/editorial.aspx?CC=52806.

Domino, E. (2005). Nurses are what nurses do – are you where you should be? AORN,
81(1), 187-201.

Donahue, M. P. (1996). Nursing: the finest art: An illustrated history (2nd Ed.). St. Louis:
Mosby.

Doheny, Kathleen. (2006). Treating the nurse shortage. Workforce Management, 85(19),
1-42.
Doheny, Kathleen. (2006). Nursing in critical condition: Workforce management. The
Insider: Trends & Topics in Workforce Management, October 9, 2006.

Donelan, C., Dusek, J., Gosnell, D. (2005). Professionalism. Clinical Nurse Specialist
19(2), 72.

Dreher, G., Ash, R. (1990). A comparative study of mentoring among men and women
in managerial, professional, and technical positions. Journal of Applied
Psychology, 75(5), 539-546.

Duffield, C., Pallas, L., Aitken, L. (2004). Nurses who work outside nursing. Journal of
Advanced Nursing, 47(6), 664-671.

Duffield, C., Aitken, L., O‟Brien-Pallas, L. Wise, W. (2004). A stepping stone to future
careers. The Journal of Nursing Administration, 34(5), 238-245

Du Toit, D. (1995). A sociological analysis of the extent and influence of professional

socialization on the development of a nursing identity among nursing at two
universities in Brisbane, Australia. Journal of Advanced Nursing, 21(1), 164-171.

Duffy, M.E. (2002). Methodological issues in the web-based research. Journal of

Nursing Scholarship, 34, 83-88.

Dumont, M. (1970). The changing face of professionalism. In Netzer (1970). Education,

Administration, and Change (pp. 22-24). New York: Harper & Row.

Eagelson, R. (2001). Model of professionalism. Wyoming Nurse, 14(2), 5.

Eagly, A. Chaiken, S. (1998). Attitudes structure and function. In Gilbert, D., Fiske, S.,
The Handbook of Social Psychology, (2), 269-322. Boston: McGraw-Hill. 4th Ed.

Elman, N., Felder-Kaye, J., Robiner, W. (2005). Professional development: Training for
professionalism as a foundation for competent practice in psychology.
Professional Psychology: Research and Practice, 36(4), 367-375.

Elzinga, A. (1990). The knowledge aspect of professionalization: the case of science-

based education in Sweden. In Torstendahl, R., Burrage, M. (1990). The
formation of professions: year, knowledge state and strategy. London: SAGE
Publications.

Eraut, M. (1994). Developing professional knowledge and competence. London: The

Falmer Press.

Espeland, K. (2006). Overcoming burnout: How to revitalize your career. The Journal of
Continuing Education in Nursing, 37(4), 178-184.
Evans, J. (2004). Men nurses: a historical and feminist perspective. Journal of Advanced
Nursing, 47(3). 321-328.

Eyre, E. (2009). Professionalism pays. Training Journal, News Feature, January, 23-24.

Farran, C. (1997). Running your career: Creating stable work in unstable times. Austin:
Bard Press.

Fawcett, D. (2002). Mentoring – what it is and how to make it work. AORN, 75(5), 950-
954.

Fetzer, S. J. (2003). The role of self-actualization. Nursing Education Perspective, 24(3),

139-143.

Fink, A. (1995). The survey handbook. Thousand Oaks, CA: Sage.

Fishbein, M., Triandis, H., Kanfer, F., Becker, M., Middlestaft, S. & Eichler, A. (1992).
Factors influencing behavior and behavior change. In Baum, (Ed). Handbook of
Health Psychology (pp. 3-17). New Jersey: Lawrence Erlbaum Associates.

Fitzgerald, W. (1992). Training versus development. Training and Development May

1992, 81-84.

Fletcher, C.E. (2001). Hospital rn‟s job satisfactions and dissatisfactions. Journal of
Nursing Administration, 31, 324-331.

Frank, K. (2005). Benefits of professional nursing organization membership. AORN

Journal, 82(1), 13-14.

Freeman. M. (1994). Attitudes toward professionalism among selected practitioners of

continuing higher education. University of Wyoming, Laramie.

French, S.E. (1994). Nursing as a career choice for women. Journal of Advanced
Nursing, 19(1), 140-151.

Fullam, C., Lando, A. (1998). The triad of empowerment: Leadership, environment, and
professional traits. Nursing Economics, 16(5), 254-257.

Fuller, J. (1995). Challenging old notions of professionalism: How can nurses work with
paraprofessional ethnic health workers? Journal of Advanced Nursing, 22(3), 465-
472.

Gall, M.D., Borg, W.R., Gall, J.P. (1996). Educational Research: An introduction, (6th
Ed.). New York: Longmen U.S.A.
Gagen, L., Bowie, S. (2005). Effective mentoring: a case for training mentors for novice
teachers. Journal of Physical Education, 76(7), 40-45.

Garman, A., Evans, R., Krause, K., Anfossi, J. (2006). Professionalism. Journal of
Healthcare Management, 51(4), 219-222.

Garvey, B. (1995). Healthy signs for mentoring. Education & Training, 35(5), 12-19.

Garvey, B., Alred, G. (2000). Educating mentors. Mentoring & Tutoring, 8(2), 113-126.

Gay, L.R. (1992). Educational research: Competencies for analysis and application. New
York: MacMillian.

George, D., Mallery, P. (2003). SPSS for Windows step by step: A simple guide and
reference. (4th Ed.). Boston: Allyn & Bacon.

Giddens, J. (2006). Comparing the frequency of physical examination techniques

performed by associate and baccalaureate degree prepared nurses in clinical
practice: does education make a difference? Journal of Nursing Education,
45(3), 136-139.

Gladwell, M. (2000). The Tipping Point. New York: Little, Brown, and Company.

Glasman, L. (2006). Forming attitudes that predict future behavior: A meta-analysis of

attitude-behavior relation. Psychological Bulletin, 132(5), 778-822.

Goode, W.J. (1957). The Librarian: From Occupation to Profession? American

Sociological Review, 11, 194-200.

Green, J. (2006). The encyclopedia of police science. New York: Rutledge Taylor &
French Group.

Greenwood, E. (1957). Attributes of profession. Social Work, 2, 44-46.

Griffitts, L. (2002). Geared to achieve with lifelong learning. Nursing Management,

33(11), 22-25.

Grindel, C. (2003). Mentoring managers. Nephrology Nursing Journal, 30(5), 517-522.

Griscti, O., Jacono, J. (2006). Effectiveness of continuing education programmes in

nursing: Literature review. Journal of Advanced Nursing, 55(4), 449-456.

Gross, M. (1999). Ethics education and physician morality. Social Science & Medicine,
49, 329-342.
Hagerty, B.M., Patusky, K.L. (2003). Reconceptualizing the nurse-patient relationship.
Journal of Nursing Scholarship, 35(2), 145-152.

Haley-Andrews, S. (2001). Role play: mentoring, membership in professional

organizations, and the pursuit of excellence in nursing. Journal of the Society
of Pediatric Nurses, 6, 147-148, 151.

Hall, R. (1968). Professionalization and bureaucratization. American Sociological

Review, 33.

Hall, R. H. (1968). Professionalization and bureaucration. Administrative Science

Quarterly. 3(1), 92 – 104.

Halter, M. (2002). Said another way: The place of baccalaureate nursing programs in the
liberal arts setting. Nursing Forum, 37(1), 21-29.

Harvey, M., Buckley, M. R., Novicenic, M. (2006). Addressing ethical issues with the
inpatriation of nursing professionals. Journal of Applied Management and
Entrepreneurship, 11(4), 18-32.

Hatcher, L. (1994). A step-by-step approach to using the SAS(R) system for factor
analysis and structural equation modeling. North Carolina: SAS Institute.

Hausner, J. A. (2002). An examination of the relationship between psychological

empowerment and professionalism in nursing. Doctoral Thesis. The University of
Iowa, Iowa City. UMI 3073374.

Health Resources and Services Administration Bureau of Health Professions, (2002).

Projected supply, demand, and shortages of registered nurses: 2000 – 2020.
Retrieved on October 1, 2006, from
http://www.ahca.org/research/rnsupply_demand.pdf.

Heath, J., Andrews, J., & Graham-Garcia, J. (2001). Assessment of professional

development of critical care nurses: A descriptive study. American Journal
of Critical Care, 10(1), 17-22.

Hemsley-Robinson, Barbara. (1995). Nurses‟ educational preparation and attitudes

toward containment. AORN Journal, 62 (3), 404-410.

Hesook, S. (1983). The nature of theoretical thinking in nursing, 2nd ed. Connecticut:
Appleton-Century Crofts.

Hodges, H. (2005). Professional resilience, practice longevity, and parse‟s theory for
baccalaureate education. Journal of Nursing Education, 44(12), 548-554.
Holden, J. (2006). How can we improve the nursing work environment? The American
Journal of Maternal/Child Nursing, 31(1), 34-38.

Holyoake, D. (2002). Male identity in mental health nursing. Nursing Standard, 16(48),
33-37.

Hom, E. (2003). Coaching and mentoring new graduates entering perinatal nursing
practice. Journal of Perinatal Nursing, 17(1), 35-49.

Hopkins, M.E. (2001). Critical condition. Nurse Week, 2, 15-18.

Hunt, G., Wainwright, P. (1994). Expanding the role of the nurse. London: Blackwell
Scientific Publications.

Ingersoll, G., Olsan, T., Drew-Cates, J., DeVinney, B. Davies, J. (2002). Nurses job
satisfaction, organizational commitment, and career intent. Journal of
Nursing Administration, 32, 250-263.

Irvine, D., Evans, M. (1995). Job satisfaction and turnover among nurses: integrating
research findings across studies. Nursing Research, 44(4), 246-253.

Jackson, J. (1970). Professions and professionalization. London: Cambridge at the

University Press.

Jacox, A. (1978) Professional socialization of nurses. In Chaska, The nursing profession:

views through the mist, (pp. 10-19), New York: McGraw-Hill Book Company.

Johnson & Johnson. (2002). Nursing shortage: Johnson & Johnson campaign aims to
increase awareness, general interest. Nursing Economics, 20(2), 93-94.

Joint Commission on Accreditation of Healthcare Organizations. (2001). Health care at

the crossroads: Strategies for addressing the evolving nursing crisis. Retrieved on
October 4, 2004, from www.jcaho.org.

Jones, C., Gates, M. (2007). The costs and benefits of nurse turnover: a business case for
nurse retention. Online Journal of Nursing Issues, 12(3).

Jordan, C., Thomas, M., Evans, M., Green, A. (2008). Nursing public policy on
competency: how will nursing address this complex issue? Journal of
Continuing Education, 19(2), 86-91.

Josiah Macy, Jr. Foundation (2007). Continuing education in the health professions:
Improving healthcare through lifelong learning. The Journal of Continuing
Education in Nursing, 39(3), 112-118.
Jost, S. (2000). An assessment and intervention strategy for managing staff needs during
change. Journal of Nursing Administration, 30(1), 34-40.

Kaplan, S.; Asmundsdottir, EE. (2000). Icelandic occupational therapists attitudes

toward professionalism. Scandinavian Journal of Occupational Therapy, 7(2), 67-
75.

Kelly, C. M. (2002). Investing in the future of nursing education. Nursing Education

Perspective, 23(1), 24-29.

Kennedy, A., Bassett, C., James, L., Jarrett, L., Watson, P., Kirwan, P., Warren, L.,
Mealing, L., Carthy, J., St Clair Hawkins, W, Flint, V., Spyropoulos, A. (1995).
A degree of professionalism. Nursing Standard, 9(35), 44-45.

Kennerly, Susan. (2000). Perceived worker autonomy: The foundation for shared
governance. Journal of Nursing Administration, 30(12), 611-617.

Kidder, M., Cornelius, P. (2006). Licensure is not synonymous with professionalism: It‟s
time to stop the hypocrisy. Nurse Educator, 31(1), 15-19.

Kimball, B. Oneil, E. (2001). The evolution of crisis: Nursing in America, policy,

politics, and nursing practice. Nursing Practice, 2(3), 180-186.

Kitson, A. (1996). Does nursing have a future? British Medical Journal, 313(7072),
1647-1651.

Klakovich, M. (1995). Development and psychometric evaluation of the reciprocal

empowerment scale. Journal of Nursing Measurement, 3, 127-143.

Knox, S., Irving, J., Gharrity, J. (2001). The nursing shortage – its back! Journal of
Nursing Administration Healthcare, Law, Ethics, and Regulation, 3(4), 114-122.

Kotzer, A., Koepping, D., LeDuc, K. (2006). Perceived nursing work environment of
acute care pediatric nurses. Pediatric Nursing, 32(4), 327-332.

Kramer, M. (1974). Reality shock: Why nurses leave nursing. Saint Louis: The C.V.
Mosby Company.

Kramer, M., Schmalenberg, C. (1993). Learning from success: Autonomy and

empowerment. Nursing Management, 24(5), 58-64.

Lannon, S. (2007). Leadership skills beyond the bedside: professional development

classes for the staff nurse. The Journal of Continuing Education in Nursing,
38(1), 17-21.
Larson, M. (1990). The knowledge aspect of professionalization: The case of science-
based education in Sweden. In Torstendahl, R., Burrage, M. (1990). The
formation of professions: year, knowledge state and strategy. London: SAGE
Publications.

Larson, P. (2003). Factors influencing career decisions: Perspectives of nursing students

in three types of programs. Journal of Nursing Education, 42(4), 168-173.

LaSala, K. B., Nelson, J. (2005). What contributes to professionalism? Nursing

14(1), 63.

Laschinger, H., Havens, D. (1996). Staff nurse work empowerment and perceived
control over nursing practice: Conditions for work effectiveness, Journal
of Nursing Administration, 26(9), 27-35.

Laschinger-Spence, H., Almost, J., Tuer-Hodes, D. (2003). Workplace empowerment

and magnet hospital characteristics: Making the link. Journal of Nursing
Administration, 33(7/8), 410-422.

Last, T. (1992). Extended role of the nurse in ICU. British Journal of Nursing, 1(13),
672-675.

Leddy, Susan. (1998). Conceptual Bases of Professional Nursing. Philadelphia:

Lippincott-Raven Publishers.

Levett-Jones, T. (2005). Continuing education for nurses: a necessity or a nicety? The

Journal of Continuing Education, 36(5), 229-233.

Lewis, S. (1997). Family-friendly employment policies: a route to changing

organizational culture or playing about the margins? Gender, Work
and Organization, 4(1), 13-23.

Li, S., Kenward, K. (2006). A national survey of nursing education and practice of newly
licensed nurses. JONA’s Healthcare Law, Ethics, and Regulations, 8(14),
October/December, 110-115.

Liaschenko, J., Peter, E. (2003). Nursing ethics and conceptualizations of nursing:

profession, practice and work. Journal of Advanced Nursing, 46(5), 488-495.

Lima-Basto, M. (1995). Implementing change in nurses‟ professional behavior:

limitations of the cognitive approach. Journal of Advanced Nursing, 22(3), 480-
489.

Lindqvist, S., Duncan, A., Shepstone, L., Watts, F., Pearch, S. (2005). Development of
„Attitudes to Health Professionals Questionnaire‟ (AHPQ): A measure to assess
professional attitudes. Journal of Interprofessional Care, 19(3), 269-279.
Leonard, T. (2003). Rn to bsn-advice on returning to school. AORN Journal, 77(3), 598-
608.

Ludeman, R., Brown, C. (1989). Staff perceptions of shared governance. Nursing

Administration Quarterly, 13(4), 49-56.

Ludmerer, K. M., MD. (1999). Instilling professionalism in medical practice. The

Journal of the American Medical Association, 28(9), 881-882.

Lusch, R. F.,O‟Brien, M. (1997). Fostering professionalism. Marketing Research,

Spring, 25-31.

Lutzen, K. (1997). Nursing ethics into the next millennium: A context-sensitive

approach to nursing ethics. Nursing Ethics: An International Journal for
Health Care Professionals, 4, 218-226.

Lynn, M., Redman, R. (2005). Faces of the nursing shortage: Influences on staff nurses‟
intention to leave their positions or nursing. The Journal of Nursing
Administration, 35(5), 265-270.

Mahaffey, E. (2002). The relevance of associate degree nursing education: Past, present,
future. Online Journal of Issues in Nursing, May, 7(2).

Manojlovich, M. (2005). Predictors of professional nursing practice behaviors in hospital

settings. Nursing Research, 54(1), 41-47.

Manojlovich, M. (2007). Power and empowerment In nursing: looking backward to

inform the future. Journal of Issues in Nursing, 12(1), Retrieved on August 20,
2008, from http://www.medscape.com/viewarticle/553403_print.

Marcus, L. J. (1995). Renegotiating health care. San Francisco: Jossey-Bass Publishers.

Marrelli, Tina. (2006). Nursing in flux: Are you ready to meet the challenges of the
future? American Journal of Nursing, 106(1), 19-25.

Martin, B. (2002). Promoting a balance between personal health and professional

responsibility, Chart, 99(5), 4-5.

Martin, P. (2003). Professional Values Held by Baccalaureate and Associate Degree

Nurses. Journal of Nursing Scholarship, 35(3), 291-296.

McEwen, M., Wills, E. (2007). Theoretical basis for nursing. Philadelphia: Lippincott
Williams & Wilkins.

McKee, M. & Lessof, L. (1992). Nurse and doctor whose task is it anyway? In policy
issues in nursing (Robison J., Gray A & Elkan, R). Open University Press, pp. 60-
 67.

McKinnon, BF. (1999). Leadership: A means of empowering the nursing profession.

Contemporary Nurse, 8(1), 252-254

Mee, C. (2006). Nursing 2006 Salary Survey. Nursing 2006, 36(1), 46-51.

Mee, C., Robinson, E. (2003). What‟s different about this nursing shortage? Nursing,
33(1), 51-55.

McMullan, M., Endacott, R., Gray, M., Jasper, M., Miller, C., Scholes, J., et al.
(2003). Portfolios and assessment of competence: A review of the literature.
Journal of Advanced Nursing, 41(3), 283-294.

McNeese-Smith, D. K., & Crook, M. (2003). Nursing values and a changing nurse
workforce: values, age, and job stages. Journal of Nursing Administration, 33(5),
260-270.

Medical Professionalism Project. (2002). Medical professionalism in the new

millennium: A physician charter. Obstetrics & Gynecology, 100 (1), 170-172.

Miller, B. (1988). A Model for Professionalism. Today’s OR Nurse, 19(9), 18-23.

Miller, L., Adams, D., Beck, L. (1993). A behavioral inventory for professionalism in
nursing. Journal of Professional Nursing, 5(9), 290-295.

Miner, John B., Crane, Donald P., Vandenberg, Robert J. (1994). Congruence and fit in
professional role motivation theory. Organizational Science, 5(1), 86-97.

Moloney, M. (1986). Professionalization of nursing: Current issues and trends.

Philadelphia: J.B. Lippincott.

Monnig, G. (1978). Professionalism of nurses and physicians. In N. Chaska (Ed),

Nursing Professionalism: Views Through the Mist. (pp. 35-49), New York:
McGraw-Hill.

Mortimer, J, Simmons, R. (1978). Adult socialization. In R. Turner (Ed), Annual

Review of Sociology, (pp. 421-452), Annual Reviews, Palo Alto: California.

Mrayyan, M. (2004). Nurses‟ autonomy: Influence of nurse managers‟ actions.

Journal of Advanced Nursing, 45(3), 326-336.

Muldoon, O. (2003). Career choice in nursing students: gendered constructs as

psychological barriers. Journal of Advanced Nursing, 43(1), 93-100.

Muller, M. (1998). Nursing dynamics, 2nd Ed. South Africa: Heinemann.

Murphy, B. (2005). Nursing home administrators‟ level of job satisfaction. Journal of
Health Management, 49(5), 336-345.

Myers, S. (1990). Nursing career management: The Dalton-Thompson Model. Nursing

Management, 21(5), 97

National Center for Health Workforce Analysis, Bureau of Health Professions, Health
Resources and Services Administration. Projected supply, demand, and shortage
of registered nurses: 2000-2020. Retrieved on June 9, 2005, from
http://www.bhpr.hrsa.gov/healthworkforce.

Nelson, M. (2002). Education for professional nursing practice: Looking backward into
the future. Online Journal of Issues in Nursing, May, 7(2).

Neuhaser, P. C. (2002). Building a high-retention culture in healthcare: Fifteen ways to

get good people to stay. Journal of Nursing Administration, 32(9), 470-478.

Newman, K., Chansarkar, B. (2002). The nurse satisfaction, service, quality and nurse
retention chain: Implications for management of recruitment and retention.
Journal of Management in Medicine, 16(4/5), 271-291.

Nogueras, D. (2006). Occupational commitment, education, and experience as a

predictor of intent to leave the nursing profession. Nursing Economics, 24(2), 86-
93.

Norman, L., Donelan, K., Buerhaus, G., Williams, M., Ulrich, B., Dittus, R. (2005). The
older nurse in the workplace: Does age matter? Nurse Economics, 23(6), 282-289.

Nunnaly, J. (1978). Psychometric theory. New York: McGraw-Hill.

Nursing World: About the Code. (2008). Retrieved on November 1, 2008, from
http://www.nursingworld.org/FunctionalMenuCategories/AboutANA.aspx.

O‟Connor, A. (1992). Reasons nurses participate in continuing education. Nursing

Research, 28(6), 354-359.

Ohlen, J., Segesten, K. (1998). The professional identity of the nurse: Concepts analysis
and development. Journal of Advanced Nursing, 28(4), 720-727.

Okrainec, G.D. (1994). Perceptions of nursing education held by male nursing students.
Western Journal of Nursing Research, 16, 94-107.

Olmstead, A. (1969). Some theoretical issues in professional socialization. The Journal

of Medical Education, 44, 666-669.
O‟Lynn, C.E. (2004). Gender-based barriers for male students in nursing education
programs: Prevalence and perceived importance. Journal of Nursing
Education, 43(5), 229-236.

Osborn, T., Waeckerle, J., Perina, D. (1999). Mentorship: Through the looking glass into
our future. Annals of Emergency Medicine, 34(2), 285-289.

Oughtbridge, D. (1998). Under the thumb. Nursing Management, 4(8), 22-24.

Pankratz, L., Pankratz, D. (1974). Nursing autonomy and patient's rights: Development
of a nursing attitude scale. Journal of Health & Social Behavior, 15(3), 211-216.

Pellegrino, E. D. (2000). Medical professionalism: can it, should it survive? The Journal
of the American Board of Family Practice, 13(2), 147-149.

Perry, B. (2008). Shine on: Achieving career satisfaction as a registered nurse. The
Journal of Continuing Education in Nursing, 39(1), 17-25.

Perry, L. (1995). Continuing professional education: luxury or necessity? Journal of

Advanced Nursing, 21(4), 766-771.

Pinkerton, S. (2001). The future of professionalism in nursing. Nursing Economics,

19(3), 130-131.

Poissonnet, C.A., Veron, M. (2000). Health effects of work schedules in healthcare

professions. Journal of Clinical Nursing, 9(1), 13-23.

Polit, D. F., Hungler, B. P. (1999). Nursing Research: Principles and Methods (sixth
Ed.) Philadelphia: Lippincott.

Ponte, P., Fay, M., Brown, P., Doyle, M., Perron, J., Zizzi, L., Barrett, C. (1998). Factors
leading to a strike vote and strategies for reestablishing relationships. Journal of
Nursing Administration, 28(2), 35-43.

Porter-O‟Grady, T. (2003). Of hubris and hope: Transforming nursing for a new age.
Nursing Economics, 21(2), 59-64.

Poster, E., Adams, P., Clay, C., Garcia, B., Hallman, A., Jackson, B., Klotz, L.,
Lumpkins, R., Reid, H., Sanford, P., Slatton, K., Yuill, N. (2005). The Texas
model of differentiated entry-level competencies of graduates of nursing
programs. Nursing Education Perspective, 26(1), 18-23.

Quinn, R., Spreitzer, G. (1997). The road to empowerment: Seven questions every leader
should consider. Organizational Dynamics, Autumn, 37-49
Ragins, B., Cotton, J., Miller, J. (2000). Marginal mentoring: The effects of type of
mentor, quality of relationship, and program design on work and career attitudes.
Academy of Management Journal, 43(6), 1177-1194.

Rambur, B., McIntosh, B., Palumbo, M., Reinier, K. (2005). Education as a determinant
of career retention and job satisfaction among registered nurses. Journal of
Nursing Scholarship, 37(2), 185-192.

Remmers, H. (1959). Introduction to opinion and attitude. New York: Harper & Row.

Roehrs, C. (1999). Beyond the bedside: Facilitating reflection of nursing

professionalism. Unpublished doctoral dissertation, University of Colorado at
Boulder.

Roemer, L. (2002). Women CEOs in health care: Did they have mentors?
Health Care Management Review, 27(4), 57-67.

Roy, S., & Andrews, H. A. (1991). The Roy Adaptation Model. Connecticut: Appleton &
Lange.

Rutty, J. (1998). The nature of philosophy of science, theory and knowledge

relating to nursing and professionalism. Journal of Advanced Nursing, 28(2), 243-
250.

Ruyter, A. (2005). Should I stay or should I go? Working preferences of agency nurses.
Management Research News, 28(9), 71-73.

Saarmann, L., Frettas, L., Rapps, J., Riegel , B. (1992). The relationship of education to
critical thinking ability and values among nurses: Socialization into professional
nursing. Journal of Professional Nursing, 8(1), 26-34.

Salopek, J. (2004). Rethinking likert. Training & Development, 58(9), 26.

Sarp, N. (2005). Assessment of time management attitudes among health managers. The
Health Care Manager, 24(3), 228-232.

Schack, D. W., Hepler, C. D. (1979). Modification of hall's professionalism scale for use
with pharmacists. American Journal of Pharmaceutical Education, 43(104), 98.

Schumann, Lorna. (1990). Attitudes regarding basic nursing programs: Ratings of

baccalaureate, associate degree and diploma-prepared rns in the northwest.
Journal of Nursing Education, 29(2), 71-78.

Schutzenhofer, K. (1987). The measurement of professional autonomy. Journal of

Professional Nursing, 3, 278-283.
Schmalenberg, C., Kramer, M. (2007). Types of intensive care units with the healthiest,
most productive work environments. American Journal of Critical Care, 19(5),
458-468.

Scott, A. P. (1998). Morally autonomous practice? Advances in Nursing Science, 2(12),

69-79.

Scott-Tilley, D. (2008). Nursing competency in nursing: A concept analysis. Journal of

Continuing Education, 39(2), 58-64.

Secrest, J. A. (2003). "I was actually a nurse"; The meaning of professionalism for
baccalaureate nursing students. Journal of Nursing Education, 42(2), 77-83.

Settersein, L. (1991). Professionalism of nurse practitioners. Journal of the American

Academy of Nurse Practitioners, 3(4), 145-151.

Shafer, W., Park, L., Liao, W. (2002). Professionalism, organizational-professional

conflict and work outcomes: A study of certified management accountants.
Accounting, Auditing & Accountability Journal, 15(1), 46-68.

Shaper, K., Broome, M. C., West, M., Nash, M. (2001). Factors influencing satisfaction
and anticipated turnover for nurses in an academic medical center. Journal of
Nursing Administration, 31(4), 210-216.

Sharan, B., Merriam, R., Brockett, G. (1996). The professional practice of adult
education: An introduction. San Francisco: Jossey-Bass Publishers.

Sheahan, Dorothy. (1974). Degree, yes – education, no. Nursing Outlook, 22, 25-26.

Sherman, R. (2006). Leading a multigenerational nursing workforce: Issues, challenges

and strategies. Journal of Nursing Issues, 11(2),. Retrieved on August 20, 2008,
from http://medscape.com/viewarticle/536480_print.

Sherrod, B. D., Rasch. R. (2005). Men at work. Nurse Management, 36(10), 46-51.

Siela, D., Twibell, K., Keller, V. (2008). The shortage of nurses and nursing faculty:
What critical care nurses can do? Advanced Critical Care, 19(1), 66-77.

Simpson, I. H. (1964). Patterns of socialization into professions. Sociological Inquiry,

37, 47-54.

Simpson, I. H. (1979). From student to nurse: A longitudinal study of socialization.

London: Cambridge University Press.
Smalley, J. (2005). What's your nursing philosophy? Nursing Management, 36(12), 59-
61.

Smith, H., Hood, J., Waldman, D., Smith, V. (2005). Creating a favorable practice
environment for nurses. Journal of Nursing Administration, 35(12),.525-532.

Smith, L.S. (2007). Said another way, is nursing an academic discipline? Nursing
Forum, 35(1), 25-29.

Snizek, W. E. (1972). Hall's Professionalism Scale: An empirical reassessment.

American Sociological Review, 37, 109-114.

Sorrentino, E., Simunek, L. (1991). Nurses‟ perceptions of temporary nursing service

agencies. The HealthCare Supervisor, 9(3), 55-61.

Stechmiller-Rothscild, J., Yaradi, H. (1992). Job satisfaction among critical care nurses.
American Journal of Critical Care, 1(3), 37-44.

Stein, A. (2001). Learning and change among leaders of a professional association.

Holistic Nursing Practice, (16), 5-15.

Stern, D., Papadakis, M. (2006). The developing physician – becoming a professional.

The New England Journal of Medicine, 355(17), pp. 1794-1799.

Styles, M. (1982). Professionalism and professionhood. In M. Styles, (Ed), On Nursing

Toward a New Endowment, St Louis: Mosby.

Su-Mei, H. (1997). Does Higher Education enhance the professionalism in nursing?

Professional Nurse, 24(3), 20-22.

Takase, M., Kershaw, E., Burt, L. (2001). Nurse-environment misfit and nursing
practice. Journal of Advanced Nursing, 35(6), 819-826.

Takase, M., Maude, P., Manias, E. (2006). Role discrepancy: is it a common problem
among nurses? Journal of Advanced Nursing, 54(4), 751-759.

Tanaka, M. (2008). Professionalism in nurse leaders. Dissertation, California State

University, Fullerton, California.

Taylor, S., Field, D. (1997). Sociology of health and health care, 2nd. Ed. Madden,
Massachusetts: Blackwell Science Limited.

Texas Board of Nurse Examiners. (2006). Professional nursing education programs

approved by the board of nursing. Retrieved on October 8, 2006, from
www.bne.state.tx.us/rnschools.pdf.
Texas Board of Nurse Examiners (2007). Nurse Practice Act. Retrieved on November 1,
2008, from, http://www.bon.state.tx.us/nursinglaw/npacontents.html/

Thompson, P. (2000). Mentoring power. Reflections on Nursing Leadership, 26(3), 6.

Trachsel, P. (1998). Differences in professional socialization in rn-bsn distance learning

graduates and bsn on-campus graduates. Doctoral Dissertation, Minnesota.

Trinkoff, A., Geiger-Brown, J., Brady, B., Lipscomb, J., Mutaner, C. (2006). How long
and how much are nurses working? American Journal of Nursing, 106(4), 60-71.

Truesdell, M. (1984). Perceptions of the levels of professionalization in nursing held by

actively practicing registered nurses in Kansas. Doctoral Dissertation, Kansas
State University, Kansas.

Turner, P. (1991). Benefits and costs of continuing education in nursing education: An

analytic survey. Journal of Continuing Education in Nursing, 22(3), 104-108.

Underwood, T. (2001). The professionalization of victim assistance: An exploratory

study of attitudinal dimensions and factors. Doctoral Thesis. Kansas State
University, Manhattan, Kansas.

Upenieks, V. (2000). The relationship of nursing practice models and job satisfaction
outcomes. Journal of Nursing Administration, 30, 330-335.

Valentino, L. (2002). Future employment trends in nursing: The nursing shortage has
struck just about everywhere in the United States and there‟s no relief in sight-but
its effects vary by region and specialty. American Journal of Nursing, 102(1), 24-
28.

Vogel, Lynda. (2007). Willingness and its relevance to nursing. Advances in

Nursing Science, 30(3), E73-E83.

Vollmer, H. M., Mills, D. L. (1966). Professionalization. New Jersey: Prentice-Hall, Inc.

Wilensky, H. L. (1964). The professionalization of everyone? The American Journal of

Sociology, 73(2), 137-158.

Wade, G. H. (1999). Professional nurse autonomy: Concept analysis and application to

nursing education. Journal of Advanced Nursing, 30(2), 310-318.

Wade, G. H. (2004). A model of the attitudinal component of professional nurse

autonomy. Journal of Nursing Education, 43(3), 116-124.

Walsh, A. M. (1999). Mentoring in health administration: The critical link in executive

development. Journal, 44(4), 270-281.
Warner, L. G. (1969). Attitude as an interactional concept: Social constraint and social
distance as intervening variables between attitudes and action. American
Sociological Review, 34(2), 153-169.

Waters, V., Vivier, M. L., Chater, S., Urrea, J. H., Wilson, H. S. (1972). Technical and
professional nursing: An exploratory study. Nursing Research, 25, 124-131.

Weber, B. (2003). Florence nightingale‟s basic tenets: Would she recognize nursing
today? Plastic Surgical Nursing, 23(2), 44.

Weiss, D., Schank, M.J. (1997). Toward building an international consensus in

professional values. Nurse Education Today, 17, 366-369.

Weiss, H., Cropanzano, R. (1996). Affective events theory: A theoretical discussion of

the structure, causes, and consequences of affective experiences at work.
Research in Organizational Behavior, 18, 1-74.

Werner, P. (2001). Nursing staff member‟s intentions to use physical restraints with
older people: Testing the theory of reasoned action. Journal of Advanced
Nursing, 35(5), 784-791.

White, B.A. (1992). Professional certification is a needed option for adult and
continuing education. In M. W. Galbraith & B.R. Sisco (Eds), Confronting
controversies in challenging times: A call to action. San Francisco: Jossey Bass.

Whittaker, S., Winifred, C., Smolenski, M. (2000). Assuring continued competence -

policy questions and approaches: How should the profession respond? Online
Journal of Issues in Nursing, 5(3).

Wilson, J. (2002). The impact of shift patterns on healthcare professionals. Journal of

Nursing Management, 10, 211-219.

Wilson, T., Lindsey, S., Scholler, T. (2000). A model of dual attitudes. Psychological
Review, 107(1), 101-126.

Witt, B.S. (1992). The liberating effects of rn-bsn education. Journal of Nursing
Education, 31, 149-157.

Wood, R., Power, C. (1987). Aspects of the competence-performance distinction:

Educational, psychological and measurement issues. Journal of
Curriculum Studies, 19:5, 409-424.

Wooley, A. (1978). From rn to bsn: faculty perceptions. Nursing Outlook, 26(2), 103-
108.
Wynd, A. (2003). Current factors contributing to professionalism in nursing. Journal of
Professional Nursing, 5(18), 251-261.

Wynn, K. (1998). Under your wing: Mentoring in the profession. Magazine of Physical
Therapy, 6(2), 42-49.

Yam, J. (2004). From vocation to profession: The quest for professionalization of

nursing. British Journal of Nursing, 13(16), 978-982.

Yang, C., Gau, M., Shiau, S., Hu, W., Shih, F. (2004). Professional career development
for male nurses. Journal of Advanced Nursing, 48(6), 642-650.

Yoder, L. (1995). Staff nurse‟s career-development relationships and self-reports of

professionalism, job satisfaction and intent to stay. Nursing Research, 44, 290-
297.

Yuke, G. (2006). Leadership in Organizations, 6th ed. New Jersey: Pearson, Prentice
Hall.

Zerwekh, J., Claborn, J.C., (1997). Nursing Today: Transitions and Trends.
Philadelphia: W.B. Saunders.

Zey, M. (1997). The Mentor Connection: Strategic alliances in corporate life. New
Jersey: New Bruswick, Transaction Publishers.
APPENDICES

298
 APPENDIX A

Nursing Education Programs

299
 300

Diploma Program

The diploma school of nursing was the first type of nursing school in this country.

The program was generally two to three years in length. In the early years, the education

offered by hospitals was of the apprenticeship type of training, as there was little theory

and formal class work. Upon successful completion, the student was awarded a diploma

by the school, which was not considered an academic degree. Today, state programs

must offer the standard educational program with coursework containing nursing and

related subjects in physical and social sciences along with supervised practice. The

diploma program in nursing prepares an individual, eligible for licensure as a registered

nurse, to function as a generalist in hospitals and community institutions. The nurse

provides nursing care to and engages in therapeutic, rehabilitative, and preventive

activities in the behalf of individual patients and groups of patients. (Kelly, 1975, p. 167)

Associate Degree Program (ADN)

The associate degree programs are two years in length, and are offered by junior

or community colleges, and occasionally four-year colleges. These educational programs

were designed to prepare the individual for the baccalaureate program. Baccalaureate

educational programs contain both theoretical content and clinical experience. The ADN

role is considered a technical job and is designed to work in collaboration under the

supervision of the professional nurse. The nurse is intended to provide care to patients

requiring skill and judgment, although not intended to assume administrative

responsibilities (Kellym, 1975, pp. 169-170).

Baccalaureate Degree Program (BSN)

The baccalaureate program is considered as a minimum preparation for

professional practice. The program is usually four years in length and may be as many as
five years. The individual obtains both a college education and preparation to assume
the role of a registered professional nurse (RN) after award of a bachelor‟s degree. The
program consists of general education in liberal arts and science, as well as nursing
courses.
 APPENDIX B

First Survey Postcard

302
 303

Note: The “u” in Tourou was removed to read Touro University prior to mailing.
 APPENDIX C

Follow-up Survey Postcard

304
305
APPENDIX D

Survey Tool

306
NOTE: COMPLETION OF
THIS SURVEY INDICATES
YOUR CONSENT. 307

INCLUSION CRITERIA:
IF YOU ARE NOT: 1) CURRENTLY EMPLOYED AS A REGISTERED NURSE IN SOUTH TEXAS, OR
2) WORK LESS THAN 20 HOURS WEEKLY, YOU DO NOT MEET THE INCLUSION CRITERIA FOR
THIS STUDY. PLEASE RETURN THIS SURVEY UNCOMPLETED. PLEASE ACCEPT THE
BOOKMARK AS A TOKEN OF APPRECIATION FOR YOUR CONTINUED CONTRIBUTION TO THE
NURSING PROFESSION.

Gender Age range (years) Shift Working

Male (0) 20 or less (1) Night shift (1)
Female (1) 21 - 30 (2) Day shift (2)
31 – 40 (3) Evening shift (3)
Basic RN Education 41 - 50 (4)
Diploma (1) 51 - 60 (5) Employment Status
Associate (2) 61+ (6) Full Time (1)
Baccalaureate (3) Part Time (2)

Professional Organization Membership (Organization refers to a national, state, or local representation of

occupational interests and/or provides guidelines for practice) Are you a member of such a organization
(s)? Yes (1) No (0) If yes, list the organization(s) in which you actively participate:

National Certification:
Yes (1) No (0) If Yes, please list:

Role in Agency RN practice years Continuing Education Hours

Staff Nurse (1) Full-time years (1) (Estimated number of hours spent in
Supervisor/HN (2) Part-time years (2) formally offered continuing professional
Administration (3) (Years of practice you have educational activities during the 2007
Instructor/Educator (4) maintained for the majority calendar year)
Advanced Practice (5) of your work history) 20 hours or less (1)
School/Office Nurse (6) 21– 40 hours (2)
Researcher/Consultant (7) 41 – 60 hours (3)
Infection Control Practice (8) Other (9) 61 hours or more (4)

How satisfied are you with your role within the profession of nursing now?
Very Satisfied (4) Satisfied (3) Marginally Satisfied (2) Dissatisfied (1)
Intent to leave profession (0)

Salary (annual) Journal Subscription Do you currently have a Mentor(s)?

$ 20,999 or below (1) Yes (1) Yes (1)
$ 21,000 - $ 29,999 (2) No (0) No (0)
$ 30,000 - $ 39,999 (3) If Yes, please list: If yes, how many:
$ 40,000 - $ 49,999 (4) Within nursing:
$ 50,000 - $ 59,999 (5) Outside of nursing:
$ 60,000 - $ 69,999 (6)
$ 70,000 - $ 79,999 (7) If no, have you ever had a mentor
$ 80,000 - $ 89,999 (8) during your nursing career?
$ 90,000 - $ 99,999 (9)
$ 100,000 or more (10)

Type of Organization
Hospital (1) Industrial Setting (6) Home Health (11)
Outpt. Clinic (2) School (7) Self Emp/Private Practice (12)
Health Dept. (3) Agency/Nursing Pool (8) Correctional Medicine/Immigration(13)
Military Installation (4) Doctors Office (9) Flight Nursing (14)
Nursing Home (5) Emergency Center (10) Other (15)

Please make sure that ALL items have been answered, are clearly marked, and any changed answers have
been completely erased.

PLEASE COMPLETE ALL PAGES AND RETURN IN THE ENCLOSED SELF-ADDRESSED,

POSTAGE PAID ENVLOPE. THANK YOU VERY MUCH FOR YOUR TIME AND CONTRIBUTIONS!
 308

PROFESSIONALIZATION SCALE
Developed by Hall (1968) with revisions by Schack and Hepler (1979)

Place an X in the box following the statement in light of the way you feel as a practicing registered nurse.
There are five possible responses to each statement which may correspond to yo r own attit de: de:
Strongly Agree Agree Neutral Disagree
Strongly Disagree (SA) (A) (N)
(D) (SD)
The middle category of N is designed to indicate an essentially neutral attitude.
Please answer ALL items by placing an X in the box that best corresponds with your own attitude.
Make sure that you have NO MORE THAN ONE RESPONSE FOR EACH ITEM.

SA A N D SD
1. I believe it important to systematically read professional journals.

2. Other professions are actually more vital to society than mine.

3. My fellow professionals have a pretty good idea about each other’s

competencies.

4. People in this profession have a real calling for their work.

5. I can make my own decisions in regard to what work is to be

done.

6. I can maintain an acceptable standard of practice without continuing

education programs.

7. I am committed to regularly attend professional meetings at the

local level.

8. I think that my profession, more than any other, is essential for

society.

9. A problem in this profession is that no one really knows what his/her

colleagues are doing.

10. The dedication of people in this field is most gratifying.

11. I don’t have much opportunity to exercise my own judgment.

12. Continuing education such as self-study or seminars is

essential for my work.

13. I believe that the professional organization(s) should be supported.

 PROFESSIONALIZATION SCALE (cont.)
Strongly Agree Agree Neutral Disagree Strongly Disagree
(SA) (A) (N) (D) (SD)

SA A N D SD

14. The importance of my profession is sometimes over stressed.

15. Nurses really have no way of judging each other’s competence.

16. It is encouraging to see the high level of idealism, which is

maintained by people in this field.

17. My own professional decisions are subject to review.

18. My daily practice is all the continuing education I need.

19. The professional organization doesn’t really do much for the average
member.

20. Some other occupations are actually more important to

society than mine.

21. There is not much opportunity to judge how another person does
his/her work.

22. Most people would stay in the profession even if their income
was reduced.

23. I am my own boss in almost every work-related situation.

24. Continuing education is of little importance to my practice.

25. Although I would like to, I don’t think it is a priority to read

professional journals too often.

26. If ever an occupation is indispensable, it is this one.

27. My colleagues know how well we all do our work.

28. There are very few people who don’t really believe in their work.

29. Most of my decisions are reviewed by other people.

30. My practice would suffer if I did not attend continuing

education programs.
 APPENDIX E

Invitation Letters to Respondent’s

310
 311

THE DEGREE OF PROFESSIONALISM AMONG

ACTIVELY PRACTICING REGISTERED NURSES
IN SOUTH TEXAS

I am writing to request your assistance in a research study designed to learn about the attitudinal
attributes of professionalism among nurses who received their basic nursing degree in associate,
diploma, and baccalaureate degree programs. This research is being conducted as part of the
dissertation requirements for Kai A. Makeda, a doctoral candidate at Touro University
International, College of Health Sciences, Cypress, California.

Your participation in this study will help us to assess the level of professionalism among a
random sample of currently practicing Registered Nurses in South Texas. You are being asked to
take part in this study because you live in a county within South Texas. The questionnaire
contains a demographic page and 30 items which will take approximately 10 to15 minutes to
complete. For your convenience, you may utilize the website provided to complete the electronic
version of this survey. The survey can be accessed at the following website:
www.surveymonkey.com/Professionalism_Nursing. Although this study may not benefit you
directly, it may help us learn about factors associated with attitudes toward professionalism
among nurses within a variety of settings and educational backgrounds.

There is no potential risk to any participant by completing this questionnaire. Your answers are
completely confidential and will be released only as summaries in which no individual‟s answers
can be identified. When you return your completed questionnaire, your name will never be
connected to your answers in any way. Participation in this survey is voluntary. There are no
penalties if you choose not to participate in this study and you may choose to withdraw at any
time. Please take a few minutes from your busy schedule to share your experiences. If you prefer
not to respond, please return the blank questionnaire in the self addressed return envelope
provided to you.

Please accept the enclosed bookmark as a token of our appreciation for your assistance and
contributions to the nursing profession.

If you have any questions, please feel free to contact Kai A. Makeda, RN, MS, at (210) 601-3649.
Any questions which you may have about your rights as a research participant can be addressed
by Dr. Afshin Afrookhteh, JD, CHES, RT(Ret), Chair, Touro University International
Institutional Review Board, at (714) 226-9840, or (800) 375-9878, extension 2004, or you may
contact Dr. Steven R. Konkel, Chair, Touro University International Dissertation Committee, at
(859) 622-6343.

Completion and return of this survey implies that you have read the information and consent to
take part in the research. This study has been approved by the Touro University International
Institutional Review Board (IRB).

Thank you very much for helping with this important study. Results may be obtained upon
request by returning a stamped, self-addressed envelope to the researcher.

Sincere Regards,
Kai A. Makeda, RN, MS
 THE DEGREE OF PROFESSIONALISM AMONG
ACTIVELY PRACTICING REGISTERED NURSES
IN SOUTH TEXAS

About three weeks ago, a questionnaire was sent to you asking you about your attitudes
toward professional behavior. To the best of my knowledge, it has not been returned.

I am writing again to request your participation in this study because it will help us to
assess the level of professionalism among a random sample of currently practicing
Registered Nurses in South Texas. In order to truly obtain a representative sample within
South Texas, we need your input. The questionnaire contains a demographic page and 30
items which will take approximately 10 to15 minutes to complete. For your convenience,
you may utilize the website provided to complete the electronic version of this survey.
The website is: www.surveymonkey.com/Professionalism_Nursing. Although this
study may not benefit you directly, it may help us learn about factors associated with
attitudes toward professionalism among nurses within a variety of settings and
educational backgrounds.

There is no potential risk to any participant by completing this questionnaire. Your

answers are completely confidential and will be released only as summaries in which no
individual‟s answers can be identified. When you return your completed questionnaire,
your name will never be connected to your answers in any way. Participation in this
survey is voluntary. There are no penalties if you choose not to participate in this study
and you may choose to withdraw at any time. Please take a few minutes from your busy
schedule to share your experiences. If you prefer not to respond, please return the blank
questionnaire in the self addressed return envelope provided to you. We hope that you
have put your bookmark to use and request your valuable input.

If you have any questions, please feel free to contact Kai A. Makeda, RN, MS, at (210)
601-3649. Any questions which you may have about your rights as a research participant
can be addressed by Dr. Afshin Afrookhteh, JD, CHES, RT(Ret), Chair, Touro
University International Institutional Review Board, at (714) 226-9840, or (800) 375-
9878, extension 2004, or you may contact Dr. Steven R. Konkel, Chair, Touro University
International Dissertation Committee, at (859) 622-6343.
.
Completion and return of this survey implies that you have read the information and
consent to take part in the research. This study has been approved by the Touro
University International Institutional Review Board (IRB). Thank you very much for
helping with this important study. Results may be obtained upon request by returning a
stamped, self-addressed envelope to the researcher.

Sincere Regards,
Kai A. Makeda, RN, MS
 APPENDIX F

Sample Size and Power Analysis

313
 314

Sample Size and Power Calculation

The sample will be randomly selected from the population of South Texas

practicing registered nurses (62,527), who represent 64 counties within South Texas;

comprising 41.8 % of the total Texas registered nurse population (149,682). A listing of

nurses who are licensed in South Texas will be obtained from the Texas Board of

Nursing inclusive of residential and e-mail addresses. If it were feasible, I would prefer

the sample size to be inclusive of all of the practicing registered nurses in South Texas.

However, it is impossible to do so due to limitation of funding and time constraints. I

have chosen 20% of the South Texas population (12,506) in order to estimate the sample

size. The sample size was calculated utilizing an estimation of a population proportion

formula:

N ( pq)
n
(N1)Dpq
B2
Where q=1-p and D
4

Since there is no prior data which can be utilized to calculate the sample size, with the

assumption of the population proportion as p=0.5 and the error of estimation of

magnitude as

B=0.05.

(.05)2
D =0.000625 and q=1-0.5=0.5
4

Hence
n
(12506)(0.5)(0.5) 3126.5 387.9 388 .
(12505)(0.000625) (0.5) 8.06
(0.5)

It is known that the response rate for mail surveys will fall in the range of 50% to 55%. It
seems prudent to conservatively choose 50% as the survey return rate and therefore the

adjusted sample size estimate is 776 packets or (388/.5). This will also be an adequate

sample size in order to perform a factor analysis for the 30 items in the tool.

This power analysis is based on the use of ANOVA, with the total

professionalism dimension score as the dependent variable; and the 3 different

educational levels as the independent variable for the comparison of the difference in the

mean of professionalism among these 3 groups. The effect size is calculated from the F-

ratio using the formula:

df F
f
1 N

Where df1 is the degree of freedom of the term used in the numerator, F is the value of

the F-test, and N is the total sample size. Since the effect size among 3 groups is not

known, it will be estimated with the assumption of a small effect size between groups,

conservatively. Cohen (1988) has designated a low value as .1, a medium value as .25,

and a large value as .4. The minimum sample size of 388 registered nurses will be large

enough to detect the effect size of 10% with power set at 80% (minimizing the chance of

a Type II error) at the alpha significant level at 5% (minimizing the possibility of a Type

I error).
 APPENDIX G

IRB Considerations and Approval

316
 317

In the writing of this research proposal, it is essential to recognize that IRB review

will be necessary before the research can commence. The purpose of the IRB is to ensure

that the rights of all participants are recognized and protected throughout this study. All

collected data will remain strictly confidential. Participating in this study was voluntary,

and the respondents could choose not to participate or to stop participation at any time.

There is no potential risk for participation in the completion of the questionnaire.

Responses will be completely anonymous and names will not be required on the

questionnaire. Completion and return of the questionnaire will imply that the respondent

has read the information in the packet and consents to the use of the answers supplied.

Questionnaires were coded for the sole purpose of monitoring return rates, and will be

destroyed after the analysis of the data.

 Touro University International

Institutional Review Board for the Protection of Human Subjects

IRB REVIEW FORM

PROJECT TITLE: PROJECT INVESTIGATOR PROJECT DATE:

The Degree of Professionalism Kai Makeda 10/28/07 – 12/15/07
APPLICATION TYPE: EXEMPT X EXPEDITED REVIEW FULL REVIEW

APPLICATION STATUS: APPROVED X APPROVED WITH AMENDMENT

REQUIRES ADDITIONAL INFORMATION NOT APPROVED

THE FOLLOWING ADDITIONAL INFORMATION/AMENDMENT IS REQUIRED BY THE IRB:

1. Correct spelling of "Touro" on all communications by deleting the "u" at the end of the word “Tourou”.
2. Recruitment and Follow Up Letters: Paragraph 5 - change "research review board" to "Institutional
Review Board."
3. Recruitment and Follow Up Letters: Change “This informed consent has been approved…” to “This
study has been approved by the Touro University International Institutional Review Board (IRB).”
4. Add Committee "Chair" information as well as specific IRB Chair contact information.
5. Survey: Add statement at the beginning of the survey that completion indicates consent.
6. Elaborate on voluntary nature of the study and right to withdraw at any time without penalty.
7. Promise results upon request.

AFSHIN AFROOKHTEH 10/18/07

_
IRB Chair Date

Touro University

International 5665 Plaza

Drive, Third Floor Cypress,

CA 90630

Phone: (714)226-9840, extension 2004

Fax: (714) 226-9845

 APPENDIX H

Permission from Thomas Underwood

319
 320

From: thomas.underwood@washburn.edu [mailto:thomas.underwood@washburn.edu]

Sent: Monday, March 27, 2006 6:39 PM
To: Kai Makeda
Cc: thomas.underwood@washburn.edu
Subject: Re: Permission to utilize your survey tool

Absolutely you have my permission. Since I am obviously very interested in

this, I'd appreciate being able to read your study when completed. Best of
luck.
 APPENDIX I

Token Book Mark

321
322
 APPENDIX J

List of Respondents Professional Organization Memberships

323
 324

Table 10
Respondents Professional Organization Membership
Texas Nurses Association 14
American Nurses Association 9
American Association of Certified Nurses 8
Emergency Nurses Association 7
Association of Operating Room Nurses 6
Oncology Nursing Society 5
National Association of School Nutrition 4
American Society of PeriAnesthesia Nurses 3
Texas association of PeriAnesthesia Nurses 3
Association for Professionals in Infection Control and Epidemiology 3
Sigma Theta Tau 3
American Psychiatric Nursing Association 2
Association of Clinical Research Professions 2
Texas association of School Nurses 2
Texas Student Nurses Association 2
Black Nurses Association 2
American Nephrology Nurses Association 2
National Association of Neonatal Nurses 2
National Association of Pediatric Nurse Practitioners 2
State of Texas Chapter of Pediatric Nurse Practitioners 1
American Pain Society 1
National Association Clinical Nurse Specialist 1
Society of Gastroenterology Nurses and Associates 1
Association of Women‟s Health, Obstetrics & Neonatal Nurses 1
Dominican Nurses Association 1
Houston Area Psychiatric Nursing Association 1
American Association of Nurse Anesthetists 1
Philippine Nursing Association 1
Outpatient/Primary Care Nurses Association 1/1
American Public Health Association 1
Philadelphia Nurses Association 1
American Radiological Association 1
Texas State Bar Association 1
American Association of Nurse Assessment Coordinators 1
Healthcare Organization Nurse Executives 1
Critical Care Nurses Association 1
Michigan Nurses Association 1
Advanced Practice Nurses Association 1
National Hemophilia Foundation`` 1
World Heart Federation 1
Hemophilia & Thrombosis Research Society 1
Preventive Cardiovascular Nurse Association 1
 APPENDIX K

List of Respondents Subscriptions to Professional Journals

325
 326

Table 11
Respondents Subscriptions to Professional Journals
RN Magazine 24
American Journal of Nursing 22
Nursing 2007 20
American Journal of Critical Care 11
Journal of Oncology Nurses 5
Operating Room Nurse Journal 5
Nurse Week 5
Advanced Nurse 5
Journal of Emergency Nursing 4
Journal of PeriAnesthesia Nursing 2
Minority Nurse Magazine 2
Journal of School Nursing 2
Contemporary Pediatrics 1
Gastroenterology Nursing 1
Journal of Obstetric, Gynecological and Neonatal Nursing 1
Journal of American Psychiatric Nursing Association 1
Orthopedic Nursing 1
Journal of Nurse Anesthetist 1
Journal of Anesthesia 1
ANA Smart Brief On-line 1
Critical Care Nurse 1
Journal of Cardiovascular Nursing 1
ONS Connect 1
American Journal of Infection Control 1
Journal of Nursing Administration 1
Oncology Nursing Forum 1
American Journal of Public Health 1
Journal of Neonatal Nursing 1
Texas School Nursing News 1
Nursing Careers Today 1
Nephrology Nurse 1
Texas Nursing Magazine 1
Journal of School Scholarship 1
American Nurse Today 1
Journal of School Nursing 1
Advance Nurse Practitioner Magazine 1
EMS Magazine 1
No Listing 15
 APPENDIX L

List of Respondents Professional Certifications (ANA/ANCC)

327
 328

Table 12
Respondents Reported Professional Certifications (ANA/ANCC)
Critical Care Registered Nurse 10
Medical-Surgical 6
Emergency Nursing 6
Nurse Administrator 4
Operating Room 3
Pediatric Nurse 3
Oncology Nurse 3
School Nurse 2
Inpatient Obstetrics Registered Nurse 2
Case Manager 2
Registered Nurse (RN-C) 2
Advance Practice (APRN or BC) 1
Pediatric Nurse Practitioner 1
Pain Management 1
Registered Nurse Anesthetist 1
CCRC 1
Community Health Nursing 1
Maternal-Newborn 1
Radiologic Nursing 1
High Risk PeriAnatal Nurse 1
PeriAnesthesia Nursing 1
Ophthalmic Nursing 1
Clinical Nurse Leader 1
Bone Densitometry Technologist 1
Nephrology Nurse 1
Resident Assessment 1
Coordinator Rehabilitation 1
Registered Nurse No Listing 7