THE RELATIONSHIP BETWEEN ROLE CONCEPTION AND ETHICAL BEHAVIOUR OF STUDENT NURSES IN HONG KONG

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

Introduction
Nurses are constantly faced with making front line decisions that are ethical in nature and critical to the outcome of patient care. However, studies have shown that nurses have little authority and power to make free ethical choices. Instead of exercising what is described as ideal moral behaviour, they are very often caught in the middle of ethical conflicts under a bureaucratic hierarchy. Their role as nurses has often been the cause of these conflicts. The same phenomenon
Address for correspondence: Professor Hilary Ha-ping Yung, Department of Nursing, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong. Nursing Ethics 1997 4 (2) 0969-7330(97)NE112OA © 1997 Arnold

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

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

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

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

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

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

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Role conception and ethical behaviour of student nurses in Hong Kong 103 4) What is the relationship between the role discrepancies and ethical behaviour of degree and certificate nursing students?

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

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

Instruments
Nursing role conception instrument The Nursing Role Conception instrument (Appendix 1) is a modification of the original scale developed by Pieta,11 whose questionnaire was originally based on Corwin’s scale. 20 The three role conception scales consisted of eight professional, eight bureaucratic and seven service items. The items in each scale were composed of a hypothetical situation in which nurses might find themselves. For each situation, there were two questions: question A asked the extent to which the respondent thought the situation should be practised in nursing (the ideal), and question B the extent to which the respondent perceived the situation was actually happening at the hospital (actual). Scoring was by the Likert-type of response alternative from 1 to 5 with, ‘strongly disagree’ as 1 and ‘strongly agree’ as 5. The arithmetic sum of question A constituted the total score of ideal role conception, and question B the score of actual role conception. By subtracting the actual score from the ideal score, a difference score yielded the role discrepancy score. Positive role discrepancy scores indicated that the situation was perceived as not existing to the extent that the respondent thought that it should. Negative scores indicated that the perceived situation existed to a greater extent than the respondent thought that it should. Pieta11 established the reliability of the three subscales by test-retest and computation of Cronbach’s alpha. The content validity was determined by a panel of nurse experts with experience in teaching nursing and administration. Only
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situations that were selected at least 75% of the time were retained. Since some of the hypothetical situations related to the professional and bureaucratic scales mentioned in Pieta’s instrument are not applicable in Hong Kong, the instrument used for this study was modified by the author, based on her experience. Only those situations relevant to Hong Kong were selected and additional situations were developed resulting in a total of 23 situations. The validity of the instrument was tested again, based on Kramer’s15 ‘known group’ method. As predicted, the results showed a significant difference between the members of the nursing faculty and the administrators, with the former scoring highest on the professional scale and the latter highest on the bureaucratic. The Cronbach reliability coefficient for each role conception scale of the revised instrument for the present study was also computed.

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

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

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

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

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Role conception and ethical behaviour of student nurses in Hong Kong 107 Table 2 Means (M) and standard deviations (SD) of discrepancy role conception between certificate and degree students Group n Role conception Professional discrepancy Certificate Degree 140 81 M 5.50 8.58 SD 3.95 5.01 Bureaucratic discrepancy M –2.23 –4.49 SD 4.57 4.62 Service discrepancy M 6.78 8.45 SD 4.44 5.73

Table 3 Multiple stepwise regression with ethical score as criterion variable and role conceptions as predictors Criterion Certificate Ideal ethical score Predictors R R2 0.03 0.07 0.10 0.17 0.14 Change in R2 β –0.15 * 0.18 * 0.36 *** 0.42 *** 0.37 **

Ideal bureaucratic 0.18 Ideal service 0.25 Actual ethical score Actual service 0.31 0.42 0.37

0.03

Degree Ideal ethical score Ideal professional Actual ethical score Actual service *p < 0.05; **p < 0.01; ***p < 0.001.

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

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Table 4 Multiple stepwise regression with ethical score as criterion variable and discrepancy role conceptions as predictors Criterion Certificate Ideal ethical score Actual ethical score Degree Ideal ethical score Actual ethical score **p < 0.01. results showed that, for the certificate students, higher discrepancies in bureaucratic and service role conceptions led to lower ideal and actual ethical decisionmaking. For the degree students, higher discrepancy in professional role conception was related to lower actual ethical decision-making. In summary, a relationship between ethical scores and role conception types was observed. Among the three role conception types, the ideal professional role conception was found to be the best predictor for the ideal ethical score, and actual service role conception for the actual ethical score. A total of 14% of the variance in students’ ethical decision-making was accounted for by the actual service role conception. The discrepancy in bureaucratic and professional role conceptions was found to have a negative effect on ethical decision-making. However, given the low predictive strength of the role relationship on ethical decision-making ability, the findings of this study need to be viewed as suggestive rather than definitive. Predictors (discrepancy) Bureaucratic Service Professional Professional Bureaucratic R R2 Change in R2 β

0.27 0.22 0.28 0.25 0.37

0.08 0.05 0.08 0.07 0.14

–0.17 ** –0.22 ** –0.18 ** –0.25 ** –0.33 **

0.07

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

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Role conception and ethical behaviour of student nurses in Hong Kong 109 about the need to accomplish all routine work in order to be considered useful) had the highest agreed scores (75%). Item 4B (the need to carry out hospital routine for promotion) and item 14 (the need to finish routine work within a set time) had the second highest score (65%). These responses seem to confirm the assertion that the hospital routine was given prime importance by the degree students in the actual setting. The degree students had significantly higher discrepancy scores in all the three role conception types when compared with their certificate counterparts. The positive discrepancy scores revealed that the actual practice did not meet the nurses’ expectations whereas the negative discrepancy scores indicated that the role was practiced to a greater extent than they expected it should be. This result was consistent with that of Corwin and Taves’9 and Pieta’s11 studies on role conception. The significantly lower discrepancy role score in the certificate students could be accounted for by the early organizational socialization experienced by these students. As the certificate students were left to work independently much of the time, adhering to the organization rules and regulations and expecting them to work according to known norms were considered the most efficient and safest ways for them to practise. In fact, they had been socialized to submit to service needs and accepted it as a necessary part of their early training. Moreover, by being affiliated to the same hospital throughout their training and being part of the hospital work-force, certificate students were more likely to be involved in decisions about patient care than their degree counterparts. This might lead to less conflict in their perception of the actual practice. For the degree students, the frequent rotations to various clinical sites at different hospitals throughout the programme may prevent them from becoming acquainted with dissimilar ward practices in patient care, resulting in greater variance in their perceptions of the actual practice of patient care.

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

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

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

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Kramer M. Reality shock: why nurses leave nursing. St Louis, MO: Mosby, 1974. Brim OG. Socialization throughout the life cycle. In: Brim OG, Wheeler ES eds. Socialization after childhood: two essays. New York: Wiley, 1966: 3–49. Nord R, Fagermoen MS. The new graduate [Abstract]. Proceedings of the 9th Meeting of European Nurse-Researchers. August, Helsinki, 1986. Murray L, Morris D. Professional autonomy among senior nursing students in diploma, associate degree, and baccalaureate nursing programs. Nurs Res 1982; 31: 311–13. Frederickson K, Mayer GG. Problem solving skill: what effects does education have? Am J Nurs 1977; 77: 1167–69. Pardue SF. Decision-making skills and critical thinking ability among associate degree, diploma, baccalaureate and master’s-prepared nurses. J Nurs Educ 1987; 26: 354–61. Langston RA. Comparative effects of baccalaureate and associate degree educational programmes on the professional socialization of nursing students. In: Chaska N ed. The nurs ing profession: turning points. St Louis, MO: Mosby, 1990: 53–58. Corwin RG. The professional employee: a study of conflict in the nursing role. Am J Sociol 1961; 66: 604–15. Corwin RG, Taves MJ. Some concomitants: bureaucratic and professional conceptions of the nurse role. Nurs Res 1962; 11: 223–27. Davis CK. Anticipatory socialization: its effect on role-conceptions, role-deprivations and adaptive role-strategies of graduating student nurses in selected associate degree and baccalaureate degree programs. Dissert Abstr Int 1972; 33: 4358B (University Microfilms, no. 73–7715). Pieta BA. A comparison of role conceptions among nursing students and faculty from associate degree, baccalaureate degree, and diploma nursing programs and head nurses [Dissertation]. New York: State University of New York, 1976. Lengacher CA, Keller R. Comparison of role conception and role deprivation in LPN-transition students and traditional students in a specially designed associated program. J Nurs Educ 1992; 31: 79–84. Yung HH. Role conception and role discrepancy: a comparison between hospital-based and degree nursing students in Hong Kong. J Adv Nurs 1996; 23:184–91. Ketefian S. Professional and bureaucratic role conceptions and moral behaviour among nurses. Nurs Res 1985; 34: 248–53. Kramer M. Some effects of exposure to employing bureaucracies on the role conception and role deprivations of neophyte collegiate nurses [Dissertation]. Ann Arbor, MI: Stanford University, 1966 (University Microfilms, no. 66–14 683). Kramer M. Role model, role conceptions and role deprivation. Nurs Res 1968; 17: 115–20. Holly GM. Staff nurses’ participation in ethical decision making: a descriptive study of selected situational variables [Abstract]. Dissert Abstr Int 1986; 47: 2372B. Swider SM, McElmurry BJ, Yarling RR. Ethical decision making in a bureaucratic context by senior nursing students. Nurs Res 1985; 34: 108–12. Bevis MR. Role conception and continuing learning activities of neophyte collegiate nurses [Dissertation]. Chicago, IL: The University of Chicago, 1971. Corwin RG. Role conception and mobility aspiration: a study in the formation and transformation of bureaucratic, professional and humanitarian nursing identities [Dissertation]. Ann Arbor, MI: University of Minnesota, 1960 (University Microfilms, no. 60–3505). Ketefian S. Moral reasoning and moral behaviour. Nurs Res 1981; 30: 171–76. American Nurses’ Association. Code for nurses with interpretive statements. Kansas City, KA: American Nurses’ Association, 1976. Rest JR. Development in judging moral issues. Minneapolis, MN: University of Minnesota Press, 1979. Oddi LF, Cassidy VR. The JAND as a measure of nurses’ perception of moral behavior. Int J Nurs Stud 1994; 31: 37–47. Ketefian S. Moral reasoning and ethical practice in nursing: measurement issues. Nurs Clin North Am 1989; 24: 509–21.

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Appendix 1
Sample question from the Nursing Role Conception instrument
For the situation listed below, indicate both: A. The extent to which you think the situation should be the ideal for nursing; B. The extent to which you think the situation actually exists in the hospital. Strongly Agree Undecided Disagree Strongly agree disagree 1. A registered nurse tries to put into practice his or her standards and ideals about good nursing, even if they are in conflict with the hospital rules and procedures. A. Do you think this is what registered nurses should do? B. Do you think this is what registered nurses actually do when the occasion arises?

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

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Role conception and ethical behaviour of student nurses in Hong Kong 113 For each of the actions below, check yes or no: for column A (whether she should take this action or not); and for column B (whether she is realistically likely to take this action or not). Nursing actions A. Nurse X should do: Yes 1. Ask for an additional prescription for antacid to cover the gastrointestinal distress. 2. Forget the whole matter; this battle is not as important as some others with which Nurse X is involved. 3. Talk to the Director of Nursing and ask her to intervene; Nurse X tells her director that, if the medicine problem is not corrected, she will report the physician to the Medical Society. *Developed by and copyright of Shake Ketefian, University of Michigan (used with permission). No B. Nurse X is realistically likely to do: Yes No

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