Nursing at its Best: Competent and Caring

Abstract

An award-winning journalist spoke to a group of students during their first month in a baccalaureate nursing program, challenging the nursing profession to abandon its image of nurses as angels and promote an image of nurses as competent professionals who are both knowledgeable and caring. This presentation elicited an unanticipated level of emotion, primarily anger, on the part of the students. This unexpected reaction prompted faculty to explore the students’ motivations for entering the nursing profession and their perceptions of the relative importance of competence and caring in nursing. The authors begin this article by reviewing the literature related to motivations for selecting a profession and the contributions of competence and caring to nursing care. Next they describe their survey method and analysis and report their findings regarding student motivations and perceptions of competence and caring in nursing. Emerging themes for motivation reflected nursing values, especially altruism, and coincided with students’ beliefs of self-efficacy and goal attainment. Student responses indicated their understanding of the need for competence and revealed idealistic perceptions of caring. The authors conclude with a discussion of these themes and recommendations for student recruitment, curricular emphasis, and future research in this area.

Citation: Rhodes, M., Morris, A., Lazenby, R. (February 25, 2011) "Nursing at its Best: Competent and Caring" OJIN: The Online Journal of Issues in Nursing Vol. 16 No. 2.

DOI: 10.3912/OJIN.Vol16No02PPT01

Keywords: nursing profession, nursing shortage, competence, caring, motivation, image of nursing, nursing education, altruism, nursing values, self-efficacy, nursing student recruitment

The image of nursing is changing. Images of angels in starched skirts and nursing caps eagerly awaiting guidance from physicians has long since been replaced by images of competent, independent men and women of diverse backgrounds. Yet iconic images in nursing may continue to play a role in choosing a career. For example, individuals may choose nursing because they identify with certain nursing role models, such as Florence Nightingale, the lady with the lamp, who cared for soldiers in the Crimean War and changed the status of nurses in the 19th century. Newer images, such as those of competent and caring nurses, can also attract new members to the profession. This study explored students’ motivation(s) for entering nursing and perceptions of the importance of competence and caring in nursing.

They took offense that a ‘non-nurse’ had the audacity to say that nurses should consider relinquishing the image of “angels in white” and demand recognition for their work. An award-winning journalist spoke to a group of students during their first month of a baccalaureate program at a southeastern school of nursing in the United States (US). These students were junior level in college and beginning their nursing courses. Faculty selected this speaker with the goal of increasing both student awareness of iconic and current images associated with nursing and student recognition that nursing is a cognitively challenging discipline. The faculty wanted the students to gain an informed consumer’s perspective on the importance of nurses and to create their own personal philosophies of nursing. The speaker, who was not a nurse, focused on the importance of making the public aware of both the competencies (knowledge and skill) of registered nurses (RNs) and the caring component of nursing. She emphasized the essential work of nurses, and noted that the public remains less familiar with the competencies needed by today’s nurses than with the angelic image of nurses who put the needs of others before those of their own health and careers. Students responded with an unanticipated degree of emotion, primarily anger. Some students verbalized that nursing is a ‘calling.’ They took offense that a ‘non-nurse’ had the audacity to say that nurses should consider relinquishing the image of “angels in white” and demand recognition for their work.

Faculty feared that the students did not have a clear understanding of, or appreciation for, the knowledge required by a professional nurse. Student comments regarding the presentation suggested to the faculty that many of the students believed the most important attribute for a nurse was the ability to provide compassionate care. Faculty feared that the students did not have a clear understanding of, or appreciation for, the knowledge required by a professional nurse. In response three faculty members who worked closely with these first semester nursing students decided to explore the source(s) of student comments and reactions. They began planning an investigation of students’ motivations for seeking careers as nurses and students’ perceptions and assumptions related to nurse competence and caring in nursing. They decided to ask the following questions:

What is the stated primary motivation of students for entering the nursing profession? What are student perceptions and assumptions regarding competence in nursing? What are student perceptions and assumptions regarding caring in nursing?

Review of Related Literature

Gordon (2005) described the historical, stereotypical (iconic) view of the nurse as that of a physician’s handmaiden, dependent on the physician for direction. She explained that the nursing profession has been negligent in sharing with the public the importance of nurses’ critical thinking, problem-solving, and research skills. Nurses have failed to help the public understand that nurses’ actions involve more than nurturing; they also include assessing, surveying for risks, identifying client goals, planning independent actions, and prioritizing care. Gordon (2006) has stated that in order to gain and maintain the respect of the public and other healthcare professionals, nurses must emphasize and communicate the knowledge and skills required for professional nursing. It is also imperative that those responsible for reimbursement of nursing care understand that nurses “save lives, prevent complications, prevent suffering, and save money” (para. 5). O’Mara (1999) has argued that in order to assure reimbursement and access to needed resources nurses need to articulate the cognitive abilities nurses need in order to provide competent care. Benner, Sutphen, Leonard, and Day (2010), too, have written that nurses must learn to emphasize the tangible benefits of nurses, beyond that of caring. In the remainder of this literature review we will look at motivations for choosing nursing as a career and review the literature identifying the need for both competence and caring skills in nursing.

Motivation

According to Locke and Latham (2002), personal goals are vital for direction and maintenance of behaviors that help to achieve future rewards. Effective goal setting can be a source of motivation as an individual pursues a career. The social cognitive career theory (SCCT) has postulated that self-efficacy beliefs and outcome expectations are key motivators for career selection. Individuals who are confident of goals, who believe in their ability to reach their goals, and who believe that goal attainment will lead to a successful career are able to complete the tasks required to achieve their goals (Lent, Brown, & Hackett, 1994).

In a systematic review of literature related to career choices of gifted and talented students, Miller and Cummings (2009) identified one career motivator as the perception of a fit between a career and one’s personal self-concept. Miller and Cummings found career choices to be based on the belief that an individual possesses the necessary traits to be successful. They also found that career choices were influenced by family members, specifically mothers. These gifted students preferred careers that were prestigious and required higher levels of education. Hoke (2006) observed that to recruit talented students, the nursing profession must educate the public regarding the high level of critical thinking required for nurses and the potential for nurses to impact global problems.

Emmons (1999) approached career choices from a strivings perspective in which goals are assessed based on what the individual is striving to achieve. The list of possible goals is then assessed for the impact of specific motives on the person’s choice of goals. Other motivating factors for career choices may be based on spiritual beliefs, feelings of being ‘called’ into a specific area, and materialistic desires (Dik, Sargent, & Steger, 2009).

Competence

The U.S. Institute of Medicine (IOM) (2003) mandated increased attention to factors that promote quality and safety of patient care. Since this mandate was issued, outcomes of patient care have become increasingly important. In response, Cronenwett et al. (2007) have proposed that “statements of the knowledge, skills, and attitudes (KSAs) for each competency … should be developed during prelicensure nursing education” (p. 122). Competencies identified by the IOM and addressed by the Quality and Safety Education for Nurses (QSEN) now include patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics (Cronenwett et al., 2007; IOM, 2003).

Caring

The American Association of Colleges of Nursing (1998, 2008) and the National League for Nursing (2007) have identified caring as a foundational value for nursing. Shultz (2009) has described attempts in nursing education to guide progression from a personal identification as a caring person to a professional ‘identity of caring.’ Benner (2000), Benner, Tanner, and Chelsa (2009), and Benner and Wrubel (1989) have proposed that caring is a requisite for the development of critical thinking. Stowe (2006) investigated educational strategies in nursing education that were designed to promote understanding of caring as an abstract concept and concluded that nursing education’s efforts to “impact a more consciously caring individual for our society is invaluable” (pp. 127-128).

The above insights support Purnell’s (2009) conclusion that caring includes themes of struggle, discovery, hope, humility, and spirituality (p. 115). Falk-Rafael (1996) proposed that caring in nursing has evolved from an ordered (or required) caring (associated with characteristics such as nurturing), to an assimilated caring (as nursing developed into an autonomous profession), and then further evolved to an empowered caring (as individual nurses realized nursing interactions support caring connections) within an interprofessional healthcare delivery system that has an ever-changing power base. Falk-Rafael suggested that empowered caring is informed by both knowledge and experience.

Study Survey and Analysis

After receiving approval from the Auburn University at Montgomery Institutional Review Board, one member of the research team met, less than one week after the presentation, with the 78 students who had heard the presentation. These students had completed the first month of their baccalaureate nursing curriculum, but had not yet started their clinical experience. Students were currently enrolled in nursing concepts, pathology, nursing skills, and physical assessment courses. The faculty member explained that the student reaction to the recent speaker had been noted by the faculty who sensed that the students did not wish to relinquish their angelic image of nurses because they identified with the image of the nurse as a caring person. She added that the faculty desired to further study and understand the students’ motivation for entering a nursing program, their reactions to the presentation, and their perceptions of the importance of caring and competency in providing patient care. Students were invited to participate voluntarily in the study and assured of anonymity; informed consents were obtained. The surveys were completed individually in the classroom.

Participating nursing students were asked to write answers to the following three open-ended questions as they appeared on the questionnaire:

What was your primary motivation for entering the profession of nursing? In what way is competence important in the role of the professional nurse and how can this best be explained to non-nurses? Fully explain your answers with examples and specifics. In what way is caring important in the role of the professional nurse and how can this best be explained to non-nurses? Fully explain your answer with examples and specifics.

Seventy-four of the 78 junior level students responded to the survey. This included 62 (84%) female and 12 (16%) male respondents. In terms of ethnicity, 54 (73%) of the responders were Caucasian, 15 (20%) African American, 1 (1.4%) Mexican American, 1 (1.4%) Hispanic, 1, (1.4%) Filipino, and 2 (2.8%) were described as ‘other.’

Ages ranged from 19 to 48 years of age with 1 student (1%) being 19 years old, 14 students (19%) being 20 years of age; 23 students (31%) being 21-year-olds, 22 students (30%) ranging from 22 - 29 years of age, and 13 students (18%) being 30 - 48 years old. One student did not provide an age.

Surveys were transcribed by typing the responses onto an Excel spreadsheet; copies were distributed among the three faculty members (authors) for independent content analysis of student comments. The researchers analyzed the data using a deductive form of content analysis. As a deductive process, data analysis began with previously accepted theory (Glaser & Strauss, 1967). In this study, the question topics of motivation, caring, and competence, which are pivotal to nursing, constituted the foci for this data analysis and were used in the coding process. After researchers each conducted an independent content analysis considering the question topics, they met and determined categories of responses within the three question topic areas; these categories included motivation, competence, and caring. After the second independent analysis, faculty collectively identified emerging themes from the categorized data (see Table). For example, one category of responses included “intellectual challenge,” “love of science,” and “interest in human body." This category of responses was described as the ‘intellectual’ theme. Individual comments often met criteria for multiple themes within a single category, e.g. under Motivation, comments may have addressed both Altruism and Attractiveness of profession. In these cases the researchers included the comments under all appropriate themes. Additionally, a numerical count of the frequency with which the categories of responses occurred was conducted, determining the most prevalent themes as presented in the Findings section

Findings

Motivation

Among the 74 respondents, Altruism was identified as the most dominant theme. Students identified themselves as caring individuals. One stated, “I have a caring heart.” Several students specifically stated that they wished to help children or others “in need.” Some addressed the vulnerability of individuals and their wish to contribute to society; others identified global health needs.

Second in prevalence was Attractiveness of the nursing profession. In this theme, job security, flexibility, work conditions, and professional status were identified. Job flexibility included work schedule, the variety of options in nursing, and the ability to change jobs within a facility or throughout the country. Autonomy of practice and interaction with people were also identified as attractors. Several commented that nursing, rather than medicine, attracted them because they perceived nursing involved greater interaction with people.

In addition, students identified Background knowledge of the nursing profession as a motivator, explaining that family members who were nurses or who worked as healthcare team members gave them some understanding of what nursing is about. Others developed either positive or negative impressions of nursing as a result of personal or family illnesses. One respondent described that caring for grandparents “even being young” provided the motivation to choose nursing as a career.

Within the Spirituality theme, five respondents referenced God as their motivation for nursing. One participant stated, “I was blessed with a gentle heart, I need to share His blessing…be His instrument.” Others indicated that nursing was their “calling from God” or “purpose.” One student added that nursing would allow participation in medical mission trips.

Researchers identified the Intellectual theme from student responses indicating it would be intellectually challenging to gain nursing knowledge and skill proficiency. Several stated the human body was “fascinating” or that they had always been interested in the science of human anatomy. Some combined their interest in both science and caring for people.

The Fulfill personal needs theme emerged as students expressed the need to help others in such a way that the researchers perceived students’ self-need as greater than an expressed altruistic intention. “I want to have a rewarding [career] …need human contact” and “I would always have a job and always be needed” were examples of self-need. Others described themselves as caring people and expressed a desire for fulfillment of their dreams or goals.

Competence

Students overwhelmingly acknowledged Intelligence as a major factor in nursing competence. Three distinct areas describing Intelligence included saving lives, understanding disease processes and preventing mistakes, and patient surveillance. Students depicted saving lives in comments such as “knowledge saves lives.” Fifteen students used the words “life or death” in describing the importance of competence in nursing. Respondents acknowledged that nursing “mistakes can be fatal” indicating that knowledge is required to prevent untoward patient outcomes. Students explained the importance of Intelligence regarding patient surveillance in explaining that nurses “make assessments” and “use the knowledge and expertise for a positive outcome.” Several stated “critical thinking” was required to “make decisions” and “provide care.”

Eight respondents addressed the need for competence with regard to Skills. Several added the need to understand or use their critical thinking abilities to “perform skills and tasks well.” Two included the need for documenting patient care “accurately." Some remarked that competence was “required to be professional;” others stated that nurses need to be accountable for their competence, both in “practicing skills” and “maintaining currency.”

Students responded with contrasting themes regarding Self as it refers to competence. Several responded “with competence comes confidence,” indicating that once a nurse was competent in critical thinking, clinical judgment, and performing skills, the nurse would become confident. Others responded that experience and confidence preceded competence. Two suggested that competence is required for success in effectively providing care as well as success in one’s career.

The final theme in this category involved being Other focused. Students identified competence as prerequisite to establishing trust with others. One wrote that competence is important because “it makes patients want you to take care of them.” Another student stated “patients and health professionals trust competent nurses.” Still others discussed the role of competence in the ability to understand holistic care, adding, for example that competence “addresses patients holistically - in all dimensions.”

Caring

Altruism and attractiveness of the profession were identified as primary motivations for seeking nursing as a career. Over two-thirds expressed caring as an essential Nursing characteristic. Many described caring as “essential,” “the most important trait,” “central to nursing,” or “critical to the role.” Some provided perspectives from those receiving care: “non-caring [nurses] will give a negative persona,” a caring nurse can cause patients “not to be scared,” and the absence of care “will affect patients psychologically, emotionally and physically.” Others indicated that caring separated nursing from other professions and is essential for providing holistic care, writing for example, “must care to give patients the best possible care.” Other comments included “without caring…not a nurse” and “even if no one else cares, nurses do.”

Students identified caring as a motivation to be competent so as to promote positive Outcomes for patients. They noted that caring increases competence, ensuring nurses will properly assess patients and perform skills. Other responses included:

Without caring, you will not do your best. This will impact the dedication of nurses to provide holistic care. One willing to teach, listen while giving competent care. Caring also was considered necessary to “prevent complications” by “checking the patient” as often as needed and “performing skills that may be unpleasant.”

Regarding the theme Connection and Trust, students described the importance of caring in establishing the nurse-patient relationship from both the nurse and patient perspectives. Caring is “essential in developing the trust in the nurse-patient relationship,” a “patient [is] more likely to interact and communicate with a caring nurse,” “allows clients to understand their self-worth,” and “a nurse connects and develops relationships” by caring. Comments indicated that caring leads to trust which results in a positive impact for the patient. Responses included comments, such as “patients will most likely trust and relax/reduce anxiety” and “once a positive relationship [has developed, the nurse] can focus on health promotion of the client.” Additionally, students addressed potential problems if caring were absent, noting that the nurse “might be competent but not show any compassion or care to your patient. This builds a wall ….then your patient will not open up to you….This could interrupt a nurse’s assessment of a patient.”

...these students freely explained why they chose nursing as their profession. Students also indicated Giving of self was an important measure of nurses’ caring. One student defined caring as “the unselfish extension of one’s self.” Another stated that a nurse who does not care about anything but her/himself will not be concerned for a patient. Several students discussed going “the extra mile” to “help in any way possible.” Others described a more angelic perception of nurses’ caring, noting that nurses care for a client or family of a client “because you do so willingly, without hesitation,” and “a nurse who cares will do what needs to be done to provide the best care for her patient.”

Valuing another was described by students as showing “concern” for patients’ well-being and “empathy” towards others. One explained that caring was an “attitude toward others” and “clients need to feel that nurses care….It seems to be one of the easiest skills of nursing….Just being with someone can show that you care and respect and want to understand their situation.” Others added the following responses:

[Caring] “helps a patient feel better” [Caring] is important when the nurse has to provide unfavorable information. By taking a few extra minutes, we can give our patients a feeling of importance Additionally, one student wrote, “I believe nurses are the number one most trusted profession because of their ability to care for each patient.” In summary, these students freely explained why they chose nursing as their profession. They also identified the need for both competence and caring on the part of the nurse.

Discussion

[Students] especially noted the importance of intelligence for making sound patient care decisions. Students’ descriptions of their motivation for entering the nursing profession and their perceptions and assumptions related to nurse competence and caring both support previous research and provide implications for recruiting and retaining students in nursing education programs. Altruism and attractiveness of the profession were identified as primary motivations for seeking nursing as a career. Students demonstrated an understanding that nurse competence and caring are both essential for safe and quality patient care. Most identified caring as an essential quality of nurses. They especially noted the importance of intelligence for making sound patient care decisions and the benefits of valuing another, connection and trust, and giving of self as important ways of demonstrating care to patients. In this section themes will be discussed in the order of prevalence from student responses.

Motivation

To attract new nurses into the field nursing needs to be perceived as a financially secure career. In this study students identified Altruism, i.e., making a difference for others, as motivation for a nursing career. This finding supports the work of Cook, Gilmer, and Bess (2003) who also reported that the beginning nursing students they studied identified their desire to help others as a major reason for choosing nursing as a career. It also supports the social cognitive career theory (SCCT) premise of self-efficacy, i.e., ability to make a difference, as a career motivator (Lent, Brown, and Hackett; 1994).

The finding that Attractiveness of the nursing profession influenced the choice of nursing as a career supports the SCCT construct postulating that people will continue in a task as long as doing so has value to them. To attract new nurses into the field nursing needs to be perceived as a financially secure career. In the late 1980s and early 1990s nursing was not seen as desirable career because it lacked adequate long-term compensation and a clear career pathway (Bonawit, 1989; Champion, Austin, & Tzeng, 1987; Fagin & Maraldo, 1988; Lumby & Zetler, 1990; Meleis, 1991). Participants in this study repeatedly stated that the flexibility and job security were major factors motivating them to choose nursing as a career.

Participants in this study repeatedly stated that the flexibility and job security were major factors motivating them to choose nursing as a career. Background in nursing was another strong motivator for these nursing students. This finding supports the work of Hoke (2006) who identified that one’s perception of a given field influences interest in the field as a career, and the work of Beck (2000) who reported that one of the top eight reasons nursing was chosen as a career was because of prior work or volunteer efforts in the healthcare field.

Dik, Sargent, and Steger (2009) also found that ideas related to Spirituality or a ‘calling’ were strong motivators for selecting a career. More research is needed to better understand the nature of this individualistic motivator of career choices.

The perceived Intellectual nature of nursing motivated some students to enroll in the nursing program. The perceived Intellectual nature of nursing motivated some students to enroll in the nursing program. Miller and Cummings (2009) reported that gifted and talented students preferred careers that were prestigious and required higher levels of education. Hoke (2006) recommended that nursing better educate the public as to the high levels of critical thinking required in nursing and the potential nursing has to impact global problems. A greater understanding of this motivator may well attract more students into nursing.

Our finding of the motivating power of Personal needs were similar to those of Buddeberg-Fischer, Klaghofer, Abel, and Buddeberg (2006) who reported career choices to be based on personality traits, career motivation, and life goals. Beck (2000) also reported that love of helping others and the desire for a fulfilling profession led students into the study of nursing.

Competence

Although this cohort of students became agitated when the angelic image of nursing was questioned, their responses clearly indicated their belief that competence was at least as important as caring. Hoke (2006) posits that nursing could recruit more young people if the image of nursing was that of an intellectually challenging profession rather than that of a feminine and angelic profession. Within only weeks of beginning their nursing courses, the responses of these students touched on the three areas of competence addressed by the Quality and Safety Education for Nurses (QSEN) initiative (Cronenwett, et al, 2007), namely, knowledge, skills, and attitudes.

We identified four major themes within the Competence category: Intelligence, Skill/Tasks, Self, and Other focused. Students indicated that nurses must think critically so as to make appropriate assessments and promote positive patient outcomes. They noted that self-awareness was important because competence and confidence coexist. Students also addressed competence as a requirement for effective interactions with other healthcare professionals and for providing holistic care for patients. The competency outcomes performance assessment (COPA) model outlines eight essential competency categories for teaching nursing competencies to pre-licensure students: assessment and intervention skills, communication, critical thinking skills, human caring/relationship skills, teaching skills, management skills, leadership skills, and knowledge integration skills (Lenburg, Klein, Abdur-Rahman, Spencer, & Boyer, 2009). Students in their first semester of nursing education remarked on all of the eight categories except management and leadership in their responses regarding nursing competence. The fact that they did not address management and leadership is not surprising given their status as beginning students. We were surprised and pleased that these new students identified the majority of competencies recognized as essential by QSEN and the COPA models.

Caring

...nursing curricula can translate the desire to care into motivation for competence. Findings from this research supported Purnell’s (2009) identified themes of struggle, discovery, hope, humility, and spirituality. Students identified caring as the essential quality, the essential Nursing characteristic, of nurses and as the focus of all nursing actions. Student statements conveyed struggle in the potential for causing harm if caring was absent. Discovery, hope, humility, and spirituality were represented in nursing interactions with patients and the development of the relationships between nurses and patients that are required for effective nursing care. Findings also supported Falk-Rafael’s 1996 discussion of caring and power in nursing as described above. Falk-Rafael proposed that caring in nursing has evolved from a required caring to an assimilated caring, and then further developed to empowered caring within the interprofessional healthcare delivery system, suggesting that empowered caring is informed by knowledge and experience.

Student descriptions regarding the theme Connection & trust supported and further informed challenges inherent in communicating within professional boundaries while building a relationship. Hart (2010) stated that professional boundaries dictate professional behavior and include “issues of self-disclosure…the use of touch, and the overall manner of relating to the patient” (p. 92). Students recognized the challenge of developing therapeutic communication with patients that would promote effective nursing care.

Student responses within the theme Giving of self sustain Roach’s premise that caring is a criterion of humanness that can give meaning to one’s life. The students’ responses support Roach’s conceptualization of caring as “the locus of all attributes used to describe nursing” (2002, p. 39). The most frequently mentioned theme was caring as the essential quality of nurses.

Responses from the Valuing another theme revealed students’ respect for patients as foundational for using their critical thinking skills and serving as a client advocate. These responses support the IOM’s recommendation for patient-centered care in which the critical thinking of nurses, patients, and families merge to provide the best care for a given individual (Rubenfeld & Scheffer, 2010).

Limitations

Limitations of this study include the small sample size and conducting the study at a single school of nursing in only one location. One factor that may have influenced new nursing students to respond as they did is that the overwhelming majority of the student population was comprised of traditional, southern students active in their Christian churches. Another factor is that although students had not yet started their clinical experiences, they had already explored concepts of caring and communication, roles of professional nurses within the healthcare delivery system, and the importance of critical thinking for clinical judgment. Also the reaction to the speaker may have galvanized students’ idealistic views of nursing caring as well as increased their thinking about nursing competence. If this study is to be replicated, we would advise that the survey be given before any classes begin and before students are challenged with thinking about the image of the nursing profession.

Implications and Recommendations

In short, nursing is a very marketable profession – we all need to talk loudly about the value of a career in nursing. Students shared that they entered a nursing program because they valued a career involving altruism, making a difference, intellectual challenges, goal attainment, job security, and flexibility. Nursing needs to present itself, early and often, as a profession that offers these opportunities. Practicing nurses can share these job characteristics with children and young people as they talk with them about career options. Recruiters for nursing programs are encouraged to highlight these opportunities as they meet with potential nursing students. In short, nursing is a very marketable profession – we all need to talk loudly about the value of a career in nursing.

The findings from this study also have implications for the curriculum in nursing education programs. The findings in this study indicate that students do indeed understand the need for competence in practice. Nursing curricula can capitalize on the motivation of students to engage in intellectual challenges and become competent nurses. This suggests that nursing programs should design courses that stimulate and stretch students’ cognitive abilities.

...nursing programs should design courses that stimulate and stretch students’ cognitive abilities. Nursing students often hold idealistic perceptions of caring. Curricula design should lead students to understand that caring “stimulates critical thinking” (Zimmerman & Phillips, 2000) and is foundational in the development of competencies that will lead to better client outcomes. This research suggests that nursing curricula can translate the desire to care into motivation for competence.

Deliberate use of dissonance to promote critical thinking and reflection can be used to focus on specific concepts so as to promote transformative learning (Forbes & Hickey, 2009). Students in this study noted that while the speaker challenged their image of nurses, the experience prompted them to review their assumptions about caring and personal identity as future nurses, thus contributing to their professional transformation.

Further research to identify effective teaching strategies to promote both competence and caring in nursing will assist faculty to retain students and maintain the balance of competence and caring in nursing. A research study is already being planned to follow this cohort of students and identify their values and beliefs about nursing at the time of their graduation to determine in what ways their educational experiences may have changed their perceptions of competence and caring. Researching experienced nurses’ insights regarding competence and caring as well as reviewing their motivations for entering and remaining in the nursing profession may offer strategies that will help nursing managers improve nurse retention. Additional research should include replication of this study in associate degree and diploma pre-licensure nursing programs, registered nurse to baccalaureate programs, and baccalaureate programs in other regions of the United States.

Conclusion

The image of nurses as ‘competent and intelligent caregivers’ must become as well known as the image of nurses as ‘angels in white’ so as to attract qualified individuals to the nursing profession. This study explained how a speaker created cognitive dissonance within students that was resolved when students intentionally considered their assumptions about nursing in a reflective self-assessment that led to their growth in professional identity. The findings of this study suggest that although these students did not wish to relinquish the image of nurses as angelic care givers, they saw considerable value in promoting the image of nurses as competent and intelligent caregivers. The image of nurses as ‘competent and intelligent caregivers’ must become as well known as the image of nurses as ‘angels in white’ so as to attract qualified individuals to the nursing profession. Competence and caring are interrelated. These traits need to be developed in students and sustained in nurses to recruit nurses into the profession and move nursing forward as a profession that truly makes a difference in patient outcomes.

Letter to the Editor

by Avila

Author

Marilyn K. Rhodes, EdD, MSN, RN, CNM

E-mail: mrhodes2@aum.edu

Dr. Rhodes is an Assistant Professor at Auburn University Montgomery School of Nursing in Montgomery, AL. She has taught baccalaureate nursing students for over six years and held midwifery faculty and clinical appointments since 1982. She retired at the rank of Colonel from the United States Air Force Nurse Corps after 30 years of service. Dr. Rhodes earned a BSN at Spalding University, Louisville, KY, and an MSN with a Certificate in Midwifery from the University of KY, Lexington, KY. After nearly twenty years of midwifery, she began teaching as a clinical adjunct and returned to school to obtain an EdD in Leadership Education from her alma mater, Spalding University.

Arlene H. Morris, EdD, MSN, RN, CNE

E-mail: amorris@aum.edu

Dr. Morris is an Associate Professor at Auburn University Montgomery School of Nursing in Montgomery, AL. She has taught baccalaureate and RN to BSN students for the past 18 years. Dr. Morris, a Certified Nurse Educator, teaches a variety of courses and especially enjoys teaching professional nursing issues and gerontology. She was awarded the Distinguished Teaching Award from Auburn Montgomery. Dr. Morris graduated with her BSN from Harding University in Searcy, AR, and with her MSN from Troy University in Troy, AL. She received her EdD from Auburn University in Auburn, AL.

Ramona Browder Lazenby, EdD, RN, FNP-BC, CNE

E-mail: rlazenby@aum.edu

Dr. Lazenby is the Associate Dean and Professor at Auburn University Montgomery School of Nursing. She has taught nearly every course in the baccalaureate and graduate nursing programs and is a certified registered nurse practitioner with the university nursing care center and outreach programs. Dr. Lazenby has been awarded the Distinguished Teaching Award from Auburn Montgomery and is a Certified Nurse Educator. She received her BSN from the University of Alabama (Birmingham); her MSN from Troy University in Montgomery, AL; her Family Nurse Practitioner Certificate from the University of Alabama (Birmingham), and her EdD from Auburn University, Auburn, AL.

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TABLE QUESTION TOPICS CATEGORIES OF RESPONSES THEMES MOTIVATION



Love of people

Being needed Altruism Job security

Job flexibility

Professional goal

Appreciation for the profession Attractiveness Experiences with nurses or health care system

Family members nurses Background God Spirituality Intellectual challenge

Love of science

Interest in human body Intellectual Fulfill personal need Fulfill personal need COMPETENCE Life or death

Can hurt or kill someone

Knowledge & critical thinking

Anticipate potential problems or outcomes Intelligence Skill / Tasks Skill / Tasks Confidence

Self awareness Self Establish trust

Holistically Other focused CARING Innate quality

Requirement / essential

Perceived characteristic of nursing

Passion Nursing characteristics Motivation to be competent Outcomes Builds / establishes trust

Connection Connection & trust Angelic / servant; do what it takes Giving of self Valuing another Valuing another

© 2011 OJIN: The Online Journal of Issues in Nursing

Article published February 25, 2011