Nurse faculty and students' behavioral intentions and perceptions toward entrepreneurship in nursing
viii Table of Contents Title Page i Curriculum Vitae ii Acknowledgements iv Abstract vi Table of Contents viii List of Tables xii List of Figures xiv Chapter I: Problem and Significance 1 Problem 1 Overview of Entrepreneurship 2 Entrepreneurs in Nursing 2 Entrepreneurship Education 3 Theory of Planned Behavior 4 Entrepreneurship Education in Nursing 5 Chapter II: Perceptions Regarding Entrepreneurship in Nursing 10 Synopsis of Entrepreneurship 11 The entrepreneur 13 Nursing and Entrepreneurship 15 Need for entrepreneurship in nursing 15 Entrepreneurship Education 18 Entrepreneurship Education in Nursing 20 Perceptions of Entrepreneurship in Nursing 21
ix Overview of the literature 22 Inadequate focus on entrepreneurship 24 Research focused on entrepreneurship in nursing 27 Qualitative studies regarding entrepreneurship in nursing 33 Private practice focus 33 Traditional, social, and corporate entrepreneurship 35 Quantitative studies concerning entrepreneurship in nursing 39 Published literature reviews concerning entrepreneurship in nursing 45 Summation of entrepreneurship In nursing literature 47 Theory of Planned Behavior 49 Summation 51 Chapter III: Methods 53 Design Overview 53 Sample 54 Target Population 54 Sample Size and Power 56 Instrument 57 Survey development 57 Pilot testing of PEN survey and analysis 60 PEN survey for regional study 63 Procedures 65
X Recruitment 65 Data collection 67 I ncentive 67 Human subjects risks 68 Exempt status from RSRB 68 Waiver of consent 69 Data analysis 70 Study limitations 72 Chapter IV: Results 73 Sample 73 Recruitment and response 73 Faculty sample 74 Student sample 77 Survey response 79 Completion rate 79 Sample characteristics 84 Education level, program affiliation, & years as a nurse 85 Ethnicity, race, gender, & age 87 Descriptive Statistics 90 PEN Instrument Validation: Results of Confirmatory Factor Analysis 92 General Perceptions of Entrepreneurship in Nursing 99
xi Hypotheses and Sub-questions 103 Sub-questions (Sub-Q) 112 Chapter V: Discussion 121 Background / Purpose of Study 121 Validity and Reliability of the PEN Survey 124 Behavioral Intentions Model and Hypotheses Testing 125 Sub-questions and variance between groups 128 Relationship between years of education and sub-scales 129 SPEKand entrepreneurship behaviors 130 Role Conflict & Risk Willingness 131 Implications for Education, Practice, Research 133 Limitations 136 Conclusion 136 References 140 Appendix A PEN Survey Regional Study 149 Appendix B Recrutiment Materials 159 Appendix C Permission to Use Theory of Planned Behavior 163
xii List of Tables Table Title Page Table 1.1 Research Hypotheses and Sub-questions ,, 7 Table 2.1 Notable Nurse Entrepreneurs ,, 16 Table 2.2 Summary of Literature Search 24 Table 2.3 Research Surrounding Entrepreneurship in Nursing ....28 Table 3.1 Reviewers During Development of PEN Survey 59 Table 3.2 Pen Survey Factor Loadings 62 Table 3.3 Scale and Subscale Statistics 63 Table 3.4 Variables - PEN Survey 64 Table 3.5 Recruitment Plan 66 Table 3.6 Targeted / Planned Enrollment 70 Table 4.1 Recruitment and Response by State 84 Table 4.2 Education Level, Nursing Program Affiliation & Years as a Nurse 86 Table4.3 Ethnicity, Race, &Age 88 Table 4.4 Gender 89 Table 4.5 Dataset Means, Standard Deviations, & Measures of Symmetry 91 Table 4.6 Combined Factor Loading Averages 14-ltem 93 Table 4.7 Pilot & Study Cronbach's Alpha 95 Table 4.8 Means, & Standard Deviations (SD) for Combined, Faculty, & Students Samples 96
xiii Table 4.9 Table 4.10 Table 4.11 Table 4.12 Table 4.13 Table 4.14 Table 4.15 Table 4.16 Table 4.17 Table 4.18 Table 4.19 Table 4.20 Table 4.21 PEN Study Factor Loadings- Faculty 97 PEN Study Factor Loadings - Students 98 Role Conflict & Risk Willingness, Perceptions 100 Entrepreneurship Experiences 101 Open Ended Responses to Entrepreneurship Experiences Question 1 102 Open Ended Responses to Entrepreneurship Experiences Question 2 103 Model Results - Students 109 Model Results - Faculty 110 Model Path 95% Confidence Intervals 111 Model Fit Statistics 111 Test for Group Mean Differences between Faculty and Students 113 One-way Analysis of Variance for Relationship Between Subscales and Years of Education 115 T-test for Difference in Means on Self-Perception of Entrepreneurship Knowledge Scale (SPEK) Between Those With and Those Without Entrepreneurship Experience 119
xiv List of Figures Figure Title Page Figure 2.1 Application of TpB Applied to Entrepreneurship in Nursing 51 Figure 3.1 U.S. Census Regions and Divisions of the United States 55 Figure 4.1 Determination of Faculty Sample 76 Figure 4.2 Determination of Student Sample 78 Figure 4.3 Recruitment and Response Pattern 80 Figure4.4 Overall Completion Rates 82 Figure 4.5 Estimate Response Rates 83 Figure 4.6 Faculty and Student Age Comparisons 89 Figure 4.7 Theory of Planned Behavior Applied to Entrepreneurship in Nursing 104 Figure4.8 Theorized Model and Indicators 106 Figure 4.9 Best Fit Model 108 Figure 5.1 Behavioral Intentions Toward Entrepreneurship in Nursing (Bl-TEN) Model 126
1 Chapter I: Problem and Significance Problem Entrepreneurship has the ability to enhance economic growth, develop human capacity, and benefit communities and societies (Green, 2005). For this reason, in hopes of increasing entrepreneurial activities and behaviors, entrepreneurship education in business and other disciplines has swept college and university campuses, in the United States (US) and internationally (Kuratko, 2005; Reynolds, Carter, Gartner, Greene, & Cox, 2002). This expansion in academia is also occurring in the discipline of nursing. The exact number of entrepreneurship courses, certificate and degree programs offered in nursing is not known, but Shirey (2007a) identified four schools at major universities offering entrepreneurship content or programs to nursing students. However, based on additional schools of nursing identified by this author Shirey's findings are underestimated. Even though schools of nursing are embracing entrepreneurship curricula, empirical data on developing curricula that changes behaviors from non-entrepreneurial to entrepreneurial among nurse faculty and nursing students is absent from the literature. Consequently faculty are left without documented findings that guide nursing curricula toward facilitating entrepreneurial behaviors. Identifying factors that are associated with entrepreneurial behaviors would help strengthen curricula in entrepreneurship. Therefore, in order to construct curricula that promote behavioral change toward entrepreneurship in nursing, this study is designed
2 to explore the perceptions and behavioral intentions of nurse faculty and nursing students associated with entrepreneurial behaviors in nursing. Overview of Entrepreneurship For the purposes of this study, entrepreneurship is defined as: a creative process through which individuals accept financial risks and transform opportunities into new and innovative ideas, environments, initiatives, or products with social and/or financial benefits. The process of entrepreneurship requires recognizing opportunities, then transforming those opportunities into products or services that benefit self and others, socially and/or financially (Shane, 2003). Entrepreneurship is an extremely creative process, which Green (2005) describes as connecting creativity, dreams, and imagination by entwining them with realistic applications of economic principles that conclude in the transformation of an idea into a tangible product with social and/or financial benefits. Thus entrepreneurship allows individuals to become liberated and pursue their once intangible dreams (Green, 2005). When this process is operational, entrepreneurship provides economic and social benefit to individuals, groups, and societies. Entrepreneurs in Nursing Nursing possesses a rich and important history of nurse entrepreneurs in business, social, corporate/intrapreneurs, and academic entrepreneurship. For example, nurse entrepreneurs have elevated the position of Islamic women as nurses by working within the system of Islam (Kasule, 1998; Jan, 1986); established nursing education in countries under British influence (Palmer,
3 1984a; Palmer, 1984b); founded and operated Catholic hospitals that were financially independent of dioceses (Wall, 2002); and developed innovative biomedical devices to improve health outcomes and patient quality of life (University of Florida, College of Nursing, n.d.). According to McCline, Bhat, and Baj (2000), the profession of nursing is primed with content and contextual knowledge to create entrepreneurial initiatives. Moreover, nursing holds an advantageous position in health care, as nurses are (a) generally the primary provider for patient care twenty-four hours per day, seven days per week in acute care settings, where most errors and near misses occur, (b) concerned with individual responses and environmental influences on health, illness, disease, and death, (c) the largest group of health care professionals in the industry, and (d) capable of recognizing and critically thinking about broad perspectives of health care (leong, 2005; Manion, 1990; Roggenkamp & White, 1998). Nursing's holistic view of both the strengths and weakness in health care delivery, and direct contact with consumers' wants, needs, and concerns surrounding health care, places nursing in a position to recognize entrepreneurial opportunities that create new ventures. Entrepreneurship Education Across the nation, faculty, administrators, trustees, alumni, and community supporters of entrepreneurship are encouraging colleges and universities to develop courses, as well as undergraduate (minors and majors), and graduate programs in entrepreneurship (Katz, 2003; Kuratko, 2005). These programs are united in their objective to change participants' behavior from
4 non-entrepreneurial to engagement in entrepreneurship (Kuratko, 2005). This objective is not unique to entrepreneurship education. Behavioral change as an outcome is a premise of education, as well as the teaching-learning process (Billings &Halstead, 1998). Yet in order to strengthen curricula, determining factors associated with the desired behavior should be identified. Inherently, faculty and students participating in entrepreneurship curricula offered in business disciplines anticipate engaging in entrepreneurial behaviors as curricular outcomes. Yet in disciplines like nursing, where business and entrepreneurship are not inherent, the curricular goal of entrepreneurship education remains the same, but without data to support or repudiate factors that determine faculty and students' willingness to change from non-entrepreneurial to entrepreneurial behaviors. Since the goal of entrepreneurship education in nursing is to facilitate entrepreneurial behaviors, curricula can be enhanced to achieve this goal by assessing factors that determine nurse faculty and nursing students' behavior toward entrepreneurship. Theory of Planned Behavior A number of theories provide support for behavioral change as an outcome of education. The Theory of Planned Behavior (TpB), a psychosocial theory of behavioral change, demonstrates that behavioral intentions (Bl) (defined as the prospect of implementing the behavior of interest) directly precede human behaviors. The predictability of Bl to behavior has been confirmed in numerous studies, and more than 600 published studies have
5 used the TpB as the theoretical framework in behavioral change research (Ajzen, 1991; Ajzen & Manstead, 2007; Francis, et al, 2004). The TpB not only supports predictability of Bl toward an identified behavior, the theory describes three antecedents to Bl. These antecedents are individuals' attitudes toward the behavior (individuals' positive or negative outlook regarding the behavior), their subjective norms (the normative beliefs of the individual's sphere of influence toward initiating the behavior), and the individuals' perceived behavioral control (the control and self-confidence individuals have toward implementing the behavior) (Ajzen, 1991; Ajzen & Manstead, 2007; & Francis, et al, 2004). The three antecedents (attitude, subjective norm, and perceived behavioral control) and Bl can be assessed and scored to predict behavioral change toward the behavior of interest. The TpB recognizes the value of personal, demographic, and environmental characteristics, but classifies them as background factors that demonstrate indirect influences on attitude, subjective norm, and perceived behavioral control. (In this study education, a selected background factor, Bl and its antecedents are referenced as perceptions.) This theory provides a framework for the assessment of factors influencing behavioral intentions toward entrepreneurship in nursing among nurse faculty and nursing students. Entrepreneurship Education in Nursing Nurses' unique position to recognize entrepreneurial opportunities, combined with entrepreneurship education that is constructed from a theoretical framework of the TpB, could contribute toward resolution of the
6 multifaceted problems within today's health care system. From this perspective multiple questions are unanswered surrounding entrepreneurship education in nursing. Of special interest are the following: (a) Do nurses have favorable attitudes regarding entrepreneurship in nursing? (b) Do nurses feel supported and encouraged by peers and those they respect to engage in new entrepreneurial initiatives? (c) Do nurses feel they have control and confidence to act entrepreneurially? (d) What are nurses' intentions regarding entrepreneurial behaviors? and (e) Do nurses perceive themselves as knowledgeable regarding entrepreneurship in nursing? Research is sparse surrounding entrepreneurship in nursing, and negligible regarding entrepreneurship education in nursing and nurses' intentions to engage in entrepreneurial behaviors. Missing from the literature are explorations of the relationship between nurse faculty and students behavioral intentions and perceptions toward entrepreneurship in nursing, theoretical frameworks to guide curricula that would increase behavioral change toward entrepreneurship in nursing, and instruments that measure behavioral intentions and perceptions among nurse faculty and nursing students. In order to address the preceding questions and the identified gaps in literature, this investigation explored nurse faculty (registered nurses who work within schools of nursing) and nursing students' behavioral intentions and perceptions toward entrepreneurship in nursing. The following four hypotheses and sub-questions (Sub-Q), as outlined in Table 1.1 guided this research.
7 Table 1.1 Research Hypotheses and Sub-questions Hypotheses Sub-questions H i. Nurses demonstrating positive attitudes concerning entrepreneurship in nursing will have positive intentions to engage in entrepreneurship behaviors. H 2. Nurses demonstrating positive subjective norms concerning entrepreneurship in nursing will have positive intentions to engage in entrepreneurship behaviors. H 3. Nurses demonstrating positive perceived behavioral control concerning entrepreneurship in nursing will have positive intentions to engage in entrepreneurship behaviors. H 4. Nurses demonstrating positive self perceptions of entrepreneurship knowledge (SPEK) will have positive attitudes, subjective norms, perceived behavioral control and behavioral intentions toward entrepreneurship in nursing. Sub-Q r i How do attitudes concerning entrepreneurship in nursing vary between nursing faculty and nursing students? Sub-Q 12 What is the relationship between attitudes concerning entrepreneurship in nursing and years of education for nursing faculty and nursing students? Sub-Q 2.1 How do subjective norms concerning entrepreneurship in nursing vary between nursing faculty and nursing students? Sub-Q 22 What is the relationship between subjective norms concerning entrepreneurship in nursing and years of education for nurses? Sub-Q 31 How do perceived behavioral control concerning entrepreneurship in nursing vary between nursing faculty and nursing students? Sub-Q 3.2 What is the relationship between perceived behavioral control concerning entrepreneurship in nursing and years of education for nurses? Sub-Q 41 How do SPEK vary between nursing faculty and nursing students? Sub-Q 4.2 What is the relationship between SPEK and years of education for nurses? Sub-Q 4.3 What is the relationship between SPEK and nurses who have engaged in entrepreneurship behaviors? The aims of this study are to:
8 1. Develop and validate an instrument to assess TpB constructs tailored toward nursing entrepreneurship behavior(s); the Perceptions of Entrepreneurship in Nursing (PEN) survey; 2. Develop and empirically test a model of entrepreneurship behavior in nursing according to the Theory of Planned Behavior and the four hypotheses and corresponding sub-questions, and 3. Translate findings into recommendations for curricula pertinent to entrepreneurship education in nursing aimed at improving intentions to engage in entrepreneurship behaviors. In order to accomplish these goals a cross-sectional survey study was designed. The TpB served as the conceptual framework to guide research design, measurement, and analysis. Drawing from the TpB the Perceptions of Entrepreneurship in Nursing (PEN) survey was newly developed to measure attitudes, subjective norms, perceived behavioral control, and behavioral intentions toward entrepreneurship in nursing. The PEN survey also incorporated literature findings that assessed self-perception of entrepreneurship knowledge (SPEK) and general findings regarding role conflict, experience with entrepreneurship, hierarchical relationships, and partiality toward risk (risk willingness). The PEN survey was administered to nurse faculty and nursing students in baccalaureate and higher programs of nursing at colleges and universities from the northeastern and Atlantic states of the U.S. The PEN was pilot tested and validated with a sample of 111 nurse faculty (n=59) and nursing students (n=52) in a university setting in upstate
9 New York, through an online web based self-administered secured access system, SurveyMonkey©. This study not only fills a void in the literature but also provides the first systematic inquiry regarding behavioral intentions and perceptions of nurse faculty and nursing students toward entrepreneurship in nursing. These results provide insights for pedagogically tailoring, strengthening, and optimizing curricula that will enhance behaviors toward entrepreneurship in nursing.
10 Chapter II: Perceptions Regarding Entrepreneurship in Nursing Nationally, entrepreneurship education is emerging in elementary and secondary curricula (Consortium for Entrepreneurship Education, 2004), and on college and university campuses as cross-disciplinary courses, certificate programs, and as degree granting disciplines of study. In 2003 there were over 1,600 schools offering courses in entrepreneurship and greater than 100 centers for entrepreneurship affiliated with colleges and universities (Katz, 2003; National Consortium of Entrepreneurship Centers, 2006). By 2008 Gatewood identified greater than 2,000 postsecondary schools in the U. S. offering courses in entrepreneurship. The emphasis in entrepreneurship education is an optimistic approach to prepare communities and nations for economic vitality in the twenty-first century. This expansion has the support of faculty, administrators, and alumni constituencies, but also civic leaders, foundations, and governments interested in generating economic growth locally, nationally, and internationally (Green, 2005; Kuratko, 2005). Many disciplines traditionally viewed as "non-business" disciplines, including nursing, are embracing entrepreneurship education through classes, certificate programs, and degree granting programs (Shirey, 2007a). Entrepreneurship education is designed to raise awareness, change perceptions, and change behaviors from non-entrepreneurial to entrepreneurial (Kuratko, 2005). Changing behaviors is optimized when factors determining the behavior are known. Yet for entrepreneurship education in nursing, literature is silent regarding factors that determine behaviors (determining factors) of nurse
11 faculty and nursing students toward entrepreneurship in nursing (EIN). Without empirical data it is unclear what pedagogical and curricula concepts should be employed in developing entrepreneurship courses in nursing. The focus of this research is to identify the determinants of entrepreneurship behavior and behavioral intentions among nurse faculty and nursing students. Synopsis of Entrepreneurship Entrepreneurship refers to the academic discipline of entrepreneurship (Streeter, Jaquette, Hovis, 2002) and also to processes, functions, responsibilities, and benefits associated with creating new ventures (White & Begun, 1998; Hisrich, Peters, & Shepherd, 2005). The process of entrepreneurship is structured and systematic, involving (a) individuals' demographic and psychological attributes, (b) macro-environments and environmental factors of industry, (c) recognition of entrepreneurial opportunities that continually exist, waiting to be discovered, and (d) transformation and development of opportunities using resources, strategies, and organizational designs to create and execute new ventures (Shane, 2003). Entrepreneurship types are categorized according to interest, focus, or specialty area, i.e., family, women, minorities, international, arts, and technologies (United States Association of Small Business and Entrepreneurship, 2007); as well as four broader categories consisting of business, social, corporate entrepreneurship/intrapreneurship, and academic entrepreneurship.
12 Business entrepreneurship generally refers to proprietorship or partnership ventures (Kauffman Center for Entrepreneurial Leadership at the Ewing Marion Kauffman Foundation, 1999) capitalizing on opportunities that occurred from some form of change in which creating wealth is an outcome measurement (Dees, Haas, & Haas, 1998); while the emphasis of social entrepreneurship is creating change through a mission that generates social value as an outcome (Dees, 2001). In contrast academic entrepreneurship refers to transformation of intellectual properties into university spinoffs or companies (Shane, 2004). It also includes the development of academic programs and centers in entrepreneurship, that offer life long learning and consultation to targeted populations and communities (Kuratko, 2005; Dickerson & Nash, 1999; Streeter, et al., 2002). Corporate entrepreneurship / intrapreneurship primarily differ from business entrepreneurship by operating within an existing organization that maintains a corporate culture of entrepreneurship and innovation (Dayhoff & Moore, 2003; Mitnick & Crummette, 1987; Pinchot, 1985). Even though the terms are used interchangeably it is important to note distinctions between corporate entrepreneurship (the broad focus previously defined) and intrapreneurship (individuals within a corporation operating as a champion for renewal, innovation, and change) (D. Kelly, personal communications, May 29, 2007). For the purpose of this study, corporate entrepreneurship will refer to a category or type of entrepreneurship and intrapreneurship the individual operating as a champion for renewal, innovation, and change within an existing
13 organization. Regardless of the type of entrepreneurship category, all entrepreneurs are committed to generating a positive return on their investments, generating economic profits, creating innovative processes, and/or social enhancements. Entrepreneurship is not every small business that opens or the opening of another location, chain, or franchise store (Dees, 20011998; Drucker, 1985). Entrepreneurship is focused on novel and unique ideas (Fregetto & Fry, 2000; Solomon, 2006). The entrepreneur. Scholars agree that the word entrepreneur is derived from the French word entreprendre, which means to undertake (Drucker, 1985; Dees, 2001; Merriam-Webster's Collegiate Dictionary, 1993) and was first documented around 1800 by the French economist Jean Baptiste Say who identified the entrepreneur as moving resources from low productivity to high productivity (Drucker, 1985; Dees, 2001). According to the writings of Joseph Schumpeter, the entrepreneur creates economic change by identifying new information and opportunities that result from economic disequilibrium (Dees, 1998; Drucker, 1985; Shane, 2003). Thus an entrepreneur is one who identifies opportunity and undertakes risks to create a new venture, product, activity, or something of value (White & Begun, 1998; Hisrich, et al., 2005), but above all, entrepreneurs create change (Kirby, 2004). Carlson (1989) defined a nurse entrepreneur according to the 1986 New York State Nurses Association (NYSNA) definition as "a nurse who organizes, manages, and assumes the risk of a business with the goal of
14 making nursing more accessible to the public" (p. viii) and accepts responsibility for profits and losses. This definition is embedded in a traditional small business paradigm and reflects, for that period of time, a landmark position by the NYSNA. In contrast the International Council of Nurses (ICN) (2004) defines an entrepreneur as a nurse who accepts complete accountability "for discovering or creating unique opportunities to use personal talents, skills and energy, and who employs a strategic planning process to transfer that opportunity into a marketable service or product" (p.5). The ICN's definition embraces the concept of opportunity recognition, which aligns with the process of entrepreneurship. Finally, Australian authors Wilson and Averis (2002) describe a nurse entrepreneur as an individual "focus[ing] on the emerging health care trends in the provision of services and the need for nurturing change in nurses' employment opportunities and career expectations" (p. 17). Thus as health care trends emerge, these authors propose nurse entrepreneurs recognize and actively participate in entrepreneurial career opportunities in cutting-edge healthcare. Their definition moves beyond the individual nurse and encourages entrepreneurship in the profession of nursing. Consistent in all these definitions is the idea that entrepreneurs create change and provide new services into the economic process, regardless if it is an initiative in business, social, academic, or corporate entrepreneurship.