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The influence of nursing curriculum in associate degree nursing programs on the development of nursing professionalism in graduating nursing students

Author: Cristina M. Riter
Nursing professionalism is assumed to develop during the educational process, with the model of the baccalaureate degree program. There have been few studies on the development of professionalism in beginning nursing students, especially those in a two-year associate degree nursing program. This research study explored the concept of professional development in reaction to the increased number of associate degree registered nurses in this country since the inception of the associate degree nursing programs in the 1950s. The impact of the registered nursing shortage on the nursing profession and the educational preparedness of future registered nurses was also explored. The research question, "How does nursing curriculum impact the development of professionalism in associate degree nursing programs?" was explored. This qualitative study is a descriptive cross sectional study with a linear frame model examining the relationship between educational content captured and the development of nursing professionalism.

Table of Contents Chapter One: Introduction-----------------------------------------------------------------------------1 Significance of the study----------------------------------------------------------------------2 Professional Traits in Nursing-------------------------------------------------------2 Statement of Problem--------------------------------------------------------------------------3 Lack of Standardized Education in Nursing---------------------------------------4 Current Nursing Shortage------------------------------------------------------------6 Minority Shortages within Nursing-------------------------------------------------9 Nursing Organizations---------------------------------------------------------------15 Research question-----------------------------------------------------------------------------17 Chapter Two: Review of the Literature-------------------------------------------------------------19 Conceptual Framework-----------------------------------------------------------------------19 Theoretical Underpinnings-------------------------------------------------------------------23 Historical Development----------------------------------------------------------------------25 Development of Nursing Curriculum-------------------------------------------------------31 Context of Nursing Professionalism--------------------------------------------------------35 Implications for Nursing Education---------------------------------------------------------39 Chapter Three: Methods-------------------------------------------------------------------------------54 Introduction-------------------------------------------------------------------------------------54 Research Methodology -----------------------------------------------------------------------55 Sample: Nursing Students-----------------------------------------------------------55 Sample: Registered Nurses----------------------------------------------------------56 Sample: Nurse Educators------------------------------------------------------------58 Procedure------------------------------------------------------------------------------58

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Design of Study------------------------------------------------------------------------------59 Limitations-------------------------------------------------------------------------------------60 Chapter Four: Surveys---------------------------------------------------------------------------------62 Introduction-------------------------------------------------------------------------------------62 Results-------------------------------------------------------------------------------------------63 Chapter Five: Interviews------------------------------------------------------------------------------74 Introduction-------------------------------------------------------------------------------------74 Results-------------------------------------------------------------------------------------------74 Chapter Six: Focus Group------------------------------------------------------------------------------95 Introduction--------------------------------------------------------------------------------------95 Results--------------------------------------------------------------------------------------------96 Chapter Seven: Findings-------------------------------------------------------------------------------106 Conclusion--------------------------------------------------------------------------------------106 Triangulation of Data--------------------------------------------------------------------------108 Recommendations within Current Reality--------------------------------------------------110 Recommendations within Future Reality---------------------------------------------------111 Recommendations for Future Research-----------------------------------------------------114 References-----------------------------------------------------------------------------------------------115 Appendix-------------------------------------------------------------------------------------------------122

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Chapter I Introduction The development of nursing professionalism will be explored throughout this dissertation. The historical establishment of nursing, nursing research, and nursing professionalism will be discussed in this chapter. The impact of nursing shortages on nursing education will be explored for the effect on the body of nursing as it is today. The impact on the non-white registered nurses and male registered nurses by nursing organizations and nursing education will be discussed. The creation of the two-year associate degree registered nurses will be researched and the evidence of the changes for the body of nursing, including both positive and negative views, will be presented. This chapter will discuss nursing professionalism in relation to nursing curriculum and establish the importance of nursing curriculum on the development of nursing professionalism in graduating nursing students. The current three different entry level educational programs for registered nurses will be explored and strengths and weaknesses of each program will be presented. The history of nursing practice as it is intertwined with the history of nursing shortages will be discussed. What is nursing? The answer has been in contention since the 19 th century and the fact that it is still a question in the current 21 st century gives an indication of the scope of the problem. History supports that it is difficult for nursing to define itself; the outside forces that have shaped the definition of nursing and the role of the nurse and the internal struggles within the nursing body itself have strongly influenced the identity of nursing. Florence Nightingale, the historically credited first nursing theorist, probably did not realize that she was foreshadowing the problem of nursing identity when she stated in Notes on Nursing in 1860, “I use the word nursing for want of a better” (p. 8). What educational requirements are necessary to become a

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registered nurse? There are major inconsistencies between the educational levels of a three-year diploma nursing graduate who has no college credit, a two-year associate degree nursing graduate, a four-year baccalaureate degree nursing graduate, a six-year master degree nursing graduate and a doctorate-level nursing degree graduate; all are essentially the same as registered nurses, as long as they pass the national registered nurse licensure examination. As nursing continues to define itself as a profession, it is in question at what entry level educational preparation nursing professionalism is developed. The purpose of this study is to investigate the influence of nursing curriculum in associate degree nursing programs on the development of nursing professionalism in the graduating nursing students. The determination of that factor can have implications within nursing as nursing continues to develop into a profession with a self directed identity. Significance of the study The value of nursing research is conceived to generate new knowledge to contribute to the practice of nursing, specifically what the profession of nursing has defined as professionalism. The creation of a specific body of knowledge and the application of those findings into practice is a determining characteristic that guides the profession of nursing (Catalano, 2006). Catalano (2006) lists the professional traits associated with nursing are accepted in the field as: High intellectual level; High level of individual responsibility and accountability; Specialized body of knowledge; Knowledge that can be learned in institutions of higher education; Public service and altruistic activities; Public service valued over financial gain; Relatively high degree of autonomy and independence of practice; Need for a well

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organized and strong organization representing the members of the profession and controlling quality of practice; A code of ethics that guides the members of the profession in their practice; Strong professional identity and commitment to the development of the profession; and Demonstration of professional competency and possession of a legally recognized license (p. 5). Nursing studies are guided by strict guidelines in an effort to generate unbiased and trustworthy responses to nursing practice questions. Research is established to contribute to the professional status of nursing (Houser, 2008). There remains a serious schism between the generation of health promotion and prevention knowledge in nursing and application into practice. Researchers perceive this as a failing of nursing education in promoting research in this area, signifying the importance and power of nursing research (Pender, Murdaugh & Parsons, 2002) to nursing. Nursing practice is based upon nursing knowledge which is generated and disseminated through literature, application into practice and further research. Nursing is considered a younger profession with disciplined investigative practitioners who contribute to the body of knowledge. Research is not problem solving but applicable to the profession as a whole. The National Institute for Nursing Research promotes this scholarly activity with financial support and establishment of research priorities (Houser, 2008). It is essential to bring nursing research into nursing education so the students learn to read, understand and apply research. More importantly is the development of the concept of understanding that nursing research is an activity that graduates will be able to do as registered nurses. Evidence-based practice establishes interventions guided by the knowledge gained through nursing research; the research has a direct impact on the quality of patient care (Catalano, 2006). This research study is

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a scholarly activity investigating the influence of nursing curriculum on the development of nursing professionalism in graduating nursing students. I hope to impact nursing education to positively affect the professional concept of registered nurses, translating into a higher level of nursing care provided. Nursing professionalism was designed in the 1950s using sociological theories and the accepted ideals of society, such as the American Nurses Association’s focus on professionalism with a code of ethics, which reflected the social manners and morals of the times. Three of the seventeen tenets are that the Golden Rule should guide the nurse in professional relationships; the nurses in personal life should adhere to the standard of ethics determined by the professional role of the nurse; and the personal actions of the nurse should be congruent with the community norms and expected behaviors in the society in which they live and work (Hein, 2001). It is the professional traits of a body that differentiate the role as professional worker from that of a technical laborer. Registered Nursing is a profession based upon having the following characteristics: authoritative control of its own work and an exclusive body of knowledge, extended period of education and self regulation, specialized competence and control over work performance, credentialing method to determine competence and legal enforcement of the professional standards defined by the body, ethical practice and intrinsic rewards, existence of collegial subcultures such as professional organizations, and public acceptance. A major problem with professionalism in nursing is the lack of a standardized education for entry level into the role of the registered nurse. The nursing body and allied health professionals voice the question of why the entry level into nursing is so much lower than the admission requirements into other health care professions. The controversy surrounds the skill level of a nurse versus the knowledge base. Should nursing be a vocational trade instead of a profession? Will nursing fail

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to maintain the strides that they have gained in establishing nursing as a profession? Nursing has the designation of being the least educated for entry level requirements than any of the other health care professions (Huston, 2010). This problem is compounded because it is then transferred into all aspects of registered nursing education (Hood, 2010) with diploma nursing program graduates, associate degree nursing program graduates, and baccalaureate nursing program graduates all prepared and eligible to take the national licensure examination for licensure as a registered nurse. Nursing professionalism is assumed to develop during the educational process, yet where in the educational process that nursing professionalism actually develops. This is further complicated by the variation in entry education levels within nursing. A study examining the socialization of diploma school nursing students, associate degree nursing students, and baccalaureate degree nursing students (Alutto, Hrebiniak & Alonso, 1972) found that the ideology of nursing professionalism is expected to transfer across the diverse groups of education, gender and ethnicity; yet it does not. The study discovered that graduates had different role expectations dependent upon their educational degree and this affected the concept of nursing professionalism. Haase (1990) states that the declaration of the American Nurses Association that the baccalaureate degree become the minimal educational foundation for professional registered nurses resulted in disharmony among nursing educators of different nursing program types, such as diploma and associate degree. All nursing education programs have the responsibility to assist students in developing professional identity, which is essential for professional nursing practice. The nursing programs should include a variety of experiences, including didactic and clinical. It is important to assess beginning student nurses’ definitions of nursing and develop curriculum to enhance professional identity for the student. Curriculum should be developed to introduce information related to professional identity development, such

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as ethics, communication, and cultural competence (Cook, Gilmer, & Bess, 2003). The established professional traits for nursing can then be translated into curriculum which promotes professional behaviors. With over forty percent of the current registered nurse population from associate degree program educational levels (Joel, 2003), the increasing popularity of the associate degree nursing programs is evidence of the importance of establishing professional behavior among the graduates. The essential professional knowledge and behaviors, including skills, values, and attitudes, are the responsibility of the nursing faculty and should be formally taught to the nursing students (Fetzer, 2003). The multidimensional problem to the educational process for registered nurses involves nursing shortages and it is further complicated by these shortages. Current Nursing Shortage The current shortage of registered nurses has forced nursing education to examine how nursing curriculum addresses the development of nursing professionalism in the graduates. For most of us, we see changes in health care, such as the nursing shortage, as a personal experience in an individualized way before realizing that the problem is more widespread. This experience can be personal when a health care crisis is realized by a family member or a friend; it does not have to be self realized for it to be traumatic. Many patients in medical settings have experienced the shortage of registered nurses. The predictions for the intensity of registered nursing shortages estimate 200,000-500,000 in this country with serious concerns of catastrophic nursing shortages realized in 2010-2030. The shortage of registered nurses is higher in areas of nursing that involve direct patient care, such as hospitals, rehabilitation centers, nursing homes, and hospices. Shortages of registered nurses are also noted in home care and schools, and there is great concern in the shortage of nursing faculty within this country (Gordon, 2005). Although the recruitment

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and incentives promoted for registered nurses by healthcare facilities, particularly hospitals, give the impression that nursing care is highly valued and the registered nurse providers of that valued care are respected professionals. It would appear to be beneficial to a nurse as an individual and to nursing as a body, but nursing shortages have been detrimental to nursing overall. The shortage cycle increases the overall salary, benefits and recognition for nurses which in turn results with an increased enrollment in nursing programs across the country. When there is no longer a nursing shortage, the overall salary and benefits become more fixed. Although these shortages occur over many years, the overall effect on nursing salary and benefits is that nursing salaries will level off and stay the same for a decade, resulting in below average compensation for nurses (Pinkerton, 2001). Nursing shortages are largely regional phenomena and are closely attached to economic conditions, as the economic status decreases, enrollment in higher education increases. There is an increased demand for nurses that does not fluctuate with the financial rating of the nation and that is the increasingly older population and the healthcare needs that accompany age. This is added to the aging population of registered nurses taking retirements at a time in history when there are increasing numbers of adults needing nursing care. Healthcare facilities experiencing budget cuts have often reduced the number of nurses and have discovered that it has a long term result disastrous to the quality of healthcare (Catalano, 2006). Hospitals, rehabilitation centers, nursing homes, and hospices that involve more direct patient care result in a visible change to the patient and patient family in the patient to nurse ratio. Home care and schools are also areas in which a decrease in the time the nurse spends with patient and students make the shortage more visible. Nursing faculty shortages are visible in the college classrooms. The continued predictions for a registered nursing shortage in this country

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within the next 20 years raise serious concerns of just how far reaching the effects will be (Gordon, 2005). Impact of Past Nursing Shortages on Nursing Education The educational preparation for registered nurses can be accomplished through a variety of programs such as diploma programs, associate degree (AD) programs, and baccalaureate degree in nursing (BSN) programs. The historical diploma nursing programs were established in the hospitals during the early nineteenth century and provided no formal, higher education preparation for nursing but trained young, unmarried women in the apprenticeship type of schooling (Joel, 2003). The diploma programs were encouraged to educate and provide registered nurses in response to the growth of hospitals in the early 20 th century. The medical advances during this time in history, such as new drug therapies, longer life expectancies and the establishment of health insurance all resulted into more patients needing nursing care. Criticism of the diploma schools included that the nursing students were being used as an inexpensive source of labor (Malka, 2007). The associate degree programs were developed in response to the severe nursing shortages after World War II and were valued because the registered nurse could gain the education they needed in a two year period, as opposed to the three years necessary for the diploma nurse (Malka, 2007). Mildred Montag created the newest form of registered nurse education, the associate degree nursing program, in 1951 as a result of planned research and controlled experimentation for her doctorate dissertation. The education preparation in the associate programs is usually done at a community college level, but is not restricted to that format. The student must complete general educational and science course requirements. The associate degree attracts a diverse student population of older students, married students, and minorities (Zerwekh & Claborn, 2006). The educational process of the baccalaureate degree

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programs in the historical scope of nursing education was started with the first autonomous college of nursing at Yale School of Nursing in 1923. The nursing student who meets the general education, science and major subject requirements of a four year program attains a full academic degree of baccalaureate in science nursing degree (Catalano, 2006). The focus in the 1970s was to move the learning experience of the baccalaureate prepared nursing students from the hospital focus to the community because nursing leaders believed that nurses would never gain autonomy and independence unless they removed the nursing students from the domain of the physicians, which was the hospital itself (Malka, 2007). Regardless of the educational path, each nursing school graduate of a recognized nursing program is eligible to take the National Council Licensing Examination for Registered Nurses (NCLEX-RN) for licensure as a registered nurse (Zerwekh & Claborn, 2006). Minority Shortages within Nursing Male Minority. The presence of men as nurses, although few in number, are recorded before World War II; it may be society’s view of the powerlessness of females and roles associated with females that prevented many males from desiring to join the nursing ranks. The male nurses graduated from all male colleges and were not accepted into the American Nursing Association until after World War II (Joel, 2003). The influence of feminism on the role of the nurse has strongly shaped the essence of the registered nurse. During the eighteenth century efforts to have nursing established and recognized, the medical establishment would allow nurses to function as long as the role was understood to be a role of caretaker and mother. The nurses were to be the social, educational, and economical equals of the patients and not the higher level physicians (Gardner, 2005). The perception that nursing remains a female profession may be forced to change, if the

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continued rate of increased numbers of male nursing students continues. The surprising problem with the male registered nurses is that they are leaving the profession faster than their female counterpart, yet another factor in the development of an increasing shortage of registered nurses. The role of a male as inappropriate to provide care is an underlying perception in society. Bell-Scriber (2008) explored the experience of the male nursing student and discussed factors outside the college experience included lack of support for the male student in nursing, being questioned and teased about why a man would want to become a nurse and the unfamiliarity of being with women as classmates and coworkers. The nurse educators in this study were female as were all references to nurses within the textbook causing the male nursing student to see the closely tied association of female and nursing. Bell-Scriber (2008) found that female nursing educators communicated messages that were negative such as looks, gestures, tone of voice and inference which resulted in the male nursing student questioning their worth and their dedication to nursing. The McMillan, Morgan and Ament (2006) study exploring if female registered nurses accept male registered nurses was conducted in a large Midwestern state in America, including rural and urban areas. The study found that the rural group of registered nurses most often had associate degrees and the urban group of registered nurses predominately has baccalaureate degrees. Regardless of the educational preparation or age of the female registered nurse, the strongest determinant of acceptance by a female nurse of a male in the role of registered nurse was the amount of time the female nurse worked with the male nurse. The longer the female registered nurse worked with the male registered nurse, the more likely the female nurses were to accept the male nurses in the role of registered nurse (McMillan, Morgan & Ament, 2006).

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The following quote is the perception of a male registered nurse working in a rural health model on the impact of his gender in nursing school and now in nursing practice. He is a 2007 diploma level nursing school graduate from a nursing school in the same geographical area as the hospital in which he works. He came into nursing after working in an industrial setting for five years. When he lost his job due to downsizing, he decided to follow his dream of working in healthcare. I have noticed a lot of difference, male to female, especially in nursing school. I am not outgoing or the life of the party and I did feel treated differently in nursing school. The other students included me in things but I felt more of a loner. Now in nursing as a whole, things are a 100% turnaround. I get along with everyone. I do, though, see how men are used more for lifting and things, but patient assignment equality is given. I don’t get bad or good patients over others. Some female nurses are more willing to help and lend a hand now as opposed to nursing school. I don’t feel that I am treated any differently from the higher up personnel than women are. Now days I feel we are more accepted into the field than before and I have even heard the ladies say, what did we do before men came around? Ironic, isn’t it, in the age of liberation, we are needed and wanted more than before. The perceptions of 489 male registered nurses were investigated to determine why so few men join the ranks of registered nurse (Hart, 2005). Men revealed that they choose nursing because of a desire to help others, the multiple career paths of nursing, and the availability of steady job opportunities. The self concept of being a male nurse was identified as awkward in almost half of the respondents. Barriers to men becoming nurses were listed as the traditional female role of nursing, public perception that male nurses are gay and lack of role models.

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Nursing school difficulties were feelings of being in the minority, being used for physical strength in the clinical setting, and being thought of as uncaring. The investigators state that the male nurses expressed passion and caring in talking about nursing and communicated the positive feeling of making a difference in the life of another as rewarding in nursing (Hart, 2005). African American Minority African American females were able to break the prejudice barriers against their race to become registered nurses, but it was very difficult for black women to become nurses. The National Association of Colored Graduate Nurses (NACGN) was formed in 1908 and focused to combat discriminatory practices. The American Nurses Association had a nondiscrimination policy but required that nurses must graduate from a state supported school to become a member and many states were discriminatory, so there was round-about discrimination policy preventing black nurses from becoming American Nurses Association members (Joel, 2003). Nursing continues to lack in racial and ethnical diversity. Minority populations are underrepresented with only 12% of registered nurses nationally identifying themselves as being a racial or ethnic minority in the year 2000 in which 31% of the general population described themselves as being a racial or ethnic minority (Gardner, 2005). The American Association of Colleges of Nursing (AACN) has encouraged all nursing programs to actively recruit and retain more minority students with the stressed importance of minority role modeling. The failure of minority students in nursing programs has been attributed to feelings of isolation, distancing, discrimination and cultural ignorance on the part of faculty and students. Each nursing program should institute strategies for minority retention in their schools (Gardner, 2005).

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In Colman’s study (2008), the perceptions of African American nursing students enrolled in a predominately white two-year institution were explored in a qualitative pilot study in a community college in a suburb of Chicago, Illinois. The themes of difference, coping and survival, support systems, and institutional context were used to reveal the existence and influence of the saliency of race. The study found that minority students perceived that nonminority students and faculty responded to them differently based upon their physical appearance and behaviors. The African American students felt that the reality of a lack of support and failure of acceptance pushed the African American student to develop and use coping strategies, using overt and covert behavior strategies. This situation resulted in another impediment to the development of relationships with nonminority students and educators. The lack of support felt by the minority students was attributed to nonminority classmates, nursing faculty, and college environment. The African American nursing students also expressed the feeling that colleges are unwelcoming and lacking in cultural and racial sensitivity (Coleman, 2008). The power of nursing faculty in providing support is demonstrated in a formation of a minority nursing support group; at an area community college, there is a support group for African American nursing students which meets about three times each semester with an African American registered nurse graduate of an associate degree nursing program who serves as the facilitator for the meetings. Recently, when asked if any of the students would like to record their perceptions of what the group means to them, a second-year female African American nursing student expressed this view. She writes: For me having the opportunity to have a chance to meet with others from my same race and share our experiences in this program really helped with my success

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thus far. When I began, I walked into a class of 40 plus persons and I stood as the one and only Black American and to which in some degree made me feel uncomfortable and out of place and to be able to speak with someone who stood where I stood and may have experienced the same feeling that I felt; really it was supportive and gave me to some degree more confidence to keep up with the program. It really helps me to also feel as if someone is looking deeper into what makes another person succeed beyond just curriculum and grades but to also try and see what further influences does a person have on the success not only in school but life as well. And it really appealed to me that when people care and dig deeper beyond surface measures it can have a profound effect on a person’s outcome. Literature clearly documents a failure on the part of nursing education to meet the needs of the minority population. In a current nursing education study in California, community college statistics reveal a higher first time pass rate on National Council Licensure Examination for Registered Nurses (NCLEX-RN) for colleges with lowest numbers of minority students, child care programs, tutoring or remediation studies and an absence of any learning resource center (Seago & Spetz, 2005). This study suggests that the curriculum and teaching strategies available fail to meet the educational needs of minority students. Minority students have diverse learning needs which differ from the dominate Eurocentric perspective in such areas as multiple choice testing formats, the structure test question on the National Council Licensure Examination for Registered Nurses (Giddens, 2009). A research study looking at barriers and facilitators which affect further education by African American registered nurses that are baccalaureate degree nursing program graduates or current baccalaureate degree nursing students was recently completed in a Midwestern region of

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the country. The 75 question survey was mailed to 33 eligible nurses and 19 questionnaires were returned to the researcher. Barriers and facilitators of academia, finance, aspiration, and institution were explored. Results of the study determined that many inner city schools did not adequately prepare the African American students for success in college; African American students were not guided into college preparation classes and were not well informed about nursing programs and degrees. The surveys of a majority of subjects said that they did not receive encouragement from high school counselors and administrators. Respondents in an overwhelming majority stated that parents expected them to attend college and a large majority reported family members who attended college. Institutional barriers were a lack of faculty support, yet the majority felt that there was some support and nurturing within the nursing program by both faculty and students (Mingo, 2008). The failure of providing information to college-bound high school students about nursing programs has decreased the number of potential registered nurses and is yet another example of factors contributing to a registered nursing shortage in this country. Within the national nursing shortage subcategory of African American registered nurses, this failure of providing information to college-bound high school students that are African American likely has done immeasurable damage to decrease the numbers of potential registered nurses within the African American population. Nursing Organizations With a Focus on Quality of Nursing Practice Nursing organizations function to empower nurses in the profession of nursing and some represent all nurses while other organizations focus on specialty nursing interests. The American Nurses Association (ANA) is represented as a nursing organization for all registered nurses and has been in existence since 1908. The American Nurses Association is concerned with legislative

Full document contains 130 pages
Abstract: Nursing professionalism is assumed to develop during the educational process, with the model of the baccalaureate degree program. There have been few studies on the development of professionalism in beginning nursing students, especially those in a two-year associate degree nursing program. This research study explored the concept of professional development in reaction to the increased number of associate degree registered nurses in this country since the inception of the associate degree nursing programs in the 1950s. The impact of the registered nursing shortage on the nursing profession and the educational preparedness of future registered nurses was also explored. The research question, "How does nursing curriculum impact the development of professionalism in associate degree nursing programs?" was explored. This qualitative study is a descriptive cross sectional study with a linear frame model examining the relationship between educational content captured and the development of nursing professionalism.