5 Professional Socialization of Health-Care Professionals

Through professional socialization processes, educators support learners as they gradually develop a sense of belonging to specific professional groups. Professional socialization occurs through a combination of professional education and clinical experience (Beck, 2014). In a study of Japanese nursing students, Condon & Sharts-Hopko (2010) found that professional socialization is multidimensional and includes influences from classroom experience, clinical practice, and extracurricular elements. Zarshenas et al. (2014) explored factors that affect professional socialization of nursing students and discovered that a sense of belonging and professional identity underlies successful professional socialization. More specifically, this sense of belonging develops through educational experiences and tacit knowledge; acquiring professional identity evolves in part from internal motivation and role modelling.

Professional socialization is considered a process that begins on day one of formal education programs and continues as learners graduate and enter the workforce. Peers, instructors, preceptors, mentors, and patients/clients and their families can all be socializing agents (Chitty & Black, 2011). Black (2013) emphasizes that socialization occurs through a combination of formal and informal processes (e.g., unplanned observations). She notes that, to be most effective, formal socialization in educational programs should occur through a deliberate, systematic, block-building process. Socialization occurs in part in the clinical setting, in which learning outcomes are often achieved through observation of other practitioners who demonstrate a commitment to professional values. The clinical setting is also where learners are held accountable for their actions and the outcomes of their interventions are apparent (Gaberson et al., 2014).

Studies with social work students reveal how difficult it can be to measure values and attitudes accurately (Barretti, 2004) and to understand how changes actually occur (Valutis et al., 2012; Weiss et al., 2004). In physical therapy, the professional socialization process is highly influenced by interactions with peers and faculty (Teschendorf & Nemshick, 2001). For student athletic trainers, professional socialization is effected by legitimation from socializing agents, such as patients and clinical instructors (Klossner, 2008), and by communication with practitioners (Mensch et al., 2005).

Educators who actively guide learners toward professional socialization are generally agreed to be important. Although educators might set out to assist learners in graduating fully socialized for their professions, many report feeling unprepared to fulfill this role (Clark & Holmes, 2007; O’Shea & Kelly, 2007). Furthermore, though new graduates have the competencies for licensure, concern remains about their socialization to professional practice (Gaberson et al., 2014). Feng and Tsai (2012) conclude that new graduates are often stressed when organizational and professional values clash. More specifically, they find that the organizational value of task-oriented nursing clashes with the professional value of patient-oriented nursing, resulting in distress for neophyte nurses. Clinical educators must therefore deliberately include strategies to help learners become socialized to their professions. Understanding professional identity and values provides a foundation that can help to develop these deliberate strategies.

Professional identity is a form of social identity by which members of a profession categorize and differentiate themselves from other professions (Schein, 1978). Professional identity is categorized by Wackerhausen (2009) as macro (status, privileges, duties, and self-image of the profession) and micro (tacit behavioural norms of the profession enacted by individuals). According to Enns (2014), nursing professional identity is born from values and encompasses both the individual’s sense of self as a nurse and the image of a nurse that the person projects to others. Professional socialization, in part through formal education, means that individuals are likely to identify strongly with their own professional group (Coyle et al., 2011).

Professional values, one essential element of professional socialization, are key to success as a practitioner since they provide a foundation for behaviour (Chitty & Black, 2011). Professional values are the blueprint for action for exemplary care providers (Perry, 2009a).

Values are defined by Schwartz (1994, p. 21) as “guiding principles in the life of a person that motivate action, function as standards for judging and justifying action, and that are acquired both through socialization and through the unique learning experiences.” Some research indicates that existing values can influence career choice. For example, Adams et al. (2006) propose that nursing students are guided in their career choice in part because their personal values align with those of the profession. In other words, students might begin their training programs with certain values in place that are desired by the profession. Although the values favoured by dissimilar professions can vary, Thorpe and Loo (2003) discovered that the values of altruism (a desire to help others) and personal development (a desire to develop as a person) influence the choice of nursing as a career. Fagermoen (1997, p. 439), one of the early researchers who linked values to certain professions, concluded that common core nursing values include dignity, personhood, being a fellow human, reciprocal trust, and personalization of care. Because of the likely link between values and professional identity, Adams et al. (2006) conclude that new nursing students have some professional identity prior to professional socialization (see figure 1).

One foundation of providing competent health care might be professional socialization that develops professional identity and values. Bernard et al. (2003, p. 64) state that values are the foundation of our attitudes and beliefs that “encapsulate the aspirations of individuals and societies and encompass deeply engrained standards that determine future directions and justify past actions.” Thus, professionals determine priorities, weigh options, and choose actions based on values (Bardi et al., 2009).

In linking professional identity and values, Fagermoen (1997, p. 436) concludes that “values are inherent in developing and sustaining professional identity and are expressed in . . . actions in relation to others.” Furthermore, applying core values in professional practice increases work satisfaction, which continues the cycle of value enactment (Perry, 2009a). More specifically, nurses who perceive that they provide high-quality care and make strong connections with their patients are usually very satisfied with their career choice (Perry, 2005).

Clinical educators are positioned to cultivate professional identity and selected values, leading to effective professional socialization of health-care learners. The clinical setting is rich in opportunities for educators to use learning activities and teaching strategies that achieve what are often learning outcomes from the affective domain. Methods of teaching psychomotor skills and cognitive knowledge are often more straightforward. Effective clinical educators take the challenge to reach learners on emotional and attitudinal levels. Storytelling is an effective strategy that invites students to make links among the professionals whom they hope to be, the values that they hold, and the career fulfillment that they desire.

Using arts-based teaching strategies helps students to make an emotional connection to their learning, caters to a variety of learning styles, and increases student achievement (Perry & Edwards, 2015). Arts-based approaches can stimulate creative, critical, and analytical teaching about clinical situations. Telling stories is a teaching approach rooted in the arts. It can have positive effects on teacher-learner and learner-learner rapport, interaction, and community building. Art moves individuals to look at broader concepts and ideas, encouraging them to look at multiple facets and dimensions. Learners are encouraged to move away from breaking knowledge into discrete elements for analytical assessment and from looking at learning as a checklist or assembly line of tasks. Since professional socialization is more non-concrete, it requires multilayered and complex strategies that inspire thinking broadly, deeply, and holistically.

Clinical instructors can use relevant stories about patients to trigger transformative learning. Stories can come from many sources, including the instructor’s personal repertoire of clinical experiences, published clinical stories, or students themselves. To be the most effective, storytelling should be a deliberate and guided learning activity. Stories need to be carefully selected for their relevance to the clinical situation, learners’ level, and desired value or attitude lessons. After sharing the story (either verbally or in written form), the instructor should be prepared to lead a discussion that guides learners to express their reflections and evaluate their conclusions. A summation of the learning experience will help learners to clarify and reinforce take-away concepts and ideas.

The following is an example of a story that can create emotional connections with learning. This story can be used by nursing instructors in a post-clinical face-to-face conference or an online discussion forum after a shift on a medical unit.

A year or so ago, I was working nights. My patient became increasingly restless and agitated. He had a progressive dementia and he was more disturbed than any patient I had cared for in my 25 years or more of nursing. That night, he required two-to-one nursing care.

Around 0300 hours the other nurse I was working with observed that, in spite of his verbal lashing out, he had never once cursed. She remarked that he must not have “bad” words in his normal vocabulary because usually what is in a mind comes out in confusion. The night wore on with our patient experiencing agitation, yelling and extreme restlessness. He would bite his own hands and arms and grab on to anything near him. We began to wonder if we could ever help him rest. I remember feeling helpless and hopeless.

Then I heard him repeat a series of words in a garbled fashion and recognized the words of an old hymn. I began to sing the hymn and immediately he became quiet. The change was instantaneous and profound. The other nurse was able to leave for a break while I sat beside him singing every hymn I could remember.

As long as the hymns were sung, the patient rested. (The nurse added a side note saying that it was a good thing she was a pk—a preacher’s kid—and because of this, she knew a lot of hymns). We later found out that the man had been a lay pastor, and perhaps this explained his reaction to my music.

I loved being his nurse because none of the usual text-book interventions worked. He required flexible, creative nurses who were not afraid to try the unconventional and who were willing to keep trying until we could find a way to connect with him and his needs. Large doses of artificial sedation made no difference. Somewhere in the deepest levels of this man’s mind, our presence through music and just being near touched him. It was a profound night because all my years of training and education came down to the simple singing of a song. (Perry, 2009a, p. 210)

A storytelling strategy in clinical teaching can stimulate learners to interact with their colleagues in sharing their insights and comparing their analyses. Connectedness, interrelatedness, and integration can be an outcome when arts are the foundation of teaching strategies (Eccles & Elster, 2005). As Clarke and Widdicombe (2002, p. 45) conclude, the arts as a component of teaching strategies engage students totally, “not just with pen and pencil, but also with imagination.”

Storytelling can create transformations in the way that learners think about and view the world. Mezirow (1981) defines transformational learning as critically reflecting on our assumptions and beliefs, then intentionally creating a new view of the world. He labels this “perspective transformation.” O’Sullivan (1999) emphasizes that transformative learning involves a deep shift in consciousness that changes a person’s view of her or his place in the world. Introducing educational approaches that challenge learners consciously to examine their unrecognized underlying views and assumptions can transform their views of the world. Learning approaches that challenge students to question what they believe to be true, and ultimately to interpret information more critically, can be transformative (Melrose et al., 2013).

Research supports the potential influence of transformational learning strategies on the development of values. Williams et al. (2012) describe transformational learning approaches that enhance the development of values among nursing students. Such approaches must be based on active, realistic experiences that engage students in self-directed inquiry and critical thinking. More specifically, Williams et al. report that an effective strategy for professional socialization is to have students work in small peer groups to discuss real practice scenarios. Those exposed to this learning strategy are self-directed learners and advocates for patients and their profession upon graduation.

In the clinical situation, the strategy of practice scenarios used by Williams et al. (2012) could become real scenarios within a storytelling teaching approach rather than fictitious cases. Opportunity for students to share their clinical experiences with one another and facilitated deconstruction and discussion of these scenarios in small groups or conferences, offer the potential for transformational learning. How can clinical instructors skilfully guide these discussions to optimize this potential? Before attitudinal shifts can occur, learners need to reflect critically on assumptions that they believe are true. Challenging these assumptions, at both a cognitive level and an emotional level, can be difficult, and the process of reflection is unlikely to be spontaneous. Instead, instructors must provide learners with opportunities to question their views on specific ideas or issues. Activities with no right or wrong interpretations can stimulate critical reflection.

Mezirow (1981) emphasizes the importance of providing challenges within educational processes. Teachers who challenge learners provide them with opportunities to question commonly accepted values and to reflect critically on points of view that are different from their own. Using selected photographs as an approach to storytelling can challenge learners. The photo selected must be relevant to the clinical setting and should be chosen to challenge specific values, assumptions, and attitudes that students might hold. The image can be circulated during a group learning activity, such as a post-clinical conference, to focus students’ attention and initiate discussion of reflection questions provided by the instructor. As an alternative, students can be asked to provide images that challenge their attitudes and values and make them consider alternative views. These student-generated images can also be shared and discussed as a group.

Many open educational sources offer images that can be used for educational purposes. For example, Flickr is Creative Commons licensed, and images can be downloaded and printed for educational purposes.

Merton (1949/1957/1968) introduced role modelling as the process by which medical students in his study compared themselves with a reference group. Bandura’s (1963) social learning theory furthered our understanding of how imitation and observation of others contributes to human learning. Modelling and Role Modelling (MRM) theory, developed by Erickson, Tomlin, and Swain (1983/2010), proposes that, when learners observe models, they perceive another person’s point of view, values, and framework. The results are learner growth and improvement.

Role models influence students’ values and professional identity development, and experiences with role models can facilitate transformational learning. In a study of effective role modelling in nursing education, Mokhtari Nouri et al. (2014) conclude that educators need to pay attention to personal and environmental factors. These investigators also conclude that observational learning through role modelling is especially important in clinical settings. In such settings, instructors both teach skills and demonstrate values and attitudes as learners come to reflect what they see and hear.

Helping learners to attain learning outcomes from the affective domain is challenging, but role modelling is one strategy to support attitudinal and emotional growth (Perry, 2009b). Cultivating attitudes such as compassion and caring is complex, so reaching these learning outcomes can create emotional challenges for students and instructors (Curtis, 2014). Modelling of compassionate practice by a skilled clinical instructor or preceptor is one strategy for furthering the adoption of a professional attitude and identity by health-care learners.

The following is an example of an exemplary nurse as a role model, recorded in field notes by Perry (2009a). The role model taught the nursing intervention of touch to establish connection with a patient, a skill that is challenging to teach in any way but through modelling.

She often sits on the bed next to her patients, or she stands very close to their chairs. This physical closeness seems to create an air of familiarity. It makes their relationship close very quickly. It was by touching, by holding her patient’s hand, laying a cold cloth on her forehead, and rubbing her sore back, that the nurse communicated that she cared. All that she did with touch said how much she wanted to help. (Perry, 2009a, p. 81)

Do slowly, think aloud. Model teachers facilitate emotional growth in learners by demonstrating effective interactions and interventions. Clinical educators need to embrace the reality that everything learners see their instructors do or hear them say (or not say) might influence the socialization and eventual success of graduates. This is a heavy responsibility, but it is the reality of accepting the role of clinical instructor. Instructors who choose to maximize the potential positive effects of their role modelling might deliberately slow down their actions and interventions to allow learners time to observe fully and absorb what is happening. When appropriate role models speak aloud their rationales for selected actions and interventions, they maximize the teaching potential of a situation.

The following example of a role model (exemplary nurse) demonstrates nursing interventions in such a manner.

Her patient tonight can’t talk. Each breath is a struggle. He is so afraid that the next breath just won’t be there. In his eyes I see an unmistakable look of panic. A laryngeal cancer and tracheostomy have taken his vocal cords and a tonsillar tumour has impaired his hearing. How can she let him know that she is there, that she cares? She works slowly. She doesn’t say a word. As she strokes his hair, her eyes tell him what he so desperately wants to hear: that she is with him, that she will stay, that she will watch over him. Gradually, silently, he drifts off to sleep. When we return to the med room she tells me her beliefs about the importance of the nursing intervention of silence and touch in communicating caring. (Perry, 2009a, p. 60)

Admit it when you make a mistake. No one is perfect, including clinical educators. The educator might be less than perfectly prepared mentally, physically, or intellectually to model exemplary care on some days. Learners can observe errors in judgment, responses that are less than therapeutic, or rushed interventions. Reflective educators will be aware of possible negative modelling and openly discuss their reflections with learners. Together the instructor and students should analyze the situation and develop more optimal approaches to be used in subsequent patient care situations.

Cultivate opportunities to role-model. Since role modelling is a powerful teaching tool for health-care learners, clinical instructors should seek opportunities to model specific professional values and attitudes that they want to cultivate in students. Clearly articulating these desired values and attitudes in learning outcomes can highlight points that educators will focus on modelling. For example, if students are to develop strategies for respectful communication, then role models should prepare themselves to demonstrate this and watch for opportunities to have students observe them. Follow-up with learners is important to be sure that the role modelling is effective and that students internalize the desired learning.

Use humour appropriately. Humour is seeing what is funny in everyday encounters and maintaining a lighthearted attitude (when appropriate) in potentially difficult situations (Perry, 2009b). Curtis (2014) notes that learners value an appropriate sense of humour in role models and find that it facilitates their learning. Role models who use humour effectively and appropriately help students to manage their feelings of vulnerability and maintain their emotional well-being in challenging clinical situations.

Consider using social media. Students can receive role modelling from a variety of sources. Clinical teachers are an obvious source of modelling, but other health-care professionals in the clinical environment often model positively or negatively. In negative situations, instructors need to provide learners with opportunities to discuss and interpret what they observe. Social media such as Twitter can also provide a type of modelling for learners. In one example, students sought to develop leadership skills for the clinical setting. They were invited to follow the Twitter feed of a well-known leader in their profession and to extract leadership lessons from what they read. Students were asked to write a paper translating these leadership lessons into effective leadership approaches in the clinical setting. The activity encouraged learners to seek role models from a variety of sources and to participate in higher-order learning through analysis and evaluation. Learners are motivated to engage in this activity in part because of its novelty and in part because it uses a medium with which they are familiar and comfortable.

Fully educating health-care professionals includes helping them to become socialized to their professions. Clinical educators have an important opportunity and responsibility to guide learners in developing professional values and identities as steps in the process of professional socialization. Health-care students can bring deeply seated and well-established beliefs and assumptions to their learning. Cultivating selected values and attitudes can be a challenge for educators. Formation and transformation are possible in part through approaches such as storytelling and role modelling. Clinical educators can utilize creative teaching approaches akin to transformational learning pedagogy to facilitate professional socialization in learners.

REFERENCES

• Adams, K., Hean, S., Sturgis, P., & Macleod-Clark, J. (2006). Investigating the factors influencing professional identity of first-year health and social care students. Learning in Health and Social Care, 5(2), 55–68. https://doi.org/10.1111/j.1473-6861.2006.00119.x
• Bandura, A. (1963). Social learning and personality development. Holt, Rinehart, and Winston.
• Bardi, A., Lee, J. A., Hofmann-Towfigh, N., & Soutar, G. (2009). The structure of intraindividual value change. Journal of Personality and Social Psychology, 97(5), 913–929. https://doi.org/10.1037/a0016617
• Barretti, M. (2004). What do we know about the professional socialization of our students? Journal of Social Work Education, 40(2), 255–283.
• Beck, J. W. (2014). Deconstructing student perceptions of incivility in nursing education. Journal of Management Education, 38(2), 160–191. https://doi.org/10.1177/1052562913488112
• Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for transformation. Jossey-Bass.
• Bernard, M., Maio, G., & Olson, J. (2003). The vulnerability of values to attack: Inoculation of values and value-relevant attitudes. Personality and Social Psychology Bulletin, 29, 63–75.
• Black, B. p. (2013). Professional nursing: Concepts and challenges (7th ed.). Saunders Elsevier.
• Chitty, K. K., & Black, B. p. (2011). Becoming a nurse: Professional nursing: Concepts and challenges (6th ed.). Saunders Elsevier.
• Clark, T., & Holmes, S. (2007). Fit for practice? An exploration of the development of new qualified nurses using focus groups. International Journal of Nursing Studies, 44, 1210–1220.
• Clarke, P., & Widdicombe, J. (2002). Making a new connection: Inner-city arts training program. Education Canada, 42(2), 44–45.
• Condon, E., & Sharts-Hopko, N. (2010). Socialization of Japanese nursing students. Nursing Education Perspectives, 31, 167–170.
• Coyle, J., Higgs, J., McAllister, L., & Whiteford, G. (2011). What is an interprofessional health care team anyway? In S. Kitto, J. Chesters, J. Thistelthwaite, & S. Reeves (Eds.), Sociology of interprofessional health care practice: Critical reflections and concrete solutions (pp. 39–53). Nova Science.
• Curtis, K. (2014). Learning the requirements for compassionate practice: Student vulnerability and courage. Nursing Ethics, 21(2), 210–223. https://doi.org/10.1177/0969733013478307
• Eccles, K., & Elster, A. (2005). Learning through the arts: A new school of thought? Education Canada, 45(3), 45–48.
• Enns, B. (2014). Finding my own way: Nursing identity development from layperson to new BN graduate (Unpublished master’s thesis). Athabasca University, Athabasca, AB. https://dt.athabascau.ca/jspui/bitstream/10791/37/5/Enns_Finding_my_own_way.pdf
• Erickson, H., Tomlin, E., & Swain, M. (1983/2010). Modeling and role-modeling: A theory and paradigm for nursing. Prentice-Hall.
• Fagermoen, M. S. (1997). Professional identity: Values embedded in meaningful nursing practice. Journal of Advanced Nursing, 25(3), 434–441. https://doi.org/10.1046/j.1365-2648.1997.1997025434.x
• Feng, R., & Tsai, Y. (2012). Socialisation of new graduate nurses to practising nurses. Journal of Clinical Nursing, 21(13–14), 2064–2071. https://doi.org/10.1111/j.1365-2702.2011.03992.x
• Gaberson, K. B., Oermann, M. H., & Shellenbarger, T. (2014). Clinical teaching strategies in nursing (4th ed.). Springer.
• Klossner, J. (2008). The role of legitimation in the professional socialization of second-year undergraduate athletic training students. Journal of Athletic Training, 43(4), 379–385.
• MacLellan, D., Lordly, D., & Gingras, J. (2011). Professional socialization in dietetics:A review of the literature. Canadian Journal of Dietetic Practice and Research, 72(1), 37–42.
• Melrose, S., Park, C., & Perry, B. (2013). Teaching health professionals online. Athabasca University Press. https://doi.org/10.15215/aupress/9781927356654.01
• Mensch, J., Crews, C., & Mitchell, M. (2005). Competing perspectives during organizational socialization on the role of certified athletic trainers in high school settings. Journal of Athletic Training, 40(4), 333–340.
• Merton, R. K. (1949/1957/1968). Social theory and social structure. Free Press.
• Mezirow, J. (1981). A critical theory of adult learning and education. Adult Education Quarterly, 32, 3–23.
• Mokhtari Nouri, J., Ebadi, A., Alhani, F., & Rejeh, N. (2014). Experiences of role model instructors and nursing students about facilitator factors of role-modeling process: A qualitative research. Iranian Journal of Nursing & Midwifery Research, 19(3), 248–254.
• Mooney, M. (2007). Professional socialization: The key to survival as a newly qualified nurse. International Journal of Nursing Practice, 13, 75–80.
• Nordstrom, P., Currie, G., & Meyer, S. (2018). Becoming a nurse: Student experience of transformation and professional identity. Quality Advancement in Nursing Education, 4(2), Art. 4. https://doi.org/10.17483/2368-6669.115
• O’Shea, M., & Kelly, B. (2007). The lived experiences of newly qualified nurses on clinical placement during the first six months following registration in the Republic of Ireland. Journal of Clinical Nursing, 16, 1534–1542.
• O’Sullivan, E. (1999). Transformative learning: Educational vision for the twenty-first century. University of Toronto Press. http://wiki.sugarlabs.org/images/8/8a/O%27Sullivan19xxch8.pdf
• Perry, B. (2005). Core values brought to life through stories. Nursing Standard, 20(7), 41–48.
• Perry, B. (2009a). More moments in time: Images of exemplary nursing. Athabasca University Press.
• Perry, B. (2009b). Role modeling excellence in clinical nursing practice. Nurse Education Practice, 9, 36–44.
• Perry, B., & Edwards, M. (2015). Arts-based technologies create community in online courses. In G. Veletsianos (Ed.), Emerging technologies in distance education (2nd ed., 129–152). Athabasca University Press.
• Schein, E. H. (1978). Career dynamics: Matching individual and organisational needs. Addison-Wesley.
• Schwartz, S. H. (1994). Are there universal aspects in the content and structure of values? Journal of Social Issues, 50(4), 19–45.
• Smith, F. (1992). To think: In language, learning and education. Routledge.
• Teschendorf, B., & Nemshick, M. (2001). Faculty roles in professional socialization. Journal of Physical Therapy Education, 15, 4–10.
• Thorpe, K., & Loo, R. (2003). The values profile of nursing undergraduate students: Implications for education and professional development. Journal of Nursing Education, 42(2), 83–90. https://pubmed.ncbi.nlm.nih.gov/12622336/
• Valutis, S., Rubin, D., & Bell, M. (2012). Professional socialization and social work values: Who are we teaching? Social Work Education: The International Journal, 31(8), 1046–1057. https://doi.org/10.1080/02615479.2011.610785
• Wackerhausen, S. (2009). Collaboration, professional identity and reflection across boundaries. Journal of Interprofessional Care, 23(5), 455–473.
• Weidman, J., Twale, D., & Stein, E. (2001). Socialization of graduate and professional students in higher education: A perilous passage? John Wiley & Sons.
• Weiss, I., Gal, J., & Cnaan, R. (2004). Social work education as professional socialization: A study of the impact of social work education upon students’ professional preferences. Journal of Social Service Research, 31(1), 13–31.
• Williams, B., Spiers, J., Fisk, A., Richards, L., Gibson, B., Kabotoff, W., . . .McIlwraith, D. (2012). The influence of an undergraduate problem/context based learning program on evolving professional nursing graduate practice. Nurse Education Today, 32(4), 417–421. https://doi.org/10.1016/j.nedt.2011.03.002
• Zarshenas, L., Sharif, F., Molazem, Z., Khayyer, M., Zare, N., & Ebadi, A. (2014). Professional socialization in nursing: A qualitative content analysis. Iranian Journal of Nursing & Midwifery Research, 19(4), 432–438.