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the relationship between images of nursing and person-environment fit PDF

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i THE RELATIONSHIP BETWEEN IMAGES OF NURSING AND PERSON-ENVIRONMENT FIT Miyuki Takase Submitted in total fulfilment of the requirements of the degree of Doctor of Philosophy March 2005 School of Nursing The University of Melbourne i ABSTRACT The public image of nurses has been of great concern to the nursing profession. This image views nursing as a female occupation with nurses having little power over their practice. Researchers claim that the stereotypical public image of nursing could constrain nursing practice. For instance, nursing skills may be under- utilised and the health care environment may not adequately reward nurses for their performance. There has also been a concern that the constraints arising from the stereotypical public image of nursing may adversely affect nurses’ work behaviour. Based on the Person-Environment-Occupation Model of Occupational Performance, the thesis examined how the public image of nurses could impact on nursing practice. The thesis also explored the person-environment (mis)fit in nursing, which is characterised as (in)congruence between nurses’ professional orientation (i.e., nurses’ self-image, role expectations and work values) and their actual practice (i.e., nurses’ perception of the image of nurses held by the public, and nurses’ perceptions of their actual roles and the rewards available to them in practice). In addition, the thesis investigated the factors that could moderate nurses’ perception of the person- environment fit, and how this fit could impact on their job performance and turnover intention. Currently practising Division One and Three nurses from one university and two hospitals (N = 346) in Victoria, Australia participated in the study by completing a questionnaire. Data were analysed using a series of regression analyses. In addition, six participants from the survey sample were recruited for a focus group, in which the survey results were discussed. The results showed that nurses perceived that the public viewed them more negatively than they saw themselves as professionals. The results also showed that the public image of nurses could be manifested within the health care environment in the form of a lack of professional recognition toward nurses. In other words, the lack of public understanding of nursing contributes to the person-environment misfit. Nurses’ perception of the person-environment misfit was, however, partially moderated by the level of their collective self-esteem and their area of practice. The impact of the person-environment misfit on nurses’ job performance and their intention to leave their jobs was complex. With regard to job performance, it was ii nurses’ professional orientation that guided their performance. Positive environmental characteristics also contributed to nurses’ job performance. However, when nurses perceived a lack of recognition, their professional orientation motivated them to demonstrate better performance to change the environment in a way that would correspond to their professional needs. While a lack of professional recognition stimulated nurses’ job performance, it had a greater impact on their turnover intention. When nurses perceived their public image to be poor in addition to a lack of professional recognition at work, their intention to leave their jobs tended to increase. Based on the results, three strategies to improve nurses’ job performance and nursing retention are recommended. These strategies include improving the public image of nursing, encouraging professional socialisation in nursing, and improving the characteristics of the health care environment. iii STUDENT DECLARATION This is to clarify that: (i) this thesis comprises only my original work toward the PhD except where indicated. (ii) due acknowledgement has been made in the text to all other material used. (iii) the thesis is less than 100,000 words in length, exclusive of tables, maps, bibliographies and appendices. Signature of candidate ………………………. Date ………………………. iv ACKNOWLDGEMENTS During my PhD candidature, I received invaluable support from a number of people. I would like to express my gratitude here to acknowledge their contributions to this PhD project. Firstly, I would like to thank Dr. Phillip Maude for his academic supervision as well as for the moral support he kindly provided during my candidature. His academic feedback in preparing this thesis, as well as his encouragement and smiling face, which eased my worries at every step of conducting this study, have been greatly appreciated. Secondly, I would like to thank Associate Professor Elizabeth Manias for her constructive feedback, which was always provided in a timely fashion, on my work. It was my privilege to receive continuous supervision from her during the 3 years of my candidature. Thirdly, I would like to express my gratitude to the following people and institution for their assistance in enabling the completion of this study; Professor Patricia Dunning for assisting with the preparation of the ethics application and data collection, the six nursing experts who provided feedback on the questionnaire used in this study, Associate Professor Ian Gordon and Professor Jeffery Edwards for offering their statistical advice, and The University of Melbourne for providing a Melbourne Research Scholarship. My gratitude also goes to nurses in the two hospitals and postgraduate students in the School of Nursing in the university for allocating their precious time to participating in this study. I am also greatly indebted to Ms. Elma Avdi for English support during my candidature. It was a pleasant experience to work with her in refining this thesis as well as to discuss a number of issues related to my study topic and beyond. I was fortunate to have such precious support. Finally, I would like to thank my family, who have been patiently waiting for me in Japan. It is hard to describe my appreciation to them within a short sentence. But, I would like to express my gratitude for their constant support and understanding during the conduct of this study. v TABLE OF CONTENTS ABSTRACT ............................................................................................................................................ I STUDENT DECLARATION ............................................................................................................. III ACKNOWLDGEMENTS................................................................................................................... IV TABLE OF CONTENTS......................................................................................................................V LIST OF TABLES............................................................................................................................ VIII LIST OF FIGURES............................................................................................................................. XI CHAPTER 1: INTRODUCTION .........................................................................................................1 BACKGROUND OF THE STUDY ..............................................................................................................2 The Public Image of Nurses and Nursing Stereotyping ..................................................................2 Nursing’s Advancement toward Professionalisation ......................................................................5 The Consequences of the Different Images of Nursing ...................................................................8 RESEARCH PURPOSES AND QUESTIONS ................................................................................................9 SIGNIFICANCE OF THE THESIS.............................................................................................................10 DEFINITIONS OF TERMS ......................................................................................................................12 ORGANISATION OF THE THESIS...........................................................................................................15 CHAPTER 2: CONCEPTUAL MODEL ...........................................................................................16 INTRODUCTION...................................................................................................................................16 THE PEO MODEL ...............................................................................................................................17 Rationale for Adopting the PEO Model ........................................................................................17 The Person-Environment-Occupation Model of Occupational Performance ...............................18 IMPROVING THE PEO MODEL.............................................................................................................26 Overview of the Nursing Universe Model .....................................................................................27 Psychological Environment of Individuals ...................................................................................33 REVISED PEO MODEL FOR NURSING..................................................................................................35 PEO within the Nursing Universe.................................................................................................35 The PEO Relationship in Nursing.................................................................................................38 Psychological Environment: Moderating the Misfit .....................................................................39 The Outcomes of the (Mis)Fit .......................................................................................................39 SUMMARY ..........................................................................................................................................41 CHAPTER 3: LITERATURE REVIEW ...........................................................................................43 INTRODUCTION...................................................................................................................................43 PUBLIC IMAGE OF NURSES - INFLUENCE ON NURSING PRACTICE .......................................................43 The Public’s Perception of the Image of Nurses...........................................................................44 Nurses’ Perception of the Public Image .......................................................................................48 The Influence of the Public image of Nurses on Nursing Practice ...............................................49 THE NURSING PROFESSION AND NURSES ...........................................................................................52 Nurses’ Self-Concept ....................................................................................................................52 Impact of Professional Self-concept on Nurses Orientations toward their Roles and Work Values ......................................................................................................................................................56 THE PEO FIT IN NURSING ..................................................................................................................59 Research on Nursing Role Misfit ..................................................................................................59 Research on Nursing Value-Supply Misfit ....................................................................................63 Influential Factors on the Perception/Interpretation of the PEO Fit............................................68 THE IMPACT OF THE PEO FIT ON OCCUPATIONAL PERFORMANCE .....................................................75 Antecedents of Job Performance and Turnover Intention.............................................................76 Effect of Fit/Misfit on Job Performance........................................................................................79 The Effect of Fit/Misfit on Turnover Intention ..............................................................................86 SUMMARY ..........................................................................................................................................93 CHAPTER 4: STUDY HYPOTHESES..............................................................................................95 INTRODUCTION...................................................................................................................................95 HYPOTHESISED RELATIONSHIPS BETWEEN THE IMAGE OF NURSES AND NURSING PRACTICE ............95 vi HYPOTHESISED RELATIONSHIPS BETWEEN INDIVIDUAL DIFFERENCES AND THE PERCEPTION/INTERPRETATION OF THE PEO FIT .................................................................................99 HYPOTHESISED EFFECT OF THE PEO MISFIT ON JOB PERFORMANCE AND TURNOVER INTENTION...103 SUMMARY ........................................................................................................................................105 CHAPTER 5: METHODS OF INVESTIGATION.........................................................................106 INTRODUCTION.................................................................................................................................106 METHODS OF QUANTITATIVE STUDY ...............................................................................................106 Study Design ...............................................................................................................................106 Sample.........................................................................................................................................107 Data Collection Instruments .......................................................................................................108 Judgemental Panel Review (Content Validity Exercise).............................................................115 Pilot study ...................................................................................................................................116 Procedure for Data Collection ...................................................................................................120 Data Management.......................................................................................................................122 Data Analysis ..............................................................................................................................122 METHODS OF QUALITATIVE INQUIRY ...............................................................................................154 Purpose .......................................................................................................................................154 Focus Group Method ..................................................................................................................154 The Participants and Recruitment ..............................................................................................156 Data Collection and Procedure ..................................................................................................158 Analysis.......................................................................................................................................162 Rigor of Qualitative Data ...........................................................................................................164 ETHICAL GUIDELINES.......................................................................................................................166 SUMMARY ........................................................................................................................................167 CHAPTER 6: THE RESULTS OF PRELIMINARY ANALYSIS ................................................169 INTRODUCTION.................................................................................................................................169 THE RESPONSE RATE........................................................................................................................169 DEMOGRAPHIC ANALYSIS ................................................................................................................169 FACTOR ANALYSIS ...........................................................................................................................171 Porter Nursing Image Scale........................................................................................................171 Nurses’ Role Conception Scale...................................................................................................174 Work Value Scale........................................................................................................................177 Collective Self-esteem Scale........................................................................................................179 Task Performance Scale .............................................................................................................180 Modified Withdrawal Cognitions Scale ......................................................................................181 RELIABILITY OF THE INSTRUMENTS..................................................................................................182 DESCRIPTIVE STATISTICS .................................................................................................................183 SUMMARY ........................................................................................................................................190 CHAPTER 7: THE RESULTS OF HYPOTHESIS TESTING......................................................191 INTRODUCTION.................................................................................................................................191 HYPOTHESIS TESTING.......................................................................................................................191 Hypothesis 1................................................................................................................................191 Hypothesis 2................................................................................................................................195 Hypothesis 3................................................................................................................................196 Hypothesis 4................................................................................................................................199 Hypothesis 5 and 6......................................................................................................................206 Hypothesis 7................................................................................................................................212 Hypothesis 8................................................................................................................................218 Hypothesis 9................................................................................................................................238 SUMMARY ........................................................................................................................................249 CHAPTER 8: DISCUSSION.............................................................................................................252 INTRODUCTION.................................................................................................................................252 DISCUSSION OF THE THESIS FINDINGS..............................................................................................252 The Image of Nurses and the PEO Fit ........................................................................................252 The Factors Influencing Nurses’ Perceptions of the PEO Relationships ...................................266 The Effect of the PEO Relationships on Nurses’ Occupational Performance ............................278 vii STRATEGIES TO IMPROVE THE OCCUPATIONAL PERFORMANCE OF NURSES .....................................291 Improving the Public Image of Nursing......................................................................................291 Encouraging Professional Socialisation.....................................................................................299 Improving the Health Care Environment and Nursing Roles .....................................................301 STRENGTHS OF THE THESIS ..............................................................................................................305 WEAKNESSES OF THE THESIS ...........................................................................................................307 AREAS FOR FURTHER INVESTIGATION..............................................................................................308 CONCLUSIONS ..................................................................................................................................310 REFERENCES ...................................................................................................................................313 APPENDICES ....................................................................................................................................344 APPENDIX A: THE NURSING EXPERTS INVOLVED IN THE JUDGEMENTAL PANEL REVIEW...................345 APPENDIX B: LETTER TO NURSING EXPERTS ON PILOT STUDY EVALUATION.....................................346 APPENDIX C: QUESTIONNAIRE (FINAL VERSION) ..............................................................................361 APPENDIX D: LETTER OF CONSENT FOR THE PILOT STUDY ...............................................................371 APPENDIX E: PILOT STUDY EVALUATION FORM................................................................................373 APPENDIX F: THE RESULTS OF THE PILOT STUDY ............................................................................375 APPENDIX G: COVER LETTER FOR THE QUANTITATIVE STUDY..........................................................378 APPENDIX H: BRIEF DESCRIPTIONS OF THE CASES DELETED IN THE ANALYSIS .................................380 APPENDIX I: RESULTS OF THE ANALYSIS WITH ALL THE USABLE CASES INCLUDED ..........................383 APPENDIX J: INVITATION TO FOCUS GROUP (FLIER) ..........................................................................387 APPENDIX K: PARTICIPANT INFORMATION AND CONSENT FORM FOR FOCUS GROUP.........................389 APPENDIX L: DEMOGRAPHIC QUESTIONNAIRE USED IN THE FOCUS GROUP.......................................392 APPENDIX M: THE FINAL FACTOR ANALYSIS WITH THE REVERSED SCORE IN FACTOR II...................394 APPENDIX N: THE MEANS AND THE STANDARD DEVIATIONS OF THE VARIABLES AND CORRELATION ANALYSIS .........................................................................................................................................395 APPENDIX O: THE RESULTS OF RESPONSE SURFACE ANALYSIS ON THE SELECTED RELATIONSHIPS...396 APPENDIX P: DESCRIPTION OF THE FOCUS GROUP PARTICIPANTS .....................................................404 APPENDIX Q: THE RESULTS OF THE FOCUS GROUP ANALYSIS ...........................................................405 viii LIST OF TABLES Table 6.1 Demographic data of the study participants .........................................................................................170 Table 6.2 Preliminary factor analysis of the Porter Nursing Image Scale with the variable identifier.................172 Table 6.3 Final factor analysis of the Porter Nursing Image Scale.......................................................................173 Table 6.4 Preliminary factor analysis of the Nurses’ Role Conception Scale with the variable identifier. ..........175 Table 6.5 Final factor analysis of the Nurses’ Role Conception Scale.................................................................176 Table 6.6 Preliminary factor analysis of the Work Value Scale with the variable identifier................................178 Table 6.7 Final factor analysis of the Work Value Scale .....................................................................................179 Table 6.8 Final factor analysis of the Collective Self-esteem Scale.....................................................................180 Table 6.9 Final factor analysis of the Task Performance Scale ............................................................................181 Table 6.10 Final factor analysis of the modified Withdrawal Cognition Scale ......................................................182 Table 6.11 Reliability of the instruments. ..............................................................................................................183 Table 6.12 The means/standard deviations of and the correlation between the variables ......................................184 Table 7.1 Regression analysis examining the relationship between the perceived public image of nurses and their actual roles............................................................................................................................................192 Table 7.2 Summary results of the factor-level analysis examining the relationship between the perceived public image of nurses and their actual roles...................................................................................................192 Table 7.3 Regression analysis examining the relationship between the perceived public image of nurses and the environmental supplies. ........................................................................................................................194 Table 7.4 Summary results of the factor-level analysis examining the relationship between the perceived public image of nurses and the environmental supplies. .................................................................................194 Table 7.5 Regression analysis examining the relationship between nurses’ self-concept and their role conception. ..............................................................................................................................................................196 Table 7.6 Summary results of the factor-level analysis examining the relationship between nurses’ self-concept and their role conception. .....................................................................................................................197 Table 7.7 Regression analysis examining the relationship between nurses’ self-concept and their work values. 198 Table 7.8 Summary results of the factor-level analysis examining the relationship between nurses’ self-concept and their work values............................................................................................................................198 Table 7.9 Independent t-test based on the higher/lower collective self-esteem groups. .......................................200 Table 7.10 The group difference in the perception of the overall image fit. ..........................................................201 Table 7.11 Summary results of the factor-level analysis of the group difference in the perception of the image fit. ..............................................................................................................................................................203 Table 7.12 Summary results of the role fit by collective self-esteem.....................................................................205 Table 7.13 Summary results of the value-supply fit by collective self-esteem. .....................................................206 ix Table 7.14 Independent t-test based on the length of clinical experience. .............................................................207 Table 7.15 Summary results of the image fit by the experience.............................................................................208 Table 7.16 Summary results of the role fit by the experience. ...............................................................................210 Table 7.17 Summary results of the value-supply fit by the experience. .................................................................211 Table 7.18 Independent t-test based on the clinical area. .......................................................................................213 Table 7.19 Summary results of the image fit by the clinical area...........................................................................214 Table 7.20 Summary results of the role fit by the clinical area ..............................................................................215 Table 7.21 Summary results of the value-supply fit by the clinical area................................................................216 Table 7.22 Unconstrained models based on the image fit and job performance. ...................................................219 Table 7.23 Unconstrained models based on the role fit and job performance........................................................222 Table 7.24 Unconstrained models based on the value-supply fit and job performance..........................................225 Table 7.25 Results of response surface analysis predicting job performance.........................................................229 Table 7.26 Results of re-analysed models ..............................................................................................................233 Table 7.27 Unconstrained models based on the image fit and turnover intention. .................................................238 Table 7.28 Unconstrained models based on the role fit and turnover intention. ....................................................240 Table 7.29 Unconstrained models based on the value-supply fit and turnover intention. ......................................242 Table 7.30 Results of response surface analysis.....................................................................................................244 Table A1 Descriptions of the nursing experts ......................................................................................................345 Table F1 Descriptive statistics: Demographics....................................................................................................375 Table F2 Descriptive statistics: Questionnaire.....................................................................................................376 Table F3 Descriptive statistics: Evaluation of the questionnaire .........................................................................376 Table I1 Summary results of the analysis examining the impact of the perceived public image on nursing practice .................................................................................................................................................383 Table I2 Summary results of the analysis examining the impact of nurses’ self-concept on their professional needs.....................................................................................................................................................383 Table I3 Summary results of the analysis examining the PEO fit by collective self-esteem ..............................384 Table I4 Summary results of the analysis examining the PEO fit by the length of clinical experience..............384 Table I5 Summary results of the analysis examining the PEO fit by the clinical area .......................................385 Table I6 Unconstrained models based on the PEO fit and job performance.......................................................385 Table I7 Unconstrained models based on the PEO fit and turnover intention. ...................................................386 Table I8 Results of re-analyse models ................................................................................................................386

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