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Is a lifelong process by which a person learns the ways of a group or society in order to become a functioning participant. Is a reciprocal learning process brought about by interactions with other people. Involves all of a person's interactions with various agents of socialization--family, teachers, peers, media. Interactions may be unconscious or conscious, formal or informal. Is a universal process that varies according to a person's social class, ethnic origin, sex, and religion. Is a process that produces attitudes, values, knowledge, and skills required to participate effectively as an individual or a group member. Establishes boundaries of behavior. Develops a social self or awareness of others and their expectations. Is basic to group continuity and stability.

language and increasing identification with professional role models. Stage VI: Stable internalization. Student behavior reflects the educationally and professionally approved model. However, new values and behaviors continue to be formed in the work setting.

Simpson Model

Stage 1: Proficiency in specific work tasks. Stage 2: Attachment to significant others in the work environment. Stage 3: Internalization of the values of the professional group and adoption of the behaviors it prescribes.

Hinshaw Model

MODELS OF SOCIALIZATION Various theorists have developed models of socialization applicable to nursing: Davis Model (Doctrinal Conversion) Model

Stage I: Initial innocence. Nursing students enter school with a preconceived image of nursing. Reality may cause disappointment and frustration if student experiences are different from expectations. Stage II: Labeled recognition of incongruity. Students begin to identify, articulate, and share their concerns. They discover they are not alone. Stage III: "Psyching out" and role simulation. Students begin to identify behaviors they are expected to emulate and through role modeling practice those behaviors. However, students may feel they are just "playing a game" ("psyching out" the faculty) which can result in feelings of guilt and estrangement. Stage IV: Increasing role simulation. Students continue to practice the behaviors. Stage V: Provisional internalization. Students vacillate between commitment to their former image of nursing and their performance of new professional behaviors. The new image is supported by increasing ability to use professional

Phase I: Transition of anticipated role expectations to the role expectations of societal group. Phase II has two components: Component One: Attachment to significant others. Component Two: The ability to note incongruencies between anticipated roles and those presented by their significant others. This phase may involve strong emotional reactions to conflicted sets of expectations. Resolution of conflicts is successful if their role models demonstrate appropriate behaviors and show how conflicting systems of standards and values can be integrated. Phase III: Internalization of role values/behaviors. The degree of internalization and extent of resolution of conflicts is variable.

The transition of the graduate to a full-fledged professional is facilitated if there is congruence between the norms, values, and expectations of the educational program and the realities of the work setting. Following are models of career development. Kramer (Postgraduate Resocialization) Model

Stage I: Skill and routine mastery. The nurse focuses on developing technical expertise and mastering specific skills to overcome feelings of frustration and inadequacy. Stage II: Social integration. The nurse's major concern is having peers recognize his/her competence and acceptance into group. Stage III: Moral outrage. The nurse recognizes incongruencies between the bureaucratic role (associated with rules, regulations, loyalty to administration), the professional role (associated with commitment to continued learning and

loyalty to the profession), and the service role (associated with compassion and loyalty to the client/patient). Stage IV: Conflict resolution. The nurse resolves the conflicts by surrendering behaviors and/or values or by learning to use the values and behaviors of the professional and bureaucratic system in a politically astute manner.

(Grossman, D., Cultural diversity on the unit, AJN, 95:6466, 1995).

Dalton (Career Stages) Model

Stage I: The nurse performs fairly routine duties under the direction of a mentor. Stage II: The nurse works independently as a competent peer. Stage III: The nurse guides, directs and helps others to develop. Stage IV: The nurse influences the direction of the organization or a segment of it: The nurse has the role of manager, internal entrepreneur, or idea innovator.

85% of women entering the workforce today are women, African-American, Asian-American, Hispanic Americans, and new immigrants. This trend provides an opportunity to improve nursing care by the synthesis of a broad range of culturally-related strengths; however, differences in values, beliefs, and communication patterns can give rise to conflict, alienation, poor teamwork, and reduced job satisfaction, and result in a negative impact on patient care. Nurses' beliefs, values, and perceptions are strongly influenced by their environment and background.

Some examples

Benner (Nursing Expertise) Model

Stage I: Novice. No experience. Performance is limited, inflexible, and governed by context-free rules and regulations rather than experience. Stage II: Advanced beginner. Demonstrates marginally accepted performance. Recognizes the meaningful aspects of a real situation. Has experienced enough real situations to make judgments about them. Stage III: Competent practitioner. Has 2-3 years of experience. Demonstrates organizational and planning abilities. Differentiates important factors from less important aspects of care. Coordinates multiple complex care demands. Stage IV: Proficient practitioner. Has 3-5 years of experience. Perceives situations as wholes rather than in terms of parts, as in Stage III. Uses maxims as guides for what to consider in a situation. Has holistic understanding of the client, which improves decision making. Focuses on long-term goals. Stage V: Expert practitioner. Performance is fluid, flexible, and highly proficient. No longer requires rules, guidelines, or maxims to connect an understanding of the situation to appropriate action. Demonstrates highly skilled intuitive and analytic ability in new situations. Is inclined to take a certain action because "it felt right."

Anglo-Americans tend to be more individualistic, placing a high value on individual opinions, rights, and performance. Non-Western people tend to be more collectivistic, placing a high value on group harmony, cooperation, and consensus. Thus, a nurse from a non-Western culture may be reluctant to point out her accomplishments to her supervisor, and may attribute success to the team rather than her individual efforts. Anglo-Americans tend to perceive "time is money" and value "businesslike" interactions. NonWestern people may perceive social interactions and relationships as more important than strict punctuality. Thus, a nurse from a non-Western culture may spend time socializing with patient families and co-workers, fostering feelings of resentment from Anglo-American nurses. Conversely, Anglo-American nurses may be perceived as abrupt, uncaring, or impersonal by non-Western nurses. For non-Western nurses, human relationships are important, and the individual person is more important than the product. Family, social and religious obligations receive greater priority than work. Nurses from more work-oriented cultures may be intolerant of a co-worker who requests leave or is absent because of religious rituals or care of a relative. Political systems can also influence behavior. Nurses from socialist countries may be perceived as lacking initiative or energy, but such traits are not encouraged in a socialist system. Nurses from political systems that emphasize autocratic styles


of management may not challenge orders from a physician or may follow instructions from a supervisor without question.

Nurses who constantly speak a foreign language with co-workers can induce feelings of isolation in a co-worker who does not speak that language. In hospitals where a large number of workers speak a language other than English, physician orders and codes conducted in a foreign language can cause serious breakdowns in communication. Even when both nurses speak the same language, communication can be different. Nurses educated in other countries may not be familiar with idiomatic expressions and slang words. An immigrant nurse speaking with an accent may be misunderstood or mispronounce words when giving reports. Conversely, non-native nurses may have difficultly understanding co-workers who speak English rapidly or with a regional accent. Successful communication also involves context. Western languages tend to be "low context," or verbal, using words in communication. NonWestern languages tend to be "high context" or use nonverbal cues, such as facial expressions, tone of voice, and gestures. Nurses who are "low context" communicators may be perceived as overly-talkative while nurses who are "high context" communicators may be perceived as passive, nonassertive, and uninterested. Statements such as "I shouldn't have to tell her, she should know," and "Why didn't she say something?" highlight the differences between low and high context communicators. Anglo-Americans tend to favor open, frank, and often blunt communication. Non-western cultures value social harmony and the maintenance of smooth interpersonal relationships, including deference and consideration for the feelings and needs of others. Nurses from non-Western countries may say "yes" but actually mean "no" because of a reluctance to admit disagreement or lack of understanding. Although both Western and non-Western nurses may disagree with a proposed policy, the Western nurse may respond quickly with "That's a terrible idea," while the nonWestern nurse may appear to verbally acquiesce to allow for "face-saving" or avoid direct conflict--and then be perceived by the Western nurse as insincere, deceptive, and wishy-washy.

Nonverbal communication, such as touch, facial expressions, eye contact, and personal space also differs between cultures. Outward signs of affection, such as kissing and hugging are freely bestowed by Hispanic Americans; however, Anglo Americans and Asian Americans may feel uncomfortable or embarrassed at being touched. For Anglo Americans, standing too close while talking is deemed a violation of personal space. For non-Western cultures, it is often considered rude to look directly into another's eyes. Dropping the eyes during an interaction is considered a sign of respect. This behavior may be interpreted as "suspicious" by an Anglo-American supervisor because the nurse did not look her "straight in the eye."

Key Principles to Remember Forging working relationships in a multicultural environment requires genuine commitment, empathy, and sensitivity from nursing administrators, educators, managers, and staff members. Here are some key principles to remember:

Respect individual differences. Just as we respect patients for their uniqueness, respect colleagues for their unique values, beliefs, and customs. Get out of the comfort zone. We tend to be most comfortable with those people who are like us. But clustering with only members of our own group prevents us from getting to know our colleagues and learning about other cultures. Refrain from making judgments about others until you can obtain sufficient information. Don't use your own group's standards as a frame of reference. "Different" does not mean "inferior." There is intrinsic worth in every culture. Learn to communicate more effectively. Become proficient in "low context" and "high context" communication. Listen and watch closely. Be empathetic to those learning the English language. Speak slowly and distinctly (not loudly) so you can be understood. Accentuate the positive. Share the positive aspects of your culture, such as food and festivals.