Assuming Practice Assuming Problems Sociology and Nursing Education Draft

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Title: Assuming Practice, Assuming Problems: Sociology and Nursing Education

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Corresponding Author: Prof Clinton Betts,

Corresponding Author's Institution: McMaster University

First Author: Clinton Betts

Order of Authors: Clinton Betts

Manuscript Region of Origin: CANADA

Abstract: There has been a rather intense and long running debate in the literature concerning the value of

sociology for the discipline of nursing, beginning with Hannah Cooke's (1993a) article Why teach Sociology?

Cooke's critical concerns can serve as the foundation for some important theoretical work regarding nursing,

and more specifically nursing education. That important work, I intend to suggest, is sociological in nature.

In this paper then, I argue that sociology is not only relevant to nursing education, but indeed essentialprecisely because of its tendency to problematize problems. I begin first with a brief overview of the

discussion/debate in the nursing literature regarding the value of sociology to nursing (education). Next, I

discuss the concept of assuming practice and how it relates to nursing education as well as nursing's history

of social responsibility. Following this I provide an overview of social problems theory as an example of how

and what kind of sociology can be usefully taught to nursing students, and finally, I discussion how such an

important sociological approach is germane to nursing education.


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Assuming Practice, Assuming Problems: Sociology and Nursing Education

Abstract:

There has been a rather intense and long running debate in the literature concerning the

value of sociology for the discipline of nursing, beginning with Hannah Cookes (1993a)

article Why teach Sociology? Cookes critical concerns can serve as the foundation for

some important theoretical work regarding nursing, and more specifically nursing

education. That important work, I intend to suggest, is sociological in nature. In this

paper then, I argue that sociology is not only relevant to nursing education, but indeed

essential precisely because of its tendency to problematize problems. I begin first with a

brief overview of the discussion/debate in the nursing literature regarding the value of

sociology to nursing (education). Next, I discuss the concept of assuming practice and

how it relates to nursing education as well as nursings history of social responsibility.

Following this I provide an overview of social problems theory as an example of how

and what kind of sociology can be usefully taught to nursing students, and finally, I

discussion how such an important sociological approach is germane to nursing education.

Acknowledgements:

The author would like to extend a special thank you to Dr. Dorothy Pawluch, Department

of Sociology, McMaster University for encouraging me to write this paper and providing

critical feedback.

Introduction:

There has been a rather intense and long running debate in the literature

concerning the value of sociology for the discipline of nursing. Beginning with Hannah

Cookes (1993a) article Why teach Sociology? and Sharpes (1994;1995; 1996) critique

nuscript (without Title Page)


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of both it and sociology as a value for nursing, followed by Porters (1995; 1996; 1997)

critique of Sharpe and defence of sociology in nursing education there appeared a number

of articles dealing with the issue (Balsamo & Martin, 1995a; Balsamo & Martin, 1995b;

Mulholland, 1997; Williamson, 1999; Allen, 2001; Pinikahana, 2003; Holland; 2004;

Aranda & Law, 2007). Cooke (1993) initiated the debate by calling for a more

critical and theoretically informed sociology for nurses, (p. 210) for the the

development of a new way of looking at the world one which calls into question much

that we have taken for granted, (p. 211) and to allow us to imagine new futures for

nursing and to question the current ideological consensus within it. (p. 215).

These are certainly important questions and I will return to them shortly.

Although there is certainly no intellectual or academic consensus at present in nursing

(Thorne et. al., 1998), it might be argued that it does contain, with notable exceptions of

course, an ideological consensus regarding; a) educational relevancy (Ironside, 2004),

which is to say that all education must be directly relevant to practice and b) an anti-

intellectual or task/technical ideology (Bradshaw, 1995), meaning that sophisticated

critique is viewed as little more than irrelevant academic speak . This is to say that, given

its very recent entrance into higher education, and its long history of subjugation and task

based work , nursing (both education and practice) is guilty of assuming practice (a

concept I shall explain briefly).

Hence, Cookes (1993a; 1993b) critical concerns can serve as the foundation for

some important theoretical work regarding nursing, and more specifically nursing

education. That important work, I intend to suggest, is sociological in nature. In this

paper then, I argue that sociology is not only relevant to nursing education, but indeed


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essential precisely because of its tendency to problematize problems. I begin first with a

brief overview of the discussion/debate in the nursing literature regarding the value of

sociology to nursing (education). Next, I discuss the concept of assuming practice and

how it relates to nursing education as well as nursings, often deemphasized, history of

social responsibility. Following this I provide an overview of social problems theory as

an example of how and what kind of sociology can be usefully taught to nursing students,

and finally, I discussion how such an important sociological approach is germane to

nursing education.

The Sociological Debate:

As Porter (1996) put it The two basic lines of attack have been that sociology is

currently not being taught properly by nursing educationalists and, more radically, that

it ought not be taught in the first place (p. 170). For those who take the former

position, sociology does not only inform nursing practice, it also provides an emacipatory

agenda. Indeed, Cooke (1993a) stated as much with reference to C. Wright Mills The

sociological imagination shows us that existing social relations are not fixed and

immutable and thus it expands our consciousness of the different possibilities for the

future which are open to us. In this sense sociology is an emancipatory discipline. (p.

215). Contrary to this, those who subscribe to the latter, claim that not only does it not

inform nursing practice, defined as it often is as the knowledgeable doer, (Balsamo &

Martin, 1995a; 1995b), or in Sharpes (1994) Ryleian view knowledge how [rather

than] knowledge that, (p. 392), but it risks introducing an epistemological confusion, if

you will, into the practice of nursing. This epistemological confusion is the result of; a)

nursings practice imperative whatever else it may be, nursing work can be seen


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primarily as a form of rational action; that is action which is oriented toward goals, on the

basis of knowledge about how these goals may most efficaciously be reached. (Sharpe,

1995, p. 53) and b) both the multiparadigmatic nature of sociology, and the lack of

directly applicable knowledge gleaned from sociological research.

In essence, the conflicting and controversial state of sociological theory reduces

its utility as a repository of stable and secure knowledge from which to confidently act

(practice) in the world (clinical environment). Moreover, since a nurse does, and indeed

must, act (practice) in the world (clinical environment) sociology is; a) of little use and/or

b) unnecessarily confusing. Sharpes (1994; 1995) narrow view of nursing (knowledge

how rather than knowledge what) as a discipline has been, in my view, effectively dealt

with (see Porter, 1995; 1997; Mulholland, 1997; Williamson, 1999; Pinikahana, 2003).

The majority of arguments for the teaching of sociology in nursing remain

concerned, for the most part, with what it can contribute to nursing practice (directly)

rather than the critical attitude of nursing students. In other words, the assumption is that

what nursing students should be taught is how to practice nursing and anything that does

not further this goal is simply moved into the category of unnecessary and irrelevant.

However, Sharpe, in addition to his use of a knowing how and knowing that binary,

also juxtaposed a personal education model with a semantic conjunction model (1994).

Where the former suggests that serious study of any academic discipline is useful

preparation for professional practice, since it inculcates in the student certain general

intellectual and problem-solving skills, which will be transferred to the professional

setting, (p. 391) while the latter holds that it is the substantive subject matter of the

discipline concerned which is of relevance to the problems faced by the professionals.


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(p. 391). Sharpe (1994) rejects the personal education argument first, by suggesting that

as nursing moved away from the medical model and began to develop a more holistic

(bio-psycho-social) approach, in effect a body of knowledge which nurses regard as

legitimately their own (p. 392) the usefulness of sociology for this body of

knowledge, and as well the teaching of it to nursing students, becomes questionable, if

not outright irrelevant. Second, Sharp (1994) claims that if the rational for including

sociology in the curriculum was only the development of transferable intellectual skills,

then philosophy would be as appropriate as sociology, and very possible better (p.

392). He further asserts that if the teaching of sociology was primarily an effort to foster

intellectual skills, one would expect such teaching to primarily include sociological

theory and methodology, rather, presumably, then the findings of sociological research.

It is here in fact that I think the argument for sociology in nursing education needs to be

made. Indeed, it is sociological theory and methodology that should be taught to

nursing students, rather than merely the findings of sociological research. What Sharpe

fails to recognize is that nursing is an ineluctably social enterprise (more so than

philosophical, which is not say that philosophy is irrelevant) with respect to both practice

and its long history, though often only on paper, of social responsibility particularly

with reference to social problems. Put differently, many of the problems that nurses are

faced with in practice are social problems that manifest themselves in the individual need

of, or desire for, care (cardiac disease, AIDS, addiction, cancer, child abuse, spousal

abuse and so on).

Assuming Practice and Social Responsibility in Nursing Education:


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Elsewhere I (Betts, 2006) used the phrase assuming practice to denote the

tendency in nursing to, not unlike the teaching to test that occurs with standardized

testing, teach to practice. That is to outline a priori what nursing practice is and train

(rather than education) a student to perform it. In essence, I was referring to a tyranny of

relevance , though I did not put it this way. A tyranny of relevance in nursing education

means that whatever is taught to a nursing student must somehow; a) have some direct

link to practice and b) be taught in a manner that leads to practice. Assuming practice

does not allow for the possibility that nursing practice is varied, might be (as in could, or

should) be different and is certainly not emanciptory with respect to the student.

Moreover, it is a receipt for a dogmatic approach to both individuals being cared for by

nurses and the society nurses provide service to.

Historically nursing has been viewed as a discipline that treats, cares for, or

responds to, individuals. Some have gone so far as to claim that it is not nursings

societal mandate to eliminate disease or redress the social determinants of health. These

concerns are certainly more central to knowledge domains such as epidemiology, public

health, and political sciences. (Pilkington & Mitchell, 2003, p. 105). However, as far

back as Nightingale social problems and social responsibility have been a significant

focus for nursing. Indeed Nightingale herself was responding to a social problem when

she headquartered her cadre of nurses at Scutari during the Crimean War in 1854. That

is, the social problem of the treatment of wounded soldiers. According to DeSantis and

Lipson (2007) The Committee on Curriculum for the National League for Nursing

(NLN) first published a curriculum guide in 1917 that included content on psychology,

sociology, social problems, and social problems in nursing service. (p. 7S). Indeed,


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many of the early nursing leaders (for example, Ethel Bedford-Fenwick, Lillian Wald,

Lavinia Dock, Mary Adelaide Nutting, Clara Barton and numerous others of course)

spoke often of social problems and nurses responsibility for them. For example, in 1907

Lavinia L. Dock (1907) wrote, in Some Urgent Social Claims :

But now the day has come when we might here decide on our place, our share,

and our policy toward the great social claims of education and educational

reforms, industry and the industrial situation especially as it relates to

women-child-labor, its iniquities and dangers prostitution and the white slave

traffic with its trail of disease and death, and the recent movement to teach sexual

hygiene, to inculcate a single moral standard, and to combat venereal disease of

which we make so melancholy an acquaintance not only in the wards of city

hospitals but even among our private patients; this, one of the newest reform and

educational movements, proves perhaps more strikingly than any other that a new

conception of human society has arisen and that a new ideal is to be pursued for

the future. (p. 899)

In 1931 Alice C. Lloyd (1931) wrote, in an article entitled Social Responsibility: An Aim

of Nursing Education , that To place the nursing profession on a high level, its social

responsibility must come foremost in the conception of its duties. (p. 911). Moreover, in

1941 Gladys Sellew (1941) wrote a book specifically titled Sociology and Social

Problems in Nursing Service . In short then, responsibility for social problems is nothing

new in nursing despite its often marginalized status.

Yet, in the mid-80s such social responsibility and social problems in nursing

became a central position in the curriculum revolutions attempt to shift the paradigm of


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nursing education from a Tylerian training model to a critical, emanciptory, higher

education agenda (National League for Nursing Board of Governors, 2005). Indeed the

curriculum revolution emphasized a, nearly, radical form of critique for nursing

education, citing such critical pedagogy theorists as Paulo Freire, Maxine Greene, Henry

Giroux, Michael Apple and so on. As Chopoorian (1990) put it Without a critical

analysis of the social forces, economic conditions, and political climate influencing

nursing, society, and health care, the nursing profession may collapse We need to ask

how social, political, economic, and cultural structures and fundamental societal

processes and human relations produce the problems we see in our daily work.. (p. 24).

The curriculum revolution then proposed a liberal education for nurses with an

emancipatory programme that requires teachers to be meta-strategists, problem-posers,

consultants, and nurturers of curiosity, criticism, inquiry, caring, and meaning making.

(Bevis & Murray, 1990, p. 329). Although the original participates of the curriculum

revolution did not ignore nursing practice (indeed they addressed is all to well, albeit

rather abstractly at times) neither did they assume practice. Rather, they recommended,

or perhaps demanded (it was after all a revolution), that nursing students be schooled in a

true higher education model. One perhaps similar to Girouxs (as cited by Rahmani,

2004) view. That is:

nurturing those capacities that enable [students] to take risks, to make

democratic politics and public commitments central to their lives that

obligation does not simply rest on expanding the boundaries of knowledge for

students. It also rests on making students more aware of how knowledge can be

used as a social, intellectual, and theoretical resource It means using


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knowledge in more than a narrowly instrumental way such as preparing for a

job it also means critically embracing knowledge as a means of self

development tied to modes of learning and intellectual work that address matters

of human freedom, equality, and social justice to social change, to those modes

of moral witnessing necessary to transform the underlying systemic conditions

that produce human suffering to prepare students for a very complex and

contradictory world, in which they are going to learn how to govern and not

simply be governed. (p. 647)

In other words, educating nursing students, that is future professionals vested with

authority, trust and autonomy by society, to think about practice rather then simply for

practice (Betts, 2006). Add to this Hagells (1989) comments, in her well know feminist

critique of the hegemony of the natural science model in nursing, Perhaps the most

important area for change should take place in nursing education [which] should

incorporate courses that are aimed at critically evaluating nursing theories and other

theories [including] alternative thought such as Marxism, feminism and critical

theory. (p. 231). Finally, in his text for nursing students Social Theory and Nursing

Practice , Porter (1998) claims that, in addition to sociological research findings

contributing to practice, sociologys emphasis on critical reflection can encourage

nurses to be more questioning and self aware (p. x). In other words, a multi-

paradigmatic view of, again, both the individuals nurses care for and the greater society

they serve has important value in-itself, that is, even if the results of this view do not

directly apply to nursing practice. It is here that sociologys multi-paradigmatic nature,

epistemological confusion and diverse research agendas become invaluable. It is also the


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answer, if I have done it justice, to Cookes (1993a) initial concerns. In effect, it is the

personal education model that Sharpe (1994) too easily rejects that ends up being of great

value for nursing education.

Social Problems Theory and Nursing Education:

I now wish to use Social Problems Theory (the sociology of social problems), its

history, development and controversies, to provide an example of the value that sociology

may well have for nursing education.

According to Best (2003a) there are two mutually exclusive approaches to (the

sociology of) social problems. The first is the traditional model (what Best refers to as

the mainstream approach), that social problems exist as objective conditions of the

world which require solutions and moreover that one social problem (for example,

homelessness) has little to do with other social problems (say AIDS, rape, poverty,

crime etc). This is not to say that one cannot be homeless as a result of AIDS, rape,

crime and/or poverty, rather for a traditional perspective social problems are discrete

entities that are, in a sense, self referring (homelessness refers to the problem of

homelessness). We might just as well label this the commonsense model in that, nearly

everyone (except a group of sociologist I will mention in a moment) holds this position.

As Best (2003a) explains the mainstream approach to the sociology of social

problems is more than a century old [and] as sociologists began to identify many social

problems soon, there were books and courses titled Social Problems , and a direct line

of decent runs from them to their modern counterparts. (p. 134). Indeed, when nursing

students encounter social problems in their course of their study, this is how it will

invariably be presented to them.


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The second approach to social problems (the one taken by those sociologists I just

mentioned) is concerned with the definition of social problems. By this I do not mean the

definition of a social problem, but rather asking the question; is there anything,

sociological, that connects all social problems? It turns out that indeed there might be

and that is how social problems are defined. Put simply then, the definitional

perspective essentially problematizes the traditional/mainstream/commonsense view of

what a social problem is. Although, as we shall see in a moment, the definitional view is

not a unified approach at all, it is concerned with how social problems are subjectively

(that is by individuals referring to social problems) defined, or in other words how a

social problem becomes (is constructed as) a social problem.

The history of the definitional perspective is rather complicated, however I shall

attempt to briefly review it here. Early in the 20 th century Frank (1925) claimed, in a

thoroughly objectivist fashion, that A social problem, then, appears to be any difficulty

or misbehavior of a fairly large number of persons which we wish to remove or correct,

and the solution of a social problem is evidently the discovery of a method for this

removal or correction. (p. 463). This is clearly a mainstream approach. Waller (1936)

evinced similar views a decade later and even explicitly acknowledged a debt to Franks

work, however, as Himes (1955) put it Waller saw social problems as emerging from

conflicts between the organizational and the humanitarian mores. (p. 259). Hence, in

Waller, we clearly see the emergence of a subjectivist constituent to social problems

theory. Fuller and Myers (1941a; 1941b) later suggested that Every social problem has

both an objective and a subjective aspect. where the objective element is a verifiable

condition, situation, or event. (1941a, p. 25). Although Fuller and Myers did indeed


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admit to important subjectivist (definitional) characteristics of social problems, such

problems were founded on realist assumptions. Such a constitution of social problems,

that is the combination of objective and subjective components has been referred to as the

value-conflict theory of social problems, in that while the foundation is a material one,

there exists a conflict concerning the value of such a foundation. This is in contrast to

Merton and Nisbetts (1971, as cited by Kitsuse & Spector, 1973) functionalist view,

which places significant emphasis on the objectivity of social problems, again

mainstream thinking. The value-conflict approach appears to have laid the groundwork

for a fuller articulation of the subjectivist views of, among others, Blumer (1971) and

Spector and Kitsuse (1973; Kitsuse & Spector, 1973) in the early 70s

Put simply, for Spector and Kitsuse the objective (that is realist or materialist)

conditions of a social problem, if they do indeed exist, are irrelevance to proper

sociological analysis. Moreover, they go so far as to suggest that the inclusion of

objective state of affairs in social problem analysis results is little more than a (return to)

functionalism (Spector & Kitsuse, 1973, p. 146). Hence they arrive at their, now famous,

definition of social problems we define social problems as the activities of

individuals or groups making assertions of grievance and claims with respect to some

putative condition . (Spector & Kitsuse, 1973, p. 146, original emphasis). Spector and

Kitsuse then, heralded the, now classical, definitional approach to the sociology of social

problems. The were, and still are, social constructionists in that, for them, social

problems are constructed by the subjective attitudes, activities, meanings and approaches

that individuals (or groups) evince in the definition of, and work with, what they consider


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to be social problems. As Ibarra and Kitsuse (2003) put it The very concept social

problem is itself problematic. (p. 19).

To summarize, the definitional, or social constructionist, position is, that all social

problems have a common sociology in that, in order to be a social problem, they must be

defined as such by subjective interests (again individuals or groups) called claims-

makers, and moreover these claims (about social problems) are often met with counter-

claims, which is to say other individuals or groups which may well define, handle, or deal

with the social problem in question quite differently (in fact, in some cases denying that it

is a problem altogether). From this standpoint, a social problem is not an objective

(obvious if you will) condition of the world that everyone agrees on and is working to fix.

Rather it views social problems as constructed by would-be claims-makers and counter

claims-makers in an effort to not only deal with the problem, but in fact, from a

constructionist perspective, give it existence.

Controversy in Constructionist Views of Social Problems:

The definitional perspective of social problems, instantiated largely by Spector

and Kitsuse (1973), is, of course, not without its controversy. There is indeed another

perspective, though still constructionist, which takes issue with Spector and Kitsuse and

those who followed them. Best (1995; 2003b) has labelled Spector and Kitsuses version

of constructionism strict constructionism, in that their research method precludes any

reference to objective conditions. As previously mentioned, their focus is to analyize the

claims-makers and counter claims-makers that produce the definitions, discourse and

work of social problems. This is in contrast with what Best (1995; 2003b) calls

contextual constructionism. Contextual constructionism, while recognizing the


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importance of the definitional aspects of social problems, that is claims-makers and

counter claims-makers, argues that there are some objective conditions to social problems

and moreover these can be used in sociological analysis. It is however, important to note

that this is not a regression to the previously mentioned value-conflict theory . Rather, it

is founded on constructionist assumptions, against for example nave realism or

materialism, however contextual constructionists posit that certain objective conditions

are important to social problems investigation and can therefore, albeit cautiously, be an

important element in sociological analysis:

Obviously, any discussion about social conditions is a social construction. A

claim that crime (or fear of crime) is increasing is just that a claim. But calling

a statement a claim does not discredit it. Contextual constructionists argue that

any claim can be evaluated. A claim may be based on various sorts of evidence,

such as official criminal statistics or public opinion polls, which are in turn social

constructions contextual constructionists assume that they can know with

reasonable confidence something about social [objective] conditions. (Best,

1995, p. 347-348)

I have outlined three (sociological) ways of viewing social problems; 1) the traditional

(or mainstream) view, wherein social problems are simply problems in a given society

that require a solution, 2) definitional perspectives (or strict constructionism) which hold

that social problems can only be understood by examining those (individuals and/or

groups) who define, delineate, and work with social problems (there is no problem

without someone to label it as such), and 3) contextual constructivism, which suggest that

definitional perspectives are of great importance, however there are some objective (or


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actual) characteristics to the problem being defined which can also be a matter of study

(yes people have to define a problem for it to exist, but that does not mean that such

definitional behaviour cannot be wrong).

Assuming Problems: Social Problems Theory and Nursing Education:

So what then can this aforementioned epistemological confusion, add to nursing

education? Although it is true that such confusion does not easily translate into a secure

knowledge base for practice this is just the point I wish to make. What it does do for

nursing students is to demonstrate that there is simply not a single way of

seeing/understanding the world we live (and practice) in. In effect, it prevents students

from assuming practice uncritically, or in this specific case assuming problems

uncritically. Such diversity of perspective is not only the case with social problems, but

as well with gender (the multi-faceted nature of feminism), power, (for example Marx

against Foucault), class (Marx versus Weber), human agency (Giddens versus Archer),

social progress (critical theory versus postmodernism) and so on. As Toulmin (1990) put

it, with reference to Lippman:

we may recall the comment on social and political affairs made by that

humane, grumpy, but normally clearheaded commentator, Walter Lippman, which

distils much of what has come to light in our inquiry. To every human

problem, he said, there is a solution that is simple, neat, and wrong; and that is

as true of intellectual as it is of practical problems. (p. 201)

Indeed, ignoring the complexity of the world we practice, or are going to practice, in for

some pseudo-certain knowledge from which to act (practice) is problematic, if not


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dangerously dogmatic. And it surely does not make for a critical and emancipatory (read

higher) education.

I hope that outlining the multiple perspectives of social problems theory has

provided a cogent example of how sociology might be of use in nursing education.

Indeed, this overview of social problems theory, again I hope, assists me to make three

important points. First, social problems are not necessarily uncomplicated, self-referring

conditions that simply need fixing. Second, sociology as I have attempted to argue does

have the emancipatory potential that Cooke called for in that, it provides for a complex

and multi-perspective view of a complex and multi-perspective world, and certainly one

that nursing students should have access to no less than researchers. And finally, it is

democratic in that, it tends to be inclusive (accessing a diversity of voices, perspectives,

viewpoints, positions and possibilities) rather than a monolithic, and to be sure dogmatic,

understanding that is exclusive. This fact of reality is, or can be, confusing,

epistemologically, methodologically and pragmatically, however to ignore the confusion

is, as I have mentioned several times, to risk dogmatic practice, as well as to, I think,

denigrate nursing students ability to be critically educated and still practice with

compassionate competence. Forgive the cumbersome way of putting it, but to

problematize problems is good for problems and as well, the individuals on both sides of

them (that is those afflicted and those who serve them).

Conclusion:

In this paper I have attempted to address the longstanding debate regarding the

usefulness and/or relevance of sociology to nursing. I have suggested that Hannah Cooke

(1993a) was correct when she began the debate by claiming that sociology can provide a


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critical and emancipatory agenda for nursing (education). More specifically, I have used

social problems theory to make my point. After providing an overview of the

sociological debate, I discussed the concept of assuming practice and the, little known in

many respects, history of social responsibility in nursing. Following this, I presented a

summary of the diverse perspectives of social problems and then discussed how this (as

an example of sociological theory) can, and should, be applicable to nursing education.

Finally, I would like to conclude with a recent, and insightful, comment on nursing

education from Watson and Thompson (2008). if university level education is

required for other professionals then it is also required for nurses [and] if a proper

university level education is not offered to nurses then nurses should be educated

elsewhere. (p. 982). I submit that a proper university level education means, at least,

an education in sociological theory and methodology.


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August, 11, 2008

Submitted to: Nurse Education Today

Assuming Practice, Assuming Problems: Sociology and Nursing Education

Number of Pages, including Title and References: 24

Word Count: 4533

Clinton E. Betts RN BSc BScN MEd Doctoral StudentAssistant ProfessorSchool of Nursing,Faculty of Health Sciences,McMaster University, 1200 Main Street West,Hamilton, Ontario, Canada, L8N 3Z5.Email: [email protected]

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