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Journal of Management Studies 47:1 January 2010

doi: 10.1111/j.1467-6486.2009.00860.x

Florence Nightingale Endures: Legitimizing a New


Professional Role Identity joms_860 55..84

Elizabeth Goodrick and Trish Reay


Florida Atlantic University; University of Alberta

abstract We examined the discursive processes through which a new professional role
identity for registered nurses was legitimized by analysing introductory textbooks over time.
We theorize five ways of rhetorically legitimizing a new professional role identity: naturalizing
the past, normalizing new meanings, altering identity referents, connecting with the
institutional environment, and referencing authority. In contrast to previous research focused
on legitimizing new practices, we contribute to the institutional literature by showing that
legitimizing a professional role identity requires the incremental development of new
arguments where the past is not delegitimized. Our findings also indicate that instead of a
progression from moral and pragmatic legitimacy to cognitive legitimacy, legitimizing a new
role identity may focus only on moral legitimacy. Finally, our study highlights the importance
of interactions between the professional task environment and the wider institutional
environment as part of the process of legitimizing a professional role identity.

INTRODUCTION
Processes of institutional change are beginning to receive much deserved attention. In
their recent review of the literature, Lawrence and Suddaby (2006) catalogued efforts to
understand these processes and challenged institutional researchers to further investigate
empirical examples of ‘institutional work’, which they described as purposive action
aimed at creating, maintaining, and disrupting institutions. This concept of institutional
work is grounded in the view that change occurs through a combination of agency and
institutional forces, and that one of the critical components of institutional change is
the process of legitimizing (Greenwood et al., 2002). Legitimizing refers to the process
through which innovations and changes become perceived as ‘desirable, proper, or
appropriate within some socially constructed system of norms, values, beliefs, and defi-
Address for reprints: Elizabeth Goodrick, Barry Kaye College of Business, Florida Atlantic University, 2912
College Avenue, Davie, FL 33314, USA (goodrick@fau.edu).
This paper originated in collaborative work with James R. Meindl, who is now deceased. Prior to his death,
Jim was on the faculty of the School of Management, State University of New York at Buffalo. He is best
known for his work on the ‘romance of leadership’, the tendency to attribute organizational performance to
leaders, thereby discounting other factors that may be influential.

© 2009 Blackwell Publishing Ltd and Society for the Advancement of Management Studies. Published by Blackwell
Publishing, 9600 Garsington Road, Oxford, OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA.
56 E. Goodrick and T. Reay
nitions’ (Suchman, 1995, p. 574). Empirical studies have approached legitimizing both
by examining the actual practices through which legitimizing is accomplished (e.g. Reay
et al., 2006) and by focusing on the use of discursive strategies in the process of legiti-
mizing (Deephouse and Suchman, 2008).
Legitimizing a new identity is a form of institutional work important to institutional
change (Lawrence and Suddaby, 2006). The construction of professional role identities
is particularly critical because identities describe the relationship between an actor and
the field the actor operates within (Bourdieu and Wacquant, 1992; Lawrence and
Suddaby, 2006). In their study of a symphony orchestra, Glynn and Lounsbury (2005)
drew attention to this relationship by examining the role of discourse in managing the
boundary between societal changes and the nature of a professional actor. Similarly,
studies in other settings have shown that discourse plays an important role in legitimizing
institutional change (Green et al., 2009; Phillips et al., 2004; Vaara and Tienari, 2008).
More specifically, rhetoric has been identified as an ‘important element of institutionally
embedded agency’ (Green et al., 2009, p. 12).
However, in understanding how a new professional role identity is legitimized, we
suggest that previous studies may not provide an appropriate foundation. We believe
that discourse and rhetoric are likely to be used differently when legitimizing changes
in professional role identities compared to legitimizing new practices. We make this
claim for two reasons. First, the identity literature suggests that identity in general,
and professional identity specifically, is highly resilient and does not change quickly
or easily (Albert and Whetten, 1985; Chreim et al., 2007). Therefore, legitimizing
changes in professional identity is likely to be more difficult than legitimizing changes
in practices and may require different rhetorical strategies. Second, most studies inves-
tigating how rhetoric contributes to the process of legitimizing or institutionalizing
have focused on rhetorical accounts in the media (e.g. Glynn and Lounsbury, 2005;
Green et al., 2009; Vaara et al., 2006). We suggest that to understand changes in a
concept such as role identity that is meaningful at the core of an organization or
professional group, it is critical to investigate rhetorical strategies generated within the
profession itself rather than by outsiders (e.g. media) to appropriately understand the
process of legitimizing.
For these reasons, we see that there is a gap in the literature concerning the process of
legitimizing changes in professional role identity. We attempt to fill that gap by studying
how changes in the professional role identity of registered nurses were legitimized in
nursing textbooks. Nursing is a useful and informative example to follow because the
collective identity of nurses has changed dramatically. In the mid 1950s, registered nurses
defined themselves primarily as doctors’ assistants while in more recent times they
consider themselves as more independent practitioners, taking on a relatively high profile
role in health care (Kalisch and Kalisch, 2004). We focused our attention on how
introductory nursing textbooks presented information about ‘who we are as nurses’ to
beginning student nurses. Based on our longitudinal analysis, we gained insights into the
discursive process of legitimizing a new professional role identity. In contrast to previous
research focused on legitimizing new practices, we contribute to the institutional litera-
ture by showing that legitimizing a professional role identity requires the incremental
development of new arguments where the past is not delegitimized. Our study highlights

© 2009 Blackwell Publishing Ltd and Society for the Advancement of Management Studies
Florence Nightingale Endures 57
the importance of interactions between the professional task environment and the wider
institutional environment as part of the process of legitimizing a professional role identity.
In the next section of the paper we present key points from the literature concerning
the process of legitimizing and institutional work. We also provide background informa-
tion concerning changes in nursing and the societal context over time. Next, we explain
our research methodology and findings from two connected studies. In Study A, we
investigate variation in the content of nursing role identity over time. In Study B, we
analyse the rhetorical arguments through which a new professional role identity was
legitimized We build on these findings to develop theory about ways in which discourse
may be used to legitimize a new professional role identity. Finally we present conclusions
and suggestions for further research.

THEORETICAL BACKGROUND
Legitimizing is an important component of institutional change as well as fundamental
to accomplishing institutional work (Greenwood et al., 2002; Lawrence and Suddaby,
2006; Phillips et al., 2004). As part of the growing attention to institutional change more
generally, researchers have focused on the process of legitimizing as a way to understand
how ideas, structures or practices become accepted, or develop legitimacy (Deephouse
and Suchman, 2008). Scholars have conducted both empirical and theoretical work in
attempts to bolster our collective knowledge about how institutions (the ‘enduring ele-
ments of social life’) change (Giddens, 1984, p. 24). Building on this institutional change
literature, Lawrence and Suddaby (2006) called for theorists to focus on the institutional
work of creating, maintaining, and disrupting institutions. Following Jepperson (1991),
they argue that ‘institutions are the product of purposive action’ and by understanding
such actions researchers will gain better knowledge concerning the processes of change
(Lawrence and Suddaby, 2006, p. 216).
In legitimizing or delegitimizing particular practices, ideas, or structures, actors
engage in institutional work. For example, actors may engage in developing a new
industry (Maguire et al., 2004), establishing a new professional role (Reay et al., 2006), or
delegitimizing job classifications (Oliver, 1992). In studies such as these, legitimizing has
been presented as a stage within the overall process of institutionalization (Deephouse
and Suchman, 2008; Greenwood et al., 2002). It is through the process of legitimizing
that a subject becomes perceived as acceptable and ultimately taken-for-granted
(Suchman, 1995).
In stage based models of institutionalization, different dimensions of legitimacy are
thought to chronologically define the process of legitimizing (Greenwood et al., 2002;
Suchman, 1995). In early stages material practices are aligned within prevailing norma-
tive prescriptions thus giving them moral legitimacy and/or their functional superiority
is asserted, producing pragmatic legitimacy. Cognitive legitimacy occurs later in the
process when full institutionalization occurs and practices become taken-for-granted as
the natural arrangement (Green, 2004; Green et al., 2009).
Although a few studies have examined behavioural practices by which legitimizing is
accomplished over time (e.g. Reay et al., 2006), most research attention has been on the
discursive processes through which legitimizing occurs. As part of a linguistic turn in

© 2009 Blackwell Publishing Ltd and Society for the Advancement of Management Studies
58 E. Goodrick and T. Reay
organization studies (Alvesson and Karreman, 2000), institutional theorists have become
increasingly interested in the role of language and text in legitimizing new ideas, prac-
tices, or organizational forms (Green et al., 2009; Phillips et al., 2004; Suddaby and
Greenwood, 2005). The construction of discourses to persuade particular audiences has
become a recognized way of legitimizing. For example, Vaara et al. (2006) showed how
discursive strategies of journalists legitimized changes in the pulp and paper industry.
And in extended theoretical work, Vaara and Tienari (2008) highlighted how textual
strategies could legitimize the actions of organizations.
Most accounts of institutional change recognize discursive strategies as key compo-
nents in the process of legitimizing (Deephouse and Suchman, 2008). Both Creed et al.
(2002) and Suddaby and Greenwood (2005) argued that legitimating accounts facilitate
institutional change. Suddaby and Greenwood (2005) showed that innovation was legiti-
mized through rhetorical accounts that constructed congruence between attributes of a
new organizational form, institutional logics, and broad theorizations of change. Creed
et al. (2002) found that legitimating accounts mobilized participation in changing insti-
tutional arrangements through the use of language that framed the desirability of achiev-
ing particular goals. In addition, Glynn and Lounsbury (2005) discussed how discourse
reveals changes in the institutional field. They focused on changes in the Atlanta
Symphony Orchestra to show how in the face of declining orchestral resources the dis-
course of critics legitimized the blending of a commercially oriented market logic with
the traditional aesthetic logic.
Green et al. (2009) took a discursive approach to a staged based model of institution-
alization. They investigated the way in which argument structure justifying material
practices represents shifts from moral/pragmatic legitimacy to cognitive legitimacy.
They showed that the complexity of the arguments used to support Total Quality
Management (TQM) became increasingly simplified over time. They documented how
arguments changed over time from arguments providing ‘more proof’ to those providing
‘less proof’ and interpreted those shifts as a rise in cognitive legitimacy. More specifically,
they showed that as TQM became legitimized and eventually institutionalized, rhetoric
shifted from (1) conclusions based on both a major and minor premise to (2) conclusions
based on an implicit major premise and a minor premise to (3) claims without premises.
Green et al.’s (2009) research contributes to our understanding of legitimizing by clearly
showing how rhetorical arguments are transformed as moral, pragmatic, and cognitive
legitimacy for a new practice are developed.
Although there is a growing body of research investigating the process of legitimizing
new practices, there has been little attention to processes of legitimizing a new profes-
sional role identity (Lawrence and Suddaby, 2006, pp. 223–4; Lounsbury, 2007). This
relative neglect is unfortunate because the construction of identity is central to the
creating of institutions. Identities describe the relationship between an actor and the
field in which that actor operates (Bourdieu and Wacquant, 1992) and have been found
to be tightly linked to practices in the field (e.g. Covaleski et al., 1998; Oakes et al.,
1998). Moreover, even the relatively small amount of literature on legitimizing practices
and forms may not be applicable to understanding the process of legitimizing a new
professional role identity. Professional role identity refers to a sense of self that is
associated with the enactment of a professional role (Chreim et al., 2007; Ibarra, 1999).

© 2009 Blackwell Publishing Ltd and Society for the Advancement of Management Studies
Florence Nightingale Endures 59
On a collective level, role identity provides members of a profession with a definition of
self-in-role and includes the goals, values, norms, and interaction patterns associated
with a role (Ashforth, 2001). How professionals define their role identity is critical to
how they interpret and behave in work situations (Chreim et al., 2007; Pratt et al.,
2006), and professional role identity has been found to be highly resistant to change
(Chreim et al., 2007). Consequently, legitimizing changes in professional identity may
be more difficult and require different rhetorical strategies than legitimizing changes in
practices.
Much of the literature illuminating the discursive processes through which legitimizing
occurred has focused on text produced by the media. Vaara et al. (2006), for example,
used media text concerning international mergers and acquisitions to elucidate the
textual strategies used to legitimize global industrial restructuring. Green et al. (2009)
relied on journals, magazines, and newspapers to trace the discursive arguments used to
justify the adoption of Total Quality Management by the USA business community.
While the use of the media to trace discursive strategies is appropriate to understand how
new practices in the business community are legitimized, it may be a less suitable data
source for understanding a concept such as role identity that is meaningful at the core of
a professional group. Instead, investigating the rhetorical strategies used within the
profession itself, and particularly those used to introduce newcomers to the profession,
may provide a more helpful understanding of the process of legitimizing a new profes-
sional role identity.
While the existing literature has not directly addressed the process of legitimizing a
new professional role identity, there are suggestions that links to the broader societal
environment might be critical.[1] For example, Lounsbury’s (2001) study of practice
variation showed how recyclers began to forge a distinct occupational identity that was
connected to broader ideals of the environmental movement. Rao et al. (2003) found
evidence of an identity change from ‘chefs as translator of classical cuisine’ to ‘chefs as
inventor of nouvelle cuisine’, a movement consistent with the anti-authoritarian wave in
France. Fiol and O’Connor (2006) showed how wearing white coats was important to
physicians in developing a collective professional identity that aligned with scientific
discourse of the time.
In the professional identities profiled above, there are similarities between the new
professional identities and the generally accepted social norms of the times, consistent
with neo-institutionalists’ argument that such alignment confers legitimacy (DiMaggio
and Powell, 1991; Meyer and Rowan, 1977). However, there has not been explicit
attention to the interaction between the direct professional or task environment and the
wider institutional (societal environment) in legitimizing new professional role identities.
Moreover, while there is recognition that discourse plays a central role in legitimizing
institutional change (Phillips et al., 2004; Vaara and Tienari, 2008), studies of legitimiz-
ing new institutional practices and forms using the media as text may not generalize to
professional role identity. We address these gaps in the literature through our study of
how changes in the professional role identity of registered nurses were legitimized in
nursing textbooks.
Registered nurses (RNs) presently are the largest group of health providers in the
world. In the USA alone, there are over two million licensed RNs with the majority being

© 2009 Blackwell Publishing Ltd and Society for the Advancement of Management Studies
60 E. Goodrick and T. Reay
employed in hospitals. Currently, most RNs are female, and even though increasing
numbers of men are entering the profession, less than 5 per cent are male. While the
largest portion of nurses’ time is spend in direct patient care, they also hold a number of
other roles and responsibilities, including supervising other nursing personnel (Bureau of
Health Professions, 2006).
Nursing is an excellent setting to study the process of legitimizing a new professional
role identity because there have been significant changes over time. Nursing began as a
difficult and even undesirable occupation filled with untrained lower class women, as
epitomized by Charles Dickens’ unsavoury Sarah Gamp. Over time the image of nursing
changed and became symbolized by Florence Nightingale, who was credited with the
development of modern nursing. She received notoriety for her efforts during the
Crimean War (1854–56) where she supervised a staff of volunteer nurses and developed
new ideas about how to provide nursing care (Nightingale, 1860). In the USA, nursing
schools following the Florence Nightingale model were introduced in the 1870s through
educational institutions affiliated with hospitals. In these schools of nursing, women
entered a hospital-based, apprentice style programme and learned to become a nurse by
acquiring practical skills on the job.
Even though the first university based nursing programme was started at Yale Uni-
versity in 1932, over 90 per cent of the nation’s nursing schools were still owned and
operated by hospitals in 1950. In 1952, the first nursing education programmes were
established in community colleges. In the 1960s, nursing education began to shift from
an apprentice-based model to colleges and universities where nurses were socialized into
a professional identity before they received any clinical training (Reverby, 1987). In
1958, 83 per cent of all nursing students received their education from diploma hospital
programmes compared to 64 per cent in 1966. By 1970, 54 per cent of nurses were
educated in hospital diploma programmes, and by 1990 hospital based schools of nursing
had closed or become affiliated with colleges and universities (Haase, 1990; Kalisch and
Kalisch, 2004; Melosh, 1982). Currently in 2009, nursing education is delivered exclu-
sively through college or university based programmes.
Nursing developed within a changing environment. In the first decades of the twen-
tieth century, the USA health care sector underwent a fundamental transformation.
Physicians became increasingly important as they successfully used their increased effec-
tiveness in combating disease to argue for professional oversight and to distinguish
themselves from commercial enterprises (Starr, 1982). As the strongest and most effec-
tively organized profession in USA history (Abbott, 1988; Freidson, 1970; Starr, 1982),
physicians dominated the institutional environment of health care until the 1960s (Scott
et al., 2000). However, changing public philosophy supported initiatives such as 1965
Medicare/Medicaid legislation, contributing to the decline of physician hegemony by
authorizing federal involvement in health care (Scott et al., 2000).
Also beginning in the 1960s, the society in which nurses practiced underwent broad
philosophical and cultural changes emphasizing greater equality of opportunity and
outcomes. Both the civil rights and women’s movements advocated for equal opportu-
nity and rights of disenfranchised groups. In the 1960s and 1970s, the consumer move-
ment gained strength as efforts to protect the public expanded from manufacturers of
material goods to services, particularly in health care (Kelly, 1991). And in the 1980s, the

© 2009 Blackwell Publishing Ltd and Society for the Advancement of Management Studies
Florence Nightingale Endures 61
health care organizations where nurses worked changed as hospitals began to define
themselves as business organizations. With private business organizations assumed to be
more efficient and creative than other forms of organization (Stevens, 1989), the increas-
ing costs of health care served as justification for making health care responsive to the
same market place influences as other businesses (Inglehart, 1994). Even non-profit
organizations felt compelled to organize themselves into systems, engage in strategic
planning, diversify, and identify cost centres (Goodrick et al., 1997; Scott et al., 2000).
Our characterization of the institutional context shows that health care became
physician dominated and then more business focused. Nursing changed within this
context as well as within a society which over time became more equalitarian and
consumer driven. In the following sections, we examine how nursing role identity
changed and analyse how those changes were linked to society and established cultural
conventions.

METHODS AND STUDY


Methodological Overview
We used discourse analysis to investigate the use of discourse in nursing textbooks as a
primary medium for the legitimation and institutionalization of professional role identi-
ties for nurses ( Jorgensen and Phillips, 2002; Lawrence and Suddaby, 2006; Putnam and
Fairhurst, 2001). By analysing these texts, we took what is perhaps the most typical
approach to studying the collective beliefs of disciplinary fields (e.g. Agger, 1989; Altbach
and Kelly, 1988; Hackley, 2003). Nursing textbooks intended for future RNs provide a
rich source of data and serve as an important method through which ‘what nurses are’
is communicated to beginning professionals. Since textbooks are written by nurse edu-
cators for the explicit purpose of educating and socializing nursing students, they con-
sequently communicate what is ‘appropriate’ in terms of a nursing role identity. Nursing
educators play an important role in the nursing profession since they are collectively
responsible for transferring both knowledge and professional norms to students (Koff,
2004). Because of this, their authorial voices provide a relevant window into understand-
ing the collective professional role identity of nurses.
Textbooks are part of the disciplinary discourse of an academic field. As vehicles of
education and socialization, textbooks present a more normative view of nursing than
other forms of professional discourse. While textbooks are unlikely to be the first place
that new ideas about nursing are recorded, they have the advantage over the discourse
of professional associations and journals of representing what is accepted enough to be
communicated to the new student nurse. In contrast, other forms of disciplinary dis-
course are more likely to track conversations among the nursing elite. Further, as Levitt
and Nass (1989) point out, the professionalization of academics generates significant
homogeneity in textbook content in any given discipline. The words of textbook writers
represent a widely held view of how people in a field see themselves; authors do not
simply voice their own opinions. Concurrently, textbook writers contribute to the disci-
plinary discourse by the way they represent, build on, and weave together the conver-
sations taking place in the nursing field.

© 2009 Blackwell Publishing Ltd and Society for the Advancement of Management Studies
62 E. Goodrick and T. Reay
We identified representative textbooks using Brandon’s Selected List for the Small
Medical Library and Brandon’s and Hill’s Selected List of Nursing Books and Journals.
These lists are considered to be the standard selection guides for USA libraries newly
involved in the acquisition of nursing literature (Murphy, 1993). Widely accepted by the
nursing community, the books selected present contemporary concepts, theories, and
trends in nursing based on the input of nurses, librarians, and publishers (Brandon and
Hill, 1992). The authors of these textbooks were nurse educators at nursing schools,
colleges, and universities, holding a variety of positions including Coordinator of Nursing
Studies, Professor of Nursing Education, Director of Nurses and Nursing School, and
Director of Nursing Education. We collected all introductory nursing textbooks (31 texts
with 46 different authors) included in these lists for the years 1955–92. (See Appendix for
list of textbooks used.) We chose these years because, as outlined above, during this time
period the format of nursing education changed from an apprenticeship model to one
based on college or university preparation. And since role identity and education are
closely linked for professionals, this time period seemed likely to show role identity
changes if they occurred.
Introductory textbooks typically contain an introduction to both nursing and health
care in general as well as technical information on nursing practice (e.g. nutrition,
cardiovascular system). These introductions tended to capture a particular view of
nursing and were most likely to include role identity relevant material. Thus, we targeted
for our analyses introductory chapters, sections or chapters on general health care,
chapters or sections on the nurse–patient relationship, and the prefaces to all the books.
We verified our selection of material with nursing scholars at a local university. The
textual material was electronically scanned, cleaned, and stored on computer disks for
further processing. Our database consisted of 1482 pages of text.
Our first task was to document changes in statements concerning nursing role iden-
tity as presented in the textbooks. By role identity we mean the goals, values, norms,
and patterns of interaction associated with a role (Ashforth, 2001). We initially focused
on what textbook writers said about the role identity of nurses by documenting
changes over time in identity related themes, utilizing computer aided, traditional
content analytical techniques (Weber, 1990). To provide more depth, we supple-
mented this quantitative approach with representative quotes. In Study A we identified
variation in the content of nursing role identity over time. Then in Study B, we
focused on analysing the textbook explanations of why nursing role identity changed
through a formal rhetorical analysis of how nursing was legitimized (Andrews, 1990;
Putnam and Fairhurst, 2001).

Study A: Changes in Identity Related Themes


Methods. We began by identifying central themes in the texts over time (e.g. Bruner,
1990; Chreim, 2005; Czarniawska-Joerges, 1994; Dunford and Jones, 2000). We focused
on reoccurring themes that captured important aspects of role identity which reflected
central and/or distinctive elements of identity. A theme is represented in the use of a
label and its synonyms (Chreim, 2005; Huff, 1983). The frequency of a theme is one
measure of its centrality to role identity (D’Aveni and Macmillan, 1990).

© 2009 Blackwell Publishing Ltd and Society for the Advancement of Management Studies
Florence Nightingale Endures 63
Table I. Summary of themes with keyword examples

Thematic category Definition Keyword examples

Scientific basis Nursing as science Science, diagnose, assess, clinical


Subservience Lack of professional autonomy Autonomy, choice, collaboratea
Nurturance Nursing as caring Compassion, nurture, caring, heart
Patient autonomy Patients having input into their care Autonomy, independence, partner
Patient rights Patients having entitlements Advocate, rights, choice, choose
Holistic People as whole beings Holistic, well-being, wellness
Economic Nursing as a good or service Consumer, industry, efficient, buy

a
Notes: Reverse coded.

Through repeated readings of the textbooks, we identified a set of seven themes that
captured important aspects of nursing role identity and whose change and interplay over
time could be traced with traditional content analytical techniques. We then operation-
alized these themes by developing a dictionary of keyword concepts for each, drawing on
our reading of both the textbooks and nursing history (e.g. Bullough and Bullough, 1984;
Kalisch and Kalisch, 2004; Melosh, 1982; Reverby, 1987). Dictionaries were limited to
concepts that best represented their respective thematic categories. These themes are
summarized in Table I.
Each theme provides a different component of the answer to the key question of
professional role identity: As nurses, who are we? As indicated in Table I, the Scientific base
theme denotes that nurses are those whose practice is based on scientific principles and
was measured by keywords such as ‘science’, ‘diagnose’, ‘assess’, ‘cure’, ‘disease’, and
‘clinical’. The Subservience theme refers to nurses depicted in terms of following physician
orders and was identified by the absence of the following keywords: ‘autonomy’, ‘choice’,
‘choose’, ‘independent’, and ‘collaboration’. Nurturance denotes nurses’ interest in the
nurture and care of patients and was measured by keywords such as ‘compassion’,
‘nurture’, ‘devotion’, ‘comfort’, and ‘caring’. Both Patient autonomy and Patient rights
capture how nurses are described in relationship to their patients. Patient autonomy refers
to nurses being presented as those who have a partnering relationship with patients while
Patient rights captures nurses as those who treat patients with certain rights, entitlements,
and choices. Patient autonomy was measured by keywords such as ‘independence’,
‘humanistic’, and ‘partner’ while patient rights was defined by keywords like ‘advocate’,
‘choice’, and ‘choose’. Holism captures a nurse’s interest in the whole person, as opposed
to a more limited interest in illness and included keywords such as ‘holistic’, ‘well-being’,
‘health’, and ‘wellness’. Finally, the Economic theme refers to nurses and their work
included as part of an economic system and identified by keywords such as ‘consumer’,
‘industry’, ‘market’, ‘customer’, and ‘efficient’.
In trying to accurately measure these seven themes, it was important that the context
in which keywords occurred be taken into account. We were interested, for example, in
the terms ‘diagnose’ and ‘assess’ when they referred to nurses but not when they referred
to physicians. Similarly, terms like ‘autonomy’ and ‘choice’ were included as part of
Patient autonomy when the referent was the patient but not when they referred to nurses or

© 2009 Blackwell Publishing Ltd and Society for the Advancement of Management Studies
64 E. Goodrick and T. Reay
nursing. We validated our dictionaries by having two independent raters (PhD students
who were unfamiliar with the project) perform a cue-sorting task. The raters were
provided with broad definitions of the seven themes which avoided making use of
dictionary terms – and were asked to sort the 52 keywords back into their appropriate
thematic category. Keywords which were included in multiple themes with different
referents (e.g. autonomy) were sorted with the appropriate modifier (e.g. patient
autonomy, nurse autonomy). The two raters each had over 91 per cent agreement with
the researchers’ classification of keywords.
We employed a computer program, OCP (Oxford Concordance Program) to read and
analyse the text (see Cornelissen, 2008 for a recent example). This program searched the
text using the dictionaries that we had constructed, identifying every instance in which a
given word concept appeared. The output of the program is a report of the frequency
tabulation of word counts, as well as a KWIC (keyword in context) printable listing of all
‘hits’ involving a focal word concept and the sentence in which it was used. These printouts
were turned over to two trained coders who eliminated the noise typically associated with
raw frequency counts. For example, while we were interested in counting the frequency
with which the ‘rights’ of people appeared, the raw computer count initially included
‘right’ as in ‘right hand’ as well. The coders manually and independently culled through
the printouts of the sentences where keyword terms had been identified, eliminating those
which did not meet certain agreed upon criteria. For example, we eliminated terms like
‘heart’ when they referred to the organ instead of an aspect of nurturance. Similarly, we
eliminated cases in which business terms did not involve health care, for example, ‘beauty
shop’. These manual checking processes, though labour intensive, greatly increased our
confidence in the validity of the results. Overall, OCP extracted 7070 keywords from our
texts. We calculated inter-rater reliability by determining the percent agreement between
the coders on whether each of the keywords should be included in its respective dictionary.
Inter-rater reliability for each dictionary ranged from 0.76 to 1.00; the reliability across
the entire set of seven thematic dictionaries was 0.86, satisfying reliability concerns (Miles
and Huberman, 1994). The final count for the individual themes was obtained by
averaging the raters’ counts within each thematic dictionary.
We next divided the raw counts by the total number of words of text, to control for
yearly differences in the overall size of the textbook chapters as well as the fact that some
years had multiple textbooks while others had just one. In order to calculate estimates for
years in which no new textbooks were published, a standard, regression-based interpo-
lation procedure (Tabachnick and Fidell, 1996) generated slope coefficients that were
used to obtain scores for missing years which were then included in subsequent analyses.
As a further aid to detect trends and to enhance comparisons across thematic categories,
the proportions (raw count/total words) were standardized using their respective means
and converted to Z-scores.

Findings. Figure 1 visually depicts the results of the thematic analysis. Table II shows the
correlations of the Z-scores of the thematic proportions (raw count/total words) with
time. Table III shows representative quotes regarding the changes we observed in the
portrayal of nursing role identity over time and connects to the thematic categories of
nursing identity.

© 2009 Blackwell Publishing Ltd and Society for the Advancement of Management Studies
Florence Nightingale Endures 65

Figure 1. Ideological content themes

Before we examined the pattern over time, we sought to determine whether different
textbooks published in the same year painted a homogenous picture of nursing. We
found that the pattern of thematic categories was consistent across textbooks published
in the same year. In examining the pattern over time, Table II indicates that five of the

© 2009 Blackwell Publishing Ltd and Society for the Advancement of Management Studies
66 E. Goodrick and T. Reay
Table II. Zero order correlations between standardized textbook the-
matic counts and time, controlling for total words of texta

Themes Time

1. Scientific basis -0.204


2. Subservience -0.877*
3. Nurturance 0.122
4. Patient autonomy 0.742*
5. Patient rights 0.781*
6. Holistic 0.785*
7. Economic 0.847*

Notes: a These statistics were calculated using estimated proportions for the years
in which no textbooks were published. Estimates were obtained via linear and
quadratic regression analyses. n = 20. Essentially the same results were obtained
in correlational analyses that excluded estimates.
* p < 0.01 (one-tailed test).

seven identity themes (Subservience, Patient Autonomy, Patient Rights, Holistic, and Economic)
were significantly correlated with time while two themes (Scientific Basis, Nurturance) were
not. Both Figure 1 and our reading of the textbooks suggest that there were no sudden
shifts in the prevalence of the five themes correlated with time. In examining the figure,
we observed that changes took place gradually, if not always smoothly. Moreover, the
changes in the five themes did not occur in tandem – different themes changed at
somewhat different times and rates. In reading the texts, we observed subtle changes over
time in how aspects of role identity were constructed. We also observed that changes in
different aspects of role identity did not occur simultaneously. Consequently, we saw no
clear transition points in our data which would suggest the existence of distinct time
periods with consistent constructions of nursing role identity. Still, to simplify presenta-
tion of the data, we found it useful to organize our data in terms of three equal time
periods: 1955–66; 1967–79; 1980–92.
In the earliest years of our data sources (1950–66) we observe the following. First, we
see that the theme nurse Subservience is prominently portrayed, with nurses constructed as
the loyal, able assistants of physicians. Nurses are socialized to be ‘intelligent, neat,
kindly, pleasant, quick, and efficient’ (Matheney et al., 1964, p. 1). As the relatively low
incidence of the Economic theme indicates, nurses did not define themselves primarily as
part of the economic system but rather as part of a ‘service of the highest order’ (Harmer,
1955, p. 5). Nurses saw themselves as being able to determine what constitutes the best
nursing care for a patient. Being a nurse was viewed as a marriage between skilled
training and nurturing characteristics as nurses are ‘knowing of mind, skilled of hand,
and compassionate of heart’ (Rothweiler and White, 1959, p. 3).
In the middle years (1967–79), the Scientific basis and Nurturance themes, which did not
change in predominance, were used in conjunction with the Holism, Patient autonomy,
Patient rights, and Economic themes as the latter themes increased in emphasis. The
prevalence of Nurturance as a theme shows that nursing maintained a nurturing quality,
which was ‘incorporated in practices which are designed to assist patients physically,

© 2009 Blackwell Publishing Ltd and Society for the Advancement of Management Studies
Florence Nightingale Endures 67
Table III. Portrayal of nursing identity in texts over time

Examples of text What is the nursing identity?


(Who are we?)

1955–66 ‘It is this necessity for estimating the individual’s need for hourly Nurses are:
care, encouragement, and training that makes nursing a service • Nurturing (they look after patients
of the highest order’ (Harmer, 1955, p. 5) by determining what constitutes
‘The primary objects of her course in nursing are to make her the best nursing care and
knowing of mind, skilled of hand, and compassionate of heart’ delivering the appropriate
(Rothweiler and White, 1959, p. 3) services)
‘First, he [average American] expects her . . . to be intelligent, • Subservient (they take orders from
neat, kindly, pleasant, quick, and efficient’ (Matheney et al., physicians, and assist them in
1964, p. 22) their duties)
‘To the doctor, the nurse is an able assistant. She must be there • Not part of the economic system
to assist him when needed and must carry out all of his (they serve others as part of a
instructions meticulously during the long hours he is separated higher calling)
from the patient. At all times, she must relay to the patient, by • Scientifically based (they are
word and deed, her absolute trust in the doctor’s integrity and trained to evaluate the nursing
ability’ (Matheney et al., 1964, p. 23) care a patient needs)
1967–79 ‘From its earliest inception nursing has had a nurturing quality, Nurses are:
and today this quality is incorporated in practices which are • Respectful of patient autonomy
designed to assist patients physically, psychologically, and (they assist patients to meet their
sociologically’ (Krozier and Du Gas, 1967, p. 3) own needs)
‘Nurses also initiate and control nursing care that augments and • Nurturing (they provide
complements the physician’s plan of care’ (Fuerst and Wolff, supportive care to patients)
1969, p. 4) • Less subservient (they cooperate
‘The nurse therefore has a function in helping people to cope with others as part of a health
with these stresses and to make good decisions and carry out a team)
course of action consistent with good health’ (Krozier and Du • Increasingly part of an economic
Gas, 1967, p. 2) system (they recognize that people
‘A nurse may be expected by a patient to be knowledgeable, are consumers as well as patients)
skilled and understanding . . . The physician may expect the • Scientifically based (they are well
nurse to be a handmaiden, a helper, a representative of his educated, knowledgeable, and
interests, or a colleague’ (Matheney et al., 1972, p. 22) highly skilled)
‘Health care must be considered from the viewpoint of consumers
of health services as well’ (Elhart et al., 1978, p. 13)
1980–92 ‘. . . the nurse collaborates with the individual in mutually Nurses are:
planning not only the type of care the individual receives, but • Respectful of patient autonomy
also the way this care is carried out and by whom’ (Brill and (they determine care in
Kilts, 1980, p. 17) partnership with patients)
‘Nursing as a profession is unique in that it addresses in a • Protective of patient rights (they
humanistic and holistic manner the responses of individual advocate for patients)
clients and their families to actual and potential health • Holistically based (they focus on
problems’ (Potter and Perry, 1989, p. 2) the whole person when providing
‘The nurse has a primary function to care and a secondary nurturing care)
function to cure, which is carried out in cooperation with the • Scientifically based (they hold
physicians. Curing is most effectively done within an research based, independent
environment of caring’ (Sorensen and Luckmann, 1986, p. 147) knowledge upon which they base
‘Professional nursing practice is . . . sharing responsibility for their practice)
the health and welfare of all those in the community, and • Not subservient (they are
participating in programs designed to prevent illness and independent health professionals
maintain health. It is coordinating and synchronizing medical working in partnership with other
and other professional and technical services as these affect health professionals, including
patients’ (Taylor et al., 1989, p. 7) physicians)
‘Today health care is viewed as a product like breakfast cereal; it • Part of the economic system (they
is a commodity to be purchased’ (Bigelow-Kemp and Pillitteri, do their job and contribute to the
1984, p. 99) profitability of health care)

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68 E. Goodrick and T. Reay
psychologically and sociologically’ (Krozier and Du Gas, 1967, p. 3). Although dominant
in the 1950s and 1960s, we observed the decline of a previously strong aspect of nursing
role identity with the steady erosion of the Subservience theme. Instead, more emphasis on
nurse autonomy was added to the portrayal of nursing identity. This is verified by the
strong negative correlation between Subservience and time. Nurses were presented as ‘a
competent member of the health team’ (Krozier and Du Gas, 1967, p. 6). In this time
period, nurses required ‘extensive use of judgment’ (Matheney et al., 1972, p. 24). Their
relationships with patients were presented as changing, as seen in increases in impor-
tance of the Patient autonomy and Patient rights themes during this time period. Nurses were
presented as helping people make health decisions as opposed to determining what
constituted good care for them. As well, the importance of the Holistic theme increased,
indicating that nurses’ interest was expanding to the health of the whole person, as
opposed to a more limited interest in illness. Finally, increases in the Economic theme
indicate a shift towards nurses perceiving their work as part of the economic system; for
example, beginning in 1978, there is a ‘health industry’ (Henderson and Nite, 1978,
p. 46) and the consumer protections are portrayed as applying to health care services
as well as manufactured goods.
In the latter period of our data (1980 to 1992), nurses’ role identity was presented as
that of an independent health professional working in partnership with other health
professionals, including physicians, to provide care for people. We observed that the
Subservience theme continued to decline while Nurturance and Scientific basis remained
constant. ‘Caring and nurturing are enduring concepts’ (Diekelmann et al., 1980, p. 3)
and remained prominent in the textbooks. No longer based solely on a medical model,
nurses’ identity was presented with its own theoretical base of scientific principles com-
bined with humanism. ‘Because of this need to mesh science and art, body and mind,
physiology and emotion, nurses ideally practice holistic nursing’ (Sorensen and Luck-
mann, 1986, p. 2). Accordingly, we observed an increase over time in the Holistic theme.
We also observed that the terms describing who nurses care for were presented differ-
ently, reflecting shifts in nurses relationship with patients. ‘Client’ and ‘individual’ were
used as well as patient. After 1982, the use of patient was justified with statements such
as, ‘The term [patient] is not used in its former traditional context, but rather to describe
the collaborative nature of the current patient role’ (Lewis and Timby, 1992, p. 16).
Nurses were portrayed as partners with patients in determining appropriate care. This
was in opposition to previous accounts suggesting that nurses determined care for
patients. The Economic theme continued to be more predominantly presented, and
nursing work (as opposed to health care in general) was defined in business terms. There
were ‘consumers of nursing services’ (Krozier and Erb, 1983, p. 17), and ‘a hospital stay
is a purchased commodity’ (Bigelow-Kemp and Pillitteri, 1984, p. 99) as opposed to
earlier when nursing was defined as a ‘service of the highest order’ (Harmer, 1955, p. 5).
The changes in nursing role identity we observed in the textbooks correlate with
changes occurring in health care and in broader society. As women moved into more
professional roles in society, nurses changed from being ‘assistants to physicians’, to
‘independent health professionals working in partnership with other health professionals,
including physicians’. Nurses were previously described as women whose specialized
training enabled them to provide the best nursing care for patients. But over time they

© 2009 Blackwell Publishing Ltd and Society for the Advancement of Management Studies
Florence Nightingale Endures 69
came to be depicted as professionals who were part of a health care team with a
partnering relationship with patients who have certain rights, entitlements, and choices.
This shift was consistent with an increased focus on rights in society. And as health care
increasingly became viewed as an industry like other industries, the description of nurses
in relationship to the economic system changed. Initially nurses were seen as part of
a ‘service of the highest calling’, but later they were depicted as contributing to the
profitability of health care because they cared for patients who were also consumers.

Study B: Changes in the Rhetorical Justification of Nursing Definitions


Method. In Study A, we identified multiple themes as descriptors of the professional
role of a nurse and showed that the combinations of these themes changed over time.
We then wanted to understand how these changing combinations were legitimized.
Therefore we engaged in Study B, which involved a more detailed investigation of the
rhetorical argumentation used in presenting the professional nursing role. We analysed
these textbook explanations of the changes to nursing identity through a formal rhe-
torical analysis of the type and content of arguments used to legitimize how nursing
was defined. In this section, we explain our methodology and present our results for
Study B.
Rhetorical study, a type of discourse analysis, focuses on human efforts to be persua-
sive (Andrews, 1990; Golden-Biddle and Locke, 1993; Putnam and Fairhurst, 2001).
Like other forms of discourse analysis, rhetorical study is interested in the role of
language in structuring social action but is distinguished by its focus on suasion and
influence (Lawrence and Suddaby, 2006). Transitions are particularly amenable to
rhetorical analysis because rhetoric stakes out the study of the debatable as its territory
(Huff, 1983). Rhetorical analysis highlights the forms of arguments associated with the
construction, maintenance, and disruption of institutions (Lawrence and Suddaby,
2006). Since rhetorical study is interested in how claims are made and warranted, it
provides tools for discerning the basis for accepting a conclusion as legitimate (Toulmin
et al., 1979). Here we are interested in how textbook writers claim specific role identity
attributes for nursing and the content of those claims (Glynn, 2000).
We analysed discussions regarding the role identity of nursing by examining how
authors framed and argued for the correctness of their definition of nursing in our
introductory textbooks by using a system of formal rhetorical categories as presented by
Smith (1969). We focused on how texts framed the changing definitions of nursing
because ‘what nursing is’ implies ‘who we are as nurses’, allowing us to systematically
capture how identity role changes were legitimized. Smith’s (1969) categorization pro-
vided labels and ways of talking about the patterns we identified in our initial reading and
coding of text. Thus in accordance with Smith (1969), we categorized arguments in
nursing textbooks into one of the following three types: (1) arguments from definition, (2)
arguments from comparison, and (3) arguments from testimony. We explain these
categories below.
First, arguments from definition rely on logic and take the form of an implicit syllogism
(logical argument) in which the conclusions follow from acceptance of the premises. We
found that nursing definitions were justified by arguments from definition in which the

© 2009 Blackwell Publishing Ltd and Society for the Advancement of Management Studies
70 E. Goodrick and T. Reay
Table IV. Summary of rhetorical techniques used to justify nursing definitions

Technique Definition Example

1. Arguments by definition Implicit syllogisms in which ‘As both society and the health
conclusions follow from the care system continue to change,
premises, specifically those the role of the contemporary
which link definitional changes nurse is changing too’
in nursing to societal changes
2. Arguments by comparison
A. Comparisons to the past Arguing that nursing has a ‘Caring and nurturing are
relationship to the past enduring concepts . . . It can
be said now, with the same
assurance as at the beginning,
nurses care about people’
B. Comparisons to referent Arguing for a particular nursing ‘For a definition of nursing to be
groups definition because it helpful to a nurse it must . . .
differentiates nursing from other describe what is unique about
health work nursing and differentiate it from
other endeavours’
3. Arguments by testimony
A. Implied consensus Arguing for a particular nursing ‘. . . has widespread acceptance’
definition because it is widely
accepted
B. Nursing authorities Citing others ‘Nursing has been defined by
Martha Rogers as follows . . . ’
C. Professional associations Adopting official definitions of ‘In 1980, the Congress for
professional nursing Nursing Practice defined nursing
organizations as . . . ’

implicit syllogism attributed changes within nursing to societal trends. Second, argu-
ments from comparisons rely on the similarity or differences between two things. Two
different types of comparisons were used to justify nursing definitions: comparisons to the
past and comparisons to referent groups. Arguments from comparison were used to
argue both that there was a relationship between nursing today and in the past, and that
nursing was different from the past. Arguments from comparison to referent groups were
used to define nursing by differentiating nurses from other health care workers. And
third, arguments from testimony use authorities, statistics, facts, laws, and precedents to
support a point. Arguments from testimony rely on explicit or implicit authority for
legitimacy. Adopting professional nursing associations’ definitions, citing nursing
authorities, and implied consensus in the profession were the types of arguments from
testimony used to justify nursing definitions. Table IV provides a summary of these
arguments and provides textual examples of each.
By convention, rhetorical analysis is typically conducted by a single analyst, given the
demands of having to create an in-depth understanding of the text (Donnellon et al.,
1986). Since there were two researchers, we devised a simple procedure to produce a
coherent analysis. First, we worked together to identify and select relevant portions of

© 2009 Blackwell Publishing Ltd and Society for the Advancement of Management Studies
Florence Nightingale Endures 71
the text for this analysis. Aided by the search function of a conventional word processing
program, and using key words and phrases such as ‘nursing is’, ‘definitions’, and
‘defined’, relevant sections of text were culled from each textbook. In several instances,
we reviewed the hard copy of the text to clarify and reach agreement about where
discussions began and ended. The selected text included the nursing definitions, associ-
ated commentary, and general discussion about nursing that preceded explicit definitions
of nursing. Next, one researcher conducted a detailed dissection of each portion of
the text, observing and classifying instances that fit the various categories. The results
of this were subsequently presented to, and scrutinized by a second researcher. This
process yielded a total of 93 pages for analysis, from which a total of 44 rhetorical
arguments regarding the definition of nursing could be identified, sorted, and
interpreted.

Findings. Based on our categories of arguments (Comparisons, Definitions, and Testi-


mony), we identified four different types of rhetoric used to justify changing definitions:
(1) Comparison to referent groups; (2) Comparison to the past emphasizing similarities; (3) Comparison
to the past emphasizing differences; and (4) Testimony based on implicit or explicit authority.
The first type of rhetoric used to justify nursing definitions was an argument using
Comparisons to referent groups. Initially, the comparison was either to other types of nursing
personnel or to health care workers in general. While the distinction between nursing
and other health care workers continued, justifications using comparisons to other
nursing personnel such as nursing aides did not. Instead, there was an increasing
emphasis on distinguishing nursing from medicine. In 1959, Rothweiler and White,
define nursing by distinguishing the functions of the registered nurse from other types of
nursing personnel requiring less study. They state:

We also have the people who do the caring or nursing: the ‘practical’ nurse, the
‘vocational’ nurse, the ‘nurse aide’, the ‘nursing attendant’, and others. How does the
professional nurse differ from these others who are also caring for the sick and
helpless? Why is a systematic and organized course of study necessary for her?
(Rothweiler and White, 1959, p. 4)

Twenty-one years later Brill and Kilts (1980) argue that their definition of nursing
reflects nursing leaders developing ‘conceptual bases for nursing practice which are
separate and distinct from medical practices and which place nurses in a collaborative,
rather than dependent position within the health care system’ (p. 16).
The second type of rhetoric we observed is an argument by Comparison to the past
emphasizing similarities. Narrow and Buschle (1982), for example, emphasize continuity
with the past to justify a specific perspective on nursing when they adopt and then
expand upon a 1960s’ definition of nursing. They justify using this ‘timeless’ definition as
a springboard for their own views by arguing that many currently popular emphases are
implied rather than explicitly stated in this older definition. They argue that the state-
ment ‘she helps the patient to carry out the therapeutic plan as initiated by the physician’
from the 1960s’ definition ‘recognizes that the patient should be an active participant in
his own care whenever possible’ (1982, p. 42). Similarly, Krozier and Erb (1987) justify

© 2009 Blackwell Publishing Ltd and Society for the Advancement of Management Studies
72 E. Goodrick and T. Reay
changes in nursing by arguing that they are consistent with Florence Nightingale’s vision
at the turn of the century. A nurse, according to Krozier and Erb, is one who has added
‘specific characteristics of true professionalism’ to the ‘humanistic caring, nurturing,
comforting, and supporting’ characteristics of the traditional nurse (1987, p. 7). The
characteristics of true professionalism, ‘education, a code of ethics, mastery of a craft, an
informed membership involved in the organized profession, and accountability for
actions’, are constructed to be additions to the more traditional nurturing image of a
nurse rather than in opposition to it (1987, p. 7).
The third type of rhetoric we observed is an Argument from comparison to the past empha-
sizing differences. In our texts, this rhetoric appeared concurrently with an Argument from
definition. For example, Du Gas (1977, p. 9) argues in her definition of nursing, that the
‘broader range of activities than is represented in the traditional image of the nurse at the
bedside of the sick patient’ is due to ‘the role of nursing constantly changing in response
to societal needs’. This strategy of attributing changes in nursing to societal changes
constructs nursing as simply a reflection of societal needs. Nurses’ new role identity
follows then from acceptance of the premises implicit in this syllogism: (1) society has
changed, and (2) nursing reflects society.
Similarly, Brill and Kilts (1980) argue that changes in nursing reflect societal change.
They claim that their definition of nursing ‘implies that the nurse no longer cares for,
does for, or decides for the “patient” but rather that the nurse collaborates with the
individual in mutually planning not only the type of care the individual receives but also
the way in which this care is carried out and by whom’ (1980, p. 17). Here nursing is
constructed in comparison to a model of nursing where decisions were made by health
professionals because ill patients were unable to make decisions in their own best
interests. The reconstruction of nursing as a humanistic partnership between the nurse
and the patient is justified by societal trends, such as an increased focus on consumer
rights and the changing role of women in society, which ‘led to a redefinition of nursing
as a profession’ (1980, p. 17).
We also found that these last two ways of portraying change were sometimes used in
tandem; explanations of identity role change included both (1) role identity changing in
concert with societal change and (2) an emphasis on similarities to the past. Diekelmann
et al. (1980), for example, justify nursing’s focus on a holistic approach to health care as
opposed to the more restorative services by arguing that comprehensive health care is
valued and desired by society. They suggest that:

Nursing is uniquely poised to meet this challenge because the health care needs of
people everywhere, whatever their circumstances have been the focus of our work as
nurses. It can be said in all truth, at the close of this first century of nursing, that the
character of nurses and nursing has been forged not by self-interest but by intelli-
gent, imaginative, innovative responses to a maelstrom of changing social needs. It
can be said now, with the same assurance as the beginning, nurses care about
people. (p. 4)

Comparisons to the past emphasize points of continuity between nursing of the day
and earlier times. This is illustrated in the argument that a holistic approach is con-

© 2009 Blackwell Publishing Ltd and Society for the Advancement of Management Studies
Florence Nightingale Endures 73
sistent with nursing’s historical concern with caring for people and their health needs.
At the same time, the clear implication is that nursing would not have undergone such
a change if societal needs had not warranted it because nursing is not motivated by
serving its own interests but by meeting the needs of society. Thus, the implicit syllo-
gism used here to justify a holistic approach is: (1) societal needs have changed, (2)
nursing reflects societal needs, and (3) thus, nursing has changed but not in its basic
character.
The final type of rhetoric we observed in the textbooks was arguments from Testimony
based on implicit or explicit authority. In the early years, the authority of textbook authors was
used to legitimate nursing definitions while professional nursing associations and con-
sensus in the profession were relied on in later years. Early definitions tended to be
offered without explanation other than ‘this is the definition being used in this textbook’
and nursing, at least through the 1960s, was framed as an extension of everyday
activities. For example, in a textbook by Matheney et al. (1968, p. 17), it is asserted that
nursing requires a problem-solving approach which ‘involves the ordinary mental activi-
ties carried out daily by every person’.
Beginning in 1985, the official status of professional associations was used to justify
adopting particular nursing definitions. Nursing theorists were given the authority to
redefine nursing and consensus in the profession was used to justify adopting a particular
nursing definition. For example, before adopting the American Nursing Association’s
(ANA) 1980 definition of nursing, Lewis and Timby (1992, p. 4), argue that, ‘It [nursing]
has changed and will continue to change as theorists refine the science of nursing’. Kemp
et al. (1989, p. 9) justify adopting this same definition of nursing both by the fact that it
is the official ANA definition and that it ‘is the definition most accepted today as best
describing the functions of a modern nurse’.

LEGITIMIZING A NEW ROLE IDENTITY


In the previous sections we presented the findings from our data analysis that shows
evidence of change in how nursing role identity was presented (Study A) and four
rhetorical arguments justifying the existence of, and any changes to, nursing (Study B).
More specifically, in Study A we identified the temporal patterns of relative emphasis on
each of seven thematic categories (Scientific Basis; Nurturance; Subservience; Patient Autonomy;
Patient Rights; Holism; Economics). And in Study B we identified four rhetorical arguments
used to justify definitions of nursing role identities (Comparison to referent groups; Comparison
to the past emphasizing similarities; Comparison to the past emphasizing differences; Testimony based on
implicit or explicit authority). In this section, we draw on these combined findings to under-
stand how discourse in textbooks was used in legitimizing changes to the professional role
identity for nurses. Through our analysis of the rhetorical arguments, we identified five
ways language was used to legitimize a new professional role identity: (1) Naturalizing the
past; (2) Normalizing new meanings; (3) Altering identity referents; (4) Connecting with
the institutional environment; and (5) Referencing authority. These rhetorical arguments
we identified were all related to moral legitimacy; that is, they were focused on justifying
the new professional role identity as appropriate.

© 2009 Blackwell Publishing Ltd and Society for the Advancement of Management Studies
74 E. Goodrick and T. Reay
Naturalizing the Past
The rhetorical argument Comparison to the past emphasizing similarities and the identity
themes of Holism and Patient Autonomy provide the foundation for the first way of legiti-
mizing role identity. Rather than disruptive rhetoric which focuses on discrepancies
between the present and the past (e.g. Rao et al., 2003), the rhetoric we observed in the
textbooks presented the new role identity as appropriate for nurses by making it relevant
to the past. Language portrayed the new role identity as congruent with previous ways
of nursing, and differences between the new and the old were minimized through the
rhetoric of congruency and harmony. In contrast to previous institutional theory indi-
cating the importance of discrediting prevailing ideas (e.g. Greenwood and Hinings,
1988; Oliver, 1992), the new role identity was presented through the use of ideas and
concepts that were already recognized as legitimate. The nursing role identity was
portrayed as either consistent with, implied in, or in addition to older traditional aspects.
For example, the increased prevalence of new role identity themes such as Holism and
Patient Autonomy were presented in ways that did not discredit the past. Instead, at each
step along the way, the text showed threads of connections and points of contact with the
past so that the new role identity was presented as relatively similar. Krozier and Erb
(1987), for example, argued that these changes in nursing were consistent with Florence
Nightingale’s vision at the turn of the century.
With a basic message that currently popular emphases are an expansion of historical
ones, this type of rhetoric suggests that the newer, emerging role identity of nursing is a
natural descendant of its own ancestry, and bears some of its latent, but nevertheless,
inherited characteristics. As a result, the new role identity of nursing is not a rejection or
contradiction of older identities, but a progeny of it. Even as the text continuously
legitimized selected aspects of the old role identity, other aspects were not discussed; the
texts did not refer to those facets. This lack of attention in the textbooks over time
suggests that some aspects of the old role identity were delegitimized because they were
not reproduced.

Normalizing New Meanings


Based on our analysis of changes in the themes of Nurturance, Patient Autonomy, and Patient
Rights together with Study B’s first and second rhetorical arguments of Comparison to the
past emphasizing similarities and Comparisons to referent groups we identified a second way of
legitimizing the new role identity – legitimizing by normalizing new meanings. In this
type of rhetoric, old labels were stretched to incorporate new meanings (Albert, 1992;
Gioia et al., 2000). Through this mechanism, old meanings gradually eroded and were
replaced with the new. New meanings were legitimized both through their association
with the old labels and by their presentation as resonating with social and economic
changes that had occurred in the larger institutional environment, such as an increased
focus on consumer rights and the changing role of women. The new professional role
identity was made to appear appropriate through rhetorical arguments which minimized
its novelty. The new role identity was thus presented as normal or natural by the use of
rhetorical arguments framing it with old labels that were used to reflect new meanings.
Below, we provide examples.

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Florence Nightingale Endures 75
The words used for nurturing behaviours such as ‘helping’, ‘caring’, and ‘supporting’
remained the same throughout the 37 years we tracked, but the meaning for each of
these labels changed. For example, in the 1950s’ textbooks, ‘caring’ meant that a nurse
determined what constituted the best care for patients, much like a mother would do
for a child (Smith, 1980). Later, ‘caring’ was used to explain the way in which nurses
empowered patients to have a strong voice in their own care; facilitating a change in how
nurses were defined in relationship to their patients. The latter shift was consistent with
broader changes in society in reflecting a concern with human worth and dignity and the
importance of choice to that dignity (Gruending, 1985; Waterman, 1984).
As well, the meaning of the label ‘professional’ changed over time. In early texts, the
term ‘professional’ referred to a registered nurse who was formally educated, to differ-
entiate that role from other types of nursing personnel. Later, the meaning of ‘profes-
sional’ shifted and became more akin to the sociological use of the term in which
professional refers to an occupation having an independent body of knowledge, an
ethical code, education controlled by the occupation, and accountability for actions. This
shift was consistent with broad cultural changes taking place in society which supported
women having professional roles. Specifically, the advent of the women’s movement
helped legitimate a professional agenda for nursing, allowing nursing to loosen its links to
subordinate ideals about women (Bullough and Bullough, 1984).
The meaning of the term ‘patient’ was also changed in the texts over time. Until 1980,
‘patient’ was the only term used for the people who received care. After that, ‘client’ and
‘individual’ were also used. Starting in 1982, the use of the word ‘patient’ was justified.
The basic argument in these textbooks is that the meaning of ‘patient’ should expand to
reflect current philosophies – humanism and holism – rather than only denoting an ill
person dependent upon health care providers. This use of language was important in
legitimizing the new professional role identity because it implied that nurses were defined
in relationship to the recipient of care. Nurses were no longer presented as ‘mothers’ to
the ill but rather partners in decision-making with people both sick and well.

Altering Identity Referents


Study B’s first rhetorical argument Comparison to referent groups and the theme of Subservience
from Study A provide the foundation for explaining our third way of legitimizing a new
professional role identity: altering identity referents. Rather than explicitly discounting
the previous role identity, the referent group to whom comparisons were made was
altered which minimized the scale of change. The presence of other groups and profes-
sions help to distinguish and define the role identity of any given group by providing
external referents, points of comparison, and contrasts (Ashforth and Mael, 1989; Tajfel
and Turner, 1979). Consequently, the identity of a group and the relative salience of its
constituent elements is partly a function of identifying and defining other groups as being
similar to, or different from itself. This implies that one means by which a new role
identity can be legitimized is by uncoupling role identity from its original, comparative
referents, and replacing them with different ones. Such a process is generally consistent
with ideas that social identities are comparative in nature, and can change if different
comparison groups become relevant in a particular context (Hogg and Terry, 2000). The

© 2009 Blackwell Publishing Ltd and Society for the Advancement of Management Studies
76 E. Goodrick and T. Reay
legitimizing process therefore combines language legitimizing the new referents and also
delegitimizing (by ignoring) the previously used referent groups.
The significance of a new role identity can be framed differently depending upon the
referent group chosen for comparison. Choosing the same referent group whose role
identity has remained unchanged will highlight changes in the role identity of the focal
group. Conversely, choosing a referent group whose identity is closer to the new role
identity of the focal group will lowlight the significance of a change and make it seem
more appropriate. Considering the example of decreased emphasis on Subservience over
time, we observed that in the early years of our data, nurses’ role identity was framed
through comparisons to other nursing staff such as nursing aides and practical nurses
while in later years of the textbooks, the comparison was to other health personnel
including physicians but not to nursing aides. By using different referent groups, the
language used in textbooks contributed to legitimizing the new role identity and at the
same time assisted in delegitimizing the old by playing down the differences between
nursing and referent groups. This rhetorical framing tended to minimize the significance
of the shift over time from, for example, subservience to more autonomy.

Connecting to the Institutional Environment


The third rhetorical argument from Study B, Arguments from comparison to the past empha-
sizing differences, provides the basis for our observation that the new role identity was
legitimized through rhetoric connecting it to the institutional environment. Language
used in the textbooks portrayed selected characteristics of the institutional environment
as both enabling and constraining forces that impacted on the creation and maintenance
of professional role identity. The nursing profession was presented as tightly inter-
connected with its environment and the new professional role identity was justified
as appropriate through attributions to societal trends. For example, the heightening of
interest in individualism and individual rights during the time period we studied (Scott
and Meyer, 1994; Waterman, 1984) was used to legitimize an evolving role identity that
emphasized a concern with human worth and dignity and the importance of individual
choice. By focusing on the stable relationship between societal norms and professional
role identity, the rhetoric emphasizes a different type of continuity: not between current
nursing and its own past but rather a continuity of nursing’s relationship to the society at
large. The new role identity was portrayed as a normal response to institutional forces,
developing an understated argument that the new role identity was merely an appropri-
ate response to an ever changing society. The tight connection between professional role
identity and current environmental conditions suggests that role identity facets inconsis-
tent with society were no longer appropriate.

Referencing Authority
The final way of legitimizing a new role identity is founded on Study B’s fourth rhetorical
argument, Testimony based on implicit or explicit authority. In the textbooks, changes to the
nursing role identity were constructed as appropriate through references to a number of
authorities. These authorities were: the textbook authors, nursing theorists, the profes-

© 2009 Blackwell Publishing Ltd and Society for the Advancement of Management Studies
Florence Nightingale Endures 77
sional nursing association, and stated consensus in the profession as a whole. In the
earliest textbooks we reviewed, legitimizing language referred to the authority of the
textbook authors themselves. In later years, language referred to different nursing
authorities – nursing leaders more generally, and in particular, the professional nursing
association. By using different authorities over time to create acceptance for the new
professional role identity, the old role identity was not explicitly rejected. Instead, it
received less and less attention. Consequently, delegitimizing previous authorizations
of nursing role identity was accomplished, not through direct assault, but by quietly
ignoring them.

CONCLUSIONS
In this paper, we contribute to the literature on legitimizing by focusing on the role of
rhetoric in accomplishing the institutionalization of changes to professional role identity.
We investigated the discursive processes through which a new professional role identity
was legitimized in USA nursing textbooks. While the extant literature has shown that
discourse plays a central role in legitimizing institutional change (Phillips et al., 2004;
Vaara and Tienari, 2008), our study is one of the first to empirically show how language
can be used in legitimizing a new professional role identity. Based on our data, we
theorized five rhetorical strategies through which collective professional role identities
may be legitimized and perhaps institutionalized. We summarize these strategies below.
First, rather than disruptive rhetoric which focuses on discrepancies between the
present and the past, the rhetoric we observed legitimized the new role identity by
naturalizing the past. That is, making the past relevant to the present. Second, new role
identities were legitimized by normalizing new meanings through the use of old labels
that are stretched to accommodate the new identity. A third way of legitimizing the new
professional role identity was by altering identity referents. By selectively using different
referent groups to lowlight the differences between the past and the present, the signifi-
cance of the shift in role identity over time was minimized. Fourth, new role identities
were legitimized through rhetoric connecting them with the institutional environment.
By presenting changes in role identity as normal responses to institutional forces, these
changes were legitimized without negating the past. Finally, changes to the nursing role
identity were legitimized in the textbooks by referencing different authorities over time,
including textbook authors, nursing theorists, and professional associations.
Our study contributes to the literature on legitimizing (and institutional change more
broadly) in three ways. First, our findings suggest that legitimizing changes in profes-
sional role identity occurs through somewhat different rhetorical strategies than legiti-
mizing changes in practices. Language may be used to incrementally and almost invisibly
develop new arguments supporting a new role identity without ever openly negating (or
delegitimizing) the old role identity. This process of legitimizing stands in contrast to that
identified by others in which specific arguments are made to delegitimize the past in
order to encourage the acceptance of a new practice or way of working (e.g. Glynn and
Lounsbury, 2005; Vaara and Tienari, 2002). Our study suggests that legitimizing in
different settings may have different patterns than the widely accepted stage based
processes of institutionalizing (Deephouse and Suchman, 2008) which are based on a

© 2009 Blackwell Publishing Ltd and Society for the Advancement of Management Studies
78 E. Goodrick and T. Reay
conceptualization of institutional change as episodic (Greenwood et al., 2002). The
pattern of change we observed was one of slow and evolutionary but significant change
over time. Thus we suggest that when rhetorical arguments are used in legitimizing
changes that have occurred through episodic change, these arguments are likely to reflect
the importance of a break with the past to justify adoption of the new ways. However, in
situations such as professional role identity change, where the change process itself is
more continuous, rhetorical arguments must minimize any sense of breaking from the
past and instead combine and intertwine delegitimizing and legitimizing efforts.
The second way our study contributes to the literature is through our identification
of legitimizing processes that were only focused on arguments of moral legitimacy.
Although we reviewed textual material created over a fairly lengthy period of time (37
years), unlike Green et al. (2009) we were not able to identify arguments that progressed
from a focus on moral and pragmatic legitimacy to cognitive legitimacy. Instead, we only
observed arguments based on moral legitimacy – that adopting a particular role identity
was the appropriate and right thing to do. It may be that in studying how a core, central
and enduring concept like role identity is legitimized, rhetorical arguments must be
tailored to focus on issues of moral legitimacy because pragmatism is somewhat anti-
thetical to core beliefs. However, the focus on moral legitimacy we observed may also be
related to our study of textbooks. Researchers usually restrict their attention to one type
of text, as we have done with textbooks, and as a number of scholars have done with
media accounts (e.g. Green et al., 2009; Vaara et al., 2006). Other textual materials, for
example business press or academic journal articles, may use arguments based on
pragmatism since they are targeted to already established professionals compared to the
expected newcomer audience of textbooks. Thus, we suggest that instead of considering
the process of legitimizing as consisting of a sequence of steps (moral, pragmatic, cogni-
tive), different types of textual materials may concurrently focus on developing different
types of legitimacy.
Finally, and perhaps most importantly, we believe that our study contributes to the
literature on institutional change and institutional work by highlighting the importance
of interactions between the professional task environment and the wider institutional
environment. The new nursing role identity was legitimized through arguments that
presented changes in society as justifications for changes in professional role identity.
These connections with the environment were articulated in such a way that the pro-
fessional role identity of nurses was legitimized in a changing institutional context. In this
way, the professional task environment was embedded rhetorically in the wider institu-
tional environment as part of the legitimizing process. Our study is therefore similar to
studies that found innovations were legitimized through linkages to the broader culture
(e.g. Creed et al., 2002; Suddaby and Greenwood, 2005). However, because of our focus
on rhetorical strategies used by the nursing profession to legitimize their own role
identity, we were able to highlight the specific arguments used to connect with the
institutional environment. For example, the importance of caring for patients as an
integral component of nurses’ role identity required little justification in the early years
of textbooks we studied. But in later textbooks, the arguments became married with those
of efficiency and economics, and were presented as appropriate and proper given the
current economically focused society. The importance of understanding how legitimiz-

© 2009 Blackwell Publishing Ltd and Society for the Advancement of Management Studies
Florence Nightingale Endures 79
ing processes at the professional or organizational level are connected with the broader
institutional environment is often discussed but seldom studied empirically. Our study
shows a purposeful linking of rhetorical arguments to particular components of that
environment. In our case, these arguments minimized the significance of the changing
role identity, but other studies might reveal arguments that connect with the environ-
ment in order to magnify the change. Future research in other settings is certainly
warranted.
Our study has both strengths and limitations. In seeking to understand the process of
legitimizing a new professional role identity, we relied on a rhetorical analysis of the
language used in nursing textbooks. Our choice of textbooks as data allowed us to
examine the ways in which role identity was presented to newcomers in the profession.
This provided us with information that was widely accepted because it was being taught
broadly to incoming student nurses. However, by focusing on textbooks, our study also
has limitations because we did not capture all discussion in the field concerning the
appropriate nursing role identity. Academic nursing journals likely highlight more con-
troversial issues than textbooks, and we were not able to examine rhetorical arguments
geared towards established professionals. In addition, our focus on textbooks meant that
we were unable to address how changes in the role identity were enacted in practice.
While other research has highlighted the sometimes complex relationship between
education and the hospital-based practice of nursing (e.g. Bolton, 2004; Chua and Clegg,
1989), our goal in this study was to gain insight into the ways in which nursing role
identity was presented to new entrants (student nurses). In future work we may be able
to gather rhetorical arguments from different sources, and compare those with argu-
ments identified here.
As the founder of modern nursing, Florence Nightingale has long been held up as the
ideal nurse. Over the years, what has been highlighted about her has changed. In
particular, as nursing role identity changed to include more autonomous characteris-
tics, her independent nature was emphasized, in addition to her self-sacrifice and devo-
tion (Dingwall and Allen, 2001; Whittaker and Olesen, 1964). Consequently, Florence
Nightingale continues to be presented as a symbol of modern nursing, in spite of overt
changes in the nursing role. Similarly, our study has shown that legitimizing a new
nursing role identity relied on rhetorical strategies that minimized disruption and
focused on continuity.

ACKNOWLEDGMENTS
The authors would like to thank David Deephouse, Huseyin Leblebici, Doug Creed, and Mary Ann Glynn
for comments on previous versions of this paper. We especially thank the editor, Joep Cornelissen, and the
anonymous reviewers for their very helpful comments and suggestions.

NOTE
[1] There has, however, been work on legitimation of organizational identity including research from a
discursive perspective (e.g. Brown, 2006; Maguire and Phillips, 2008) and a sensemaking perspective
within the broad remit of interpretive sociology (e.g. Corley and Gioia, 2004; Ravasi and Schultz, 2006).

© 2009 Blackwell Publishing Ltd and Society for the Advancement of Management Studies
80 E. Goodrick and T. Reay
APPENDIX: DATA SOURCES LISTED CHRONOLOGICALLY
Harmer, B. (1955). Textbook of the Principles and Practice of Nursing. New York: Macmillan.
Rothweiler, E. and White, J. M. (1959). The Art and Science of Nursing. Philadelphia, PA:
F.A. Davis Company.
Matheney, R. V., Nolan, B. T., Ehrhart, A. M., Griffin, G. J. and Griffin, J. K. (1964).
Fundamentals of Patient-Centered Nursing. St Louis, MO: Mosby.
Krozier, B. B. and Du Gas, B. W. (1967). Fundamentals of Patient Care: A Comprehensive
Approach to Nursing. Philadelphia, PA: Saunders.
Matheney, R. V., Nolan, B. T., Ehrhart, A. M. and Griffin, G. J. (1968). Fundamentals of
Patient-Centered Nursing. St Louis, MO: Mosby.
Fuerst, E. V. and Wolff, L. (1969). Fundamentals of Nursing: The Humanities and the Sciences in
Nursing. Philadelphia, PA: J.B. Lippincott.
Matheney, R. V., Nolan, B. T., Hogan, A. E. and Griffin, G. J. (1972). Fundamentals of
Patient-Centered Nursing. St Louis, MO: Mosby.
Gragg, S. H. and Rees, O. M. (1974). Scientific Principles in Nursing. St Louis, MO: Mosby.
Du Gas, B. W. (1977). Introduction to Patient Care. Philadelphia, PA: W.B. Saunders
Company.
Elhart, D., Firsich, S. C., Gragg, S. H and Rees, O. M. (1978). Scientific Principles in
Nursing. St Louis, MO: Mosby.
Henderson, V. and Nite, G. (1978). Principles and Practice of Nursing. New York:
Macmillan.
Brill, E. L. and Kilts, D. F. (1980). Foundations for Nursing. New York: Appleton-Century-
Crofts.
Diekelmann, N., Bennett, P. H., Shauger, M. and Vickerman, L. B. (1980). Fundamentals
of Nursing. New York: McGraw-Hill.
Narrow, B. W. and Buschle, K. B. (1982). Fundamentals of Nursing Practice. New York:
Wiley.
Du Gas, B. W. (1983). Introduction to Patient Care. Philadelphia, PA: W.B. Saunders
Company.
Krozier, B. and Erb, G. (1983). Fundamentals of Nursing: Concepts and Procedures. Menlo Park,
CA: Addison-Wesley.
Wolff, L., Weitzel, M., Zornow, R. A. and Zsohar, H. (1983). Fundamentals of Nursing.
Philadelphia, PA: Lippincott Company.
Bigelow-Kemp, B. and Pillitteri, A. (1984). Fundamentals of Nursing. Boston, MA: Little,
Brown and Company.
Potter, P. A. and Perry, A. J. (1985). Fundamentals of Nursing: Concepts, Process, and Practice.
St Louis, MO: Mosby.
Brill, E. L. and Kilts, D. F. (1986). Foundations for Nursing. Norwalk, CT: Appleton and
Lange.
Sorensen, K. C. and Luckmann, J. (1986). Basic Nursing. Philadelphia, PA: W.B. Saun-
ders Company.

© 2009 Blackwell Publishing Ltd and Society for the Advancement of Management Studies
Florence Nightingale Endures 81
Sundberg, M. C. (1986). Fundamentals of Nursing. Monterey, CA: Jones and Bartlett
Publishers.
Krozier, B. and Erb, G. (1987). Fundamentals of Nursing. Menlo Park, CA: Addison-
Wesley.
Narrow, B. W. and Buschle, K. B. (1987). Fundamentals of Nursing Practice. New York:
Wiley.
Potter, P. A. and Perry, A. J. (1987). Basic Nursing: Theory and Practice. St Louis, MO:
Mosby.
Kemp, B. B., Pillitteri, A. and Brown, P. (1989). Fundamentals of Nursing: A Framework for
Practice. Philadelphia, PA: J.B. Lippincott Company.
Potter, P. A. and Perry, A. G. (1989). Fundamentals of Nursing: Concepts, Process, and Practice.
St Louis, MO: Mosby.
Sundberg, M. C. (1989). Fundamentals of Nursing: With Clinical Procedures. Boston, MA:
Jones and Barlett.
Taylor, C., Lillis, C. and LeMone, P. (1989). Fundamentals of Nursing. Philadelphia, PA:
J.B. Lippincott Co.
Potter, P. A. and Perry, A. J. (1991). Basic Nursing: Theory and Practice. St Louis, MO:
Mosby.
Lewis, L. W. and Timby, B. K. (1992). Fundamental Skills and Concepts in Patient Care.
Philadelphia, PA: J.B. Lippincott.

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