PERSONALITY CHARACTERISTICS ASSOCIATED WITH SUCCESS IN LEARNING AND PRACTICING NURSE-MIDWIFERY*

Brenna H. Bry, Ph.D. and Teresa Marsico, C.N.M., M. Ed.

ABSTRACT

The California Psychological Inventory (CPI) was administered to 36 women who were accepted into two different urban, northeast, nurse-midwifery education programs. Two years later, it was determined whether or not these subjects had completed their nurse-midwifery education programs without difficulty and had entered the practice of midwifery. Then a step-wise discriminant analysis was performed on their CPI scale scores to determine which combination of scale scores best differentiated the group that completed without difficulty and was practicing from those who were not. The Sociali- zation, Dominance, Tolerance, and Self-Control scales, taken together, accounted for the group membership of all except two of the subjects. It is suggested that these findings be cross-validated on another sample of subjects to determine if the CPI is predictive of success in nurse-midwifery education and practice.

The number of nurses returning to school to study nurse-midwifery in- creases every year. l Most of these students complete their programs successfully and go into nurse- midwifery practice, but some do not. This situation has prompted Beebe to state that selection criteria must be found which will enable programs to select students with a high probability of success as practitioners as well as students. 2

Research by Machotka et al. with child health associates suggests that

??This study was made possible with funds made available through the Department of Health, Education, and Welfare, Division of Nursing, Nurse-Practitioner Training Grant l-D24-NUOOO72-01.

Address correspondence to: Dr. Brenna Bry, Gradclate School of Applied and Profes- sional Psychology, Rutgers University, Busch Campus, P.O. Box 819. Piscataway, New Jersey 08854.

personality characteristics are good candidates for those criteria. They found that given a certain minimal level of academic ability, it is person- ality characteristics and not further academic ability that relate to clinical promise. 3 White’s research into selection criteria for nurse practition- ers has also focused upon personality variables. She found that clusters of personality variables relate to success as a nurse practitioner better than do single variables alone.4 For instance, she has found that both receptive nurturant qualities (self-control, re- sponsibility, and tolerance) and as- sertive qualities (dominance, au- tonomy, exhibition, and aggression) are needed to do well in nurse prac- titioner education and practice. 5

It would not be surprising to find that personality variables were im- portant in nurse-midwifery. First, the mere act of going back to school

probably requires a certain personal- ity for an experienced nurse. The nurse has developed a high sense of competence and has been responsi- ble for supervising and teaching others. When she or he enters nurse-midwifery education, the nurse/student is regarded as less than competent and must accept guidance and supervision. In order to learn well in this situation, the nurse probably needs a great deal of tolerance-tolerance for the feeling of “not knowing” and tolerance for criticism. 6

In order to apply all of the techni- cal knowledge, the student must have other personality characteris- tics. Mulligan writes that a student must be able to be a “director,” in the theatrical sense, of the delivery.’ Besides having executive abilities like that, the student also needs self- control, for, as Mulligan points out,

Journal of Nurse-Midwifery ?? Vol. 25, No. 3, May/June 1980 11

Copyright @ 1980 by the American College of Nurse-Midwives

“it is the mother. . . who delivers her child” (p. 231), not the midwife. The nurse-midwifery student must be able to sit back and wait too.

Once nurses have completed their midwifery education, there are prob- ably further personality characteris- tics that are needed for nurse- midwifery practice. One reason for this is that nurse-midwives face a basic role definition problem.* Their role may be perceived differently by each of the parties they work with. The physician may see the nurse- midwives as physicians’ helpers, whereas nurse-midwives see them- selves as having the management re- sponsibility. The nursing staff may see nurse-midwives as simply other nurses or occasionally as a physician.

These problems are magnified in a teaching hospital where rotating staff and students make role clarification only a temporary phenomenon. There nurse-midwives must be able to withstand almost daily questioning of their roles. Beck states that a con- sequence of this situation is that many nurse-midwives return to tra- ditional nursing where the role is more consensually defined. g Perhaps these difficulties are related to the fact that only 50% of those who have

Dr. By received her BS from Denison University in Ohio and her PhD from the University of Missouri at Columbia in clinical psychology. She now teaches in the Graduate School of Applied and Professional Psychology, Rutgers University, and consults to the Nurse-Midwifery Educational Program at the College of Medicine and Dentistry of New Jersey.

Ms. Marsico received her BSN from Seton Hall University, New Jersey, and her MEd from Teachers College, Columbia University. She is a graduate of The Catholic Maternity Institute Nurse-Midwifery Program in Santa Fe, New Mexico. Ms. Marsico is Associate Projessor and Chairperson, Department of Primary Care Associates.

12

graduated from nurse-midwifery programs are currently practicing midwifery. l

Several authors have written about what personality characteristics they think nurse-midwives need in order to practice in a social system where their responsibilities and competen- ties may be questioned every day. Some of the characteristics are: 1) confidence in her or his role,6,10 2) leadership ability,6 3) tolerance of other people’s points of view9 4) ability to recognize one’s lim- itations, 6,10 and 5) political savvy. 6

The present study was designed to investigate whether or not success in midwifery education and practice is indeed related to personality char- acteristics. The personality charac- teristics of the students in several en- tering classes in midwifery education were measured and the data were saved until six months after they had graduated. Then the students were classified as either having completed their education successfully and having gone into nurse-midwifery practice or not. Then a combination of personality variables which differ- entiated those two groups was sought.

The California Psychological In- ventory (CPI) was used to measure the personality characteristics. It is a frequently used inventory of 480 statements designed for normal per- sons to which people respond by marking on a separate answer sheet indicating whether the statement is “True” or “False” for them. The CPI was standardized on over 6,000 males and 7,000 females, and it has test-retest correlations from 0.65 to 0.80. I1

The CPI yields scores on eighteen separately validated scales. The scales assess dominance, capacity for status, sociability, social pressure, self-acceptance, sense of well-being, responsibility, socialization, self- control, tolerance, good impression, communality, achievement via con- formance, achievement via indepen- dence, intellectual efficiency,

psychological mindedness, flexibility, and femininity. Complete definitions of these dimensions are available in the test manual. l2

In other research, the CPI has been useful in 1) differentiating fu- ture drop-outs from future graduates in associate nursing programs,13 2) predicting practical nursing course grades, l4 and 3) predicting staff nurse performance ratings. Machotka et al. also used the CPI in their study of predictors of clinical performance of child health associates,3 and White is using the CPI to differentiate those who succeed as nurse practitioners from those who do not.4

METHOD

Subjects

The subjects were 36 students who were accepted into two urban nurse-midwifery programs in the northeast in 1975 and 1976. One program is a masters program. The other program is a certificate pro- gram.

All subjects were females with a mean age of 30 years, median age of 28.5 years, and a range of 23- 49 years. The majority were from the northeast, but both programs drew candidates from all parts of the country. All subjects had been prac- ticing registered nurses. Five of the subjects were minority students.

Procedure

California Psychology Inventory Scores. The California Psychological Inventoy (CPI) was administered to all subjects after their decision to apply but before the completion of their first year in their nurse- midwifery program. Although the exact time that the subjects took the inventory varied within that time frame, there was no evidence that the differences in time of administra- tion affected the outcomes. The subjects were assured that the in- ventory was for research purposes

Journal of Nurse-Midwifery ?? Vol. 25, No. 3, May/June 1980

only and that the results would in no way affect either their acceptance into a program or their evaluations while they were students.

To ensure confidentiality, the un- scored answer sheets were sent di- rectly to a researcher who was not affiliated with the nurse-midwifery programs (the first author). She as- signed subject numbers and scored the answer sheets. The test scores of specific students were not fed back to their faculty members.

Establishing the Criteria of Success in Nurse-Midwife y Education and Practice. The directors of the two nurse-midwifery programs were interviewed to determine their defini- tions of success in nurse-midwifery education and practice. From the interviews, the following criteria were derived: 1) completion of the educa- tion program; 2) completion of the education program within the time that the school had set aside to edu- cate one class of students (one year for the certificate program, fifteen months for the Master’s program); 3) completion of the education program without the faculty becoming con- cerned about or experiencing dif- ficulties in educating that student; and 4) entering midwifery practice (managing patient care) within six months after graduation.

Once the criteria were determined, the program directors were asked to describe each of the subjects at least six months after their graduation in relation to each of the criteria. If a subject met all of the criteria, she was classified as having had success in learning and practicing midwifery. If she did not meet one or more of the criteria, she was not classified as having had success.

RESULTS

Table 1 shows the means and stan- dard deviations of the scores that the 36 subjects obtained on the CPI scales. None of the means differ- entiate the nurse-midwifery students as a group from other American

TABLE 1 Mean scores and standard deviations for aII of the nurse-midwifery students on the California Psychological Inventory

Scale

Dominance Capacity for Status Sociability Social Pressure Self-acceptance Sense of Well-being Responsibility Socialization Self-control Tolerance Good Impression Communality Achievement via Conformance Achievement via Independence Intellectual Efficiency Psychological-mindedness Flexibility Femininity

NOTE: N = 36

Mean SD

31.52 4.58 22.36 2.72 27.58 3.97 38.47 5.31 23.14 3.34 38.36 3.22 31.92 4.28 37.75 4.86 33.06 6.03 25.53 3.19 21.06 5.32 25.69 2.21 31.00 3.66 22.67 3.24 44.14 3.39 13.56 2.24 11.14 3.57 23.44 2.80

women, for every mean is within ten standard scores of the female nor- mative score on that scale.

Nineteen of the 36 students met all of the specified criteria and were clas- sified as having had success in learn- ing and practicing midwifery. Of the seventeen who did not meet all of the criteria, seven either left their educa- tional program without finishing or did not even start an educational program in nurse-midwifery after having committed themselves to do so. Nine of the seventeen finished their educational program but took longer than the time the school usu- ally allots to students. One of the stu- dents did very well during her educa- tion but did not enter the practice of midwifery after she graduated.

Table 2 shows the mean CPI scores for the nurse-midwifery stu- dents who met the criteria and for those who did not. It is clear from Table 2 that the students who met the criteria scored higher as a group on every single scale than did the other students. What is not clear from those single-scale scores is which combination of those scales is most important in differentiating the stu-

dents who met the criteria from those who did not.

To learn which scales are most im- portant in differentiating the two groups, a step-wise discriminant analysis was performed using the eighteen CPI scale scores and the age of the subjects as the indepen- dent variables and whether or not the subjects had met the criteria as the dependent variable. In this computa- tion, the scale which best differ- entiates between the criteria and noncriteria subjects is identified first. In this case, the Socialiition scale was identified first. By looking at only the Socialization scale score, sixteen of the nineteen criteria subjects could be classified correctly and thirteen of the seventeen noncriteria subjects could be classified correctly (or 81% correct classifications).

The next scale that the stepwise discriminant analysis identified is the scale whose score, when combined with the Socialization scale score, best improves the differentiation between the criteria and noncriteria subjects. That scale is the Dominance scale.

The CPI scale which, when com-

Journal of Nurse-Midwifery ?? Vol. 25, No. 3, May/June 1980 13

bined with the Socialization and Dominance scales, improved the classification the most is the Toler- ance scale. Those three scale scores allowed the correct classification of seventeen of the nineteen criteria subjects and sixteen of the seventeen noncriteria subjects (or 92% correct classifications).

The next CPI scale which was identified in the step-wise discrimi- nate analysis is the Self-Control scale. When combined with the scores on the Socialization, Domi- nance, and Tolerance scales, the Self-Control scale improved the cor- rect classifications to the point where all but two of the 36 subjects could be classified correctly. Only one of the students who met the criteria was misclassified, and one of the students who did not meet the criteria was misclassified (94% correct classifica- tions). (The above four scales are in- dicated in Table 2.)

The addition of three more CPI scale scores (Social Presence, Sense of Well-Being, and Flexibility) al- lowed the correct classification of the one misclassified criteria subject, but even the addition of those three more scales did not allow the correct classification of the one noncriteria Subject. The step-wise discriminant stopped after considering ten vari- ables. (The Wilks’s lambda criterion was used.)

DISCUSSION

This study was the first step in an ef- fort to identify selection criteria which will help nurse-midwifery education programs select students with a high probability of succeeding as students and then going into practice. As the first step, this study investigated if personality variables are related to success in school and to whether or not students go into practice after graduation. The results are clearly af- firmative. Ninety-four percent of the subjects could be correctly classified according to the above criteria based upon the way they answered the

14

TABLE 2 Mean CPI scores for the nurse-midwifery students who did and did not meet the criteria

Met Criteria Did Not Meet Criteria (N = 19) (N = 17)

Scale Mean Mean

Dominance 33.74 28.82” Capacity for Status 22.89 21.76 Sociability 28.89 26.12 Social Pressure 39.89 36.88 Self-acceptance 24.00 22.18 Sense of Well-being 39.10 37.53 Responsibility 33.53 30.12 Socialization 40.26 34.94” Self-control 33.53 32.53” Tolerance 26.63 24.29’ Good Impression 22.05 19.94 Communality 26.68 24.59 Achievement via Conformance 32.53 29.29 Achievement via Independence 23.37 21.88 Intellectual Efficiency 45.10 43.06 Psychological-mindedness 13.95 13.12 Flexibility 11.84 10.35 Femininity 24.00 22.82

“JJKJ Scales which, respectively and in combination, best differentiate the Criterion group from the Noncritetion group.

items on four scales of the California Psychological Inventory (CPI).

The results do not suggest how- ever that there is yet enough empiri- cal evidence to begin using the CPI as a selection criterion. The results must be cross-validated on another group of students first. It must also be noted that this study was not de- signed to identify selection criteria to replace those that are used now. It was designed with the assumption that those that are being used now would continue to be used and that some new criteria might be added to improve prediction.

If the results of this study are cross-validated, then nurse- midwifery would join the growing list of health professions in which per- sonality appears to play an important role. Kelly and Fiske15 found that personality variables were important in clinical psychology training and practice. Holt and Luborsky found that personality variables helped de- termine whether or not psychiatric residents were rated as being profes-

sionally competent. l6 And Machotka et al’s findings that personality char- acteristics were useful in predicting clinical promise in child health as- sociates were mentioned in the intro- ductioq3 as were White’s findings concerning nurse practitioners. 4

It is interesting to note exactly which combination of CPI scales proved to be most useful in differ- entiating the subjects who either did not finish school without difficulty or did not go into practice from those who accomplished both tasks suc- cessfully. First, the very most impor- tant scale in differentiating the two groups was the Socialization scale. Gough and Sandhu who developed the CPI, describe socialization as the understanding and internalization of the rules and stipulated ways of con- ducting activities in a society. I7 They have found that people who score higher on the scale are adept at sensing and interpreting nuances and subtle cues in interpersonal situations and are thus able to develop ways of behaving that fit social mores.

Journal of Nurse-Midwifery ?? Vol. 25, No. 3, May/June 1980

While socialization accounted for the greatest amount of the variance in this study, socialization alone could not account for all of the variance. A high degree of socialization had to be accompanied by a high degree of dominance, tolerance, and self- control for a student to succeed and practice. Dominance, according to Gough, l2 refers to social initiative and persistence. Tolerance refers to lack of dogmatism and prejudice, and self-control refers to low impulsivity.

Thus, from the results of this study, one gets a picture of the successful nurse-midwifery student and prac- titioner as someone 1) who has the desire and ability to understand the mores of social situations and abide by them, 2) who, once a situation is understood, will persistently take the social initiative in that situation, 3) who can accept a wide variety of situations and people without pre- judice, and 4) who is not impulsive in his or her actions.

The picture is a complex one. It is of a person who can both lead and follow, initiate and wait, and be sen- sitive to and observant of other people and accepting of what is seen. It is a picture of a person who could function well even though she or he is suddenly a student again after having been a competent practitioner for years. One also could imagine such a person serving competently as the “theatrical director” for a mother who is fully participating in her deliv-

ery. And it is easy to imagine such a person as a well-respected team member at a busy teaching hospital.

The results of this study have a great deal of face validity. Future cross-validations will show whether or not they also have predictive va- lidity.

The authors appreciate the active participation

of Clyde Sullivan, Joyce Beebe, Patricia Dub-

bert, and David Russell in the completion of

this study. They also wish to thank the nurse- midwifery students who agreed to take the

California Personality Inventory for research

purposes at a particularly busy time in their

careers. Without their cooper&ion, the study

could not have been done.

REFERENCES

1. The Research and Statistics Com- mittee: Nurse-midwifery in the United States: 1976-1977. Washington, DC, American College of Nurse-Midwives, 1978

2. Beebe JE: The future of nurse- midwifery education: Survival of the profession. I. The role of the educator. J Nurs-Midwif, 22: 16- 19 (1977)

3. Machotka P. Ott JE, Moore V. Dungy C, Fine L: Predictors of clinical performance of child health associates. J Allied Health, (Fall) 25-31 (1975)

4. White MS: Psychological charac- teristics of the nurse practitioner. Nurs Outlook 23: 160- 166 (1975)

5. Personality makes the practitioner. Amer J Nurs 79:594, 597 (1979)

6. Houde CT: Issues in nurse-

midwifery education. J Nurs-Midwif 20:9-14 (1975)

7. Mulligan JE: Professional transi- tion: Nurse to nurse-midwife. Nurs Out- look 24228-231 (1976)

8. Olsen LC: The expanded role of the nurse in maternity practice. Nurs Clinics of North Amer, 9:459-466 (1974)

9. Beck LM: The nurse-midwife. Clinical Obst Gynecol 15:357-369 (1972)

10. Long PJ: Models for midwifery clinical practice. Frontier Nurs Serv Q Bull 50(3):27-29 (1975)

11. Buros OK. (Ed.): The Sixth Mental Measurements Yearbook. Highland Park, NJ, Gryphon Press, 1965

12. Gough HG: California Psychological Inventory (revised man- ual). Palo Alto, Consulting Psychologists Press, 1969

13. Baker W: Associate degree nurs- ing students: Nonintellective differences between dropouts and graduates. Nurs Res 2442-45 (1975)

14. Thomson WD: Predicting practical nursing course grades from the California Psychological Inventory and Differential Aptitude Tests. Unpublished master’s thesis, Brigham Young University, 1969

15. Kelly EL, Fiske DW: The Predic- tion of Performance in Clinical Psychol- ogy. Ann Arbor, University of Michigan Press, 1951

16. Holt RR, Luborsky L: Personality Patterns of Psychiatrists. New York, Basic Books, 1958

17. Gough HG, Sandhu HS: Valida- tion of the CPI Socialization Scale in India. J Abnorm and Sot Psycho1 68~544-547 (1964)

Journal of Nurse-Midwifery ?? Vol. 25, No. 3, May/June 1980 15

KNM-APPROVED BASIC EDUCATION IN NURSE-MIDWIFERY

nstitutions offering ACNM-approved basic education in lurse-midwifery, internship programs or refresher programs are isted below. Approval status is subject to change periodically. This information is current as of August 1978.

booth Mateme Center 6051 Overbrook Avenue Philadelphia, PA 19131 (215) 878-7800

in affiliation with Maternity Center Association 48 E. 92nd Street, New York, NY 10028

College of Medicine and Dentistry of New Jersey School of Allied Health Professions Nurse-Midwifery Program 100 Bergen Street Newark, NJ 07102 (201) 456-4249

Columbia University Graduate Program in Maternity Jursing and Nurse-Midwifery

Department of Nursing, Faculty of Medicine Columbia-Presbyterian Medical Center 622 West 168th Street New York, NY 10032 (212) 694-5755

Zuyahoga County Hospital 3395 Scranton Road Cleveland, OH 44109 ATE Ms. Patricia J. Lupe, Education Program Director

Emory University School of Nursing Atlanta, GA 30322 (404) 329-7978

Frontier School of Midwifery and Family Nursing Hyden, KY 41749 (606) 672-2901

Georgetown University School of Nursing 3700 Reservoir Road, N.W. Washington, DC 20007 (202) 625-7572

The Johns Hopkins University School of Hygiene & Public Health Nurse-Midwifery Program Department of Maternal & Child Health 615 North Wolfe Street Baltimore, MD 21205 (301) 955-3780

LX/USC Medical Center Women’s Hospital, Room 8K5 1240 North Mission Road Los Angeles, CA 90033 (213) 226-3386

Medical University of South Carolina Nurse-Midwifey Program, College of Nursing 171 Ashley Avenue Charleston, South Carolina 29403 (803) 792-2200

Mehany Medical College Nurse-Midwifery Program Department of Nursing Education 1005 - 18th Avenue, N. Nashville, TN 37207 (615) 327-6497

St. Louis University Department of Nursing Graduate Program in Nurse-Midwifey 3525 Carolina Street St. Louis, MO 63104 (314) 664-9800

State University of New York College of Health Related Professions Nurse-Midwifery Program, Box 93 450 Clarkson Avenue Brooklyn, NY 11203 (212) 270-1359 or 1360

CB

MB

I

MB

CB

CB

MB

I

CB

CB

MB

CB

United States Air Force Nurse-Midwifey Program Malcolm Grow USAF Medical Center Andrews Air Force Base, MD 20331 (301) 981-6104

University of California at San Diego Nurse-Midwifery Program University Hospital Primary Care Unit 225 W. Dickinson San Diego, CA 92103 (714) 294-6113

University of California at San Francisco San Francisco General Hospital Room 655 1001 Potrero Avenue San Francisco, CA 94110 (415) 821-5106 or

647-7828 The University of Illinois at the Medical Center

College of Nursing Department of Maternal-Child Nursing Nurse-Midwifery Program PO. Box 6998 Chicago, IL 60680 (312) 996-7935

University of Kentucky CoUege of Nursing Lexington, KY 40506 (606) 223-5406

University of Miami School of Nursing PO. Box 248106, Main Campus Miami FL 33152 (305) 284-2830

University of Minnesota 3313 Powell Hall 500 Essex Street, N. W. Minneapolis, MN 55455 (612) 373-4199

University of Mississippi Nurse-Midwifery Program 2500 North State Street Jackson, MS 39216 (601) 987-4823

University of Utah College of Nursing Graduate Major in Maternal and Newborn Nursing and

Nurse-Midwifery 25 South Medical Drive Salt Lake City, UT 84112 (801) 581-8274

Yale University School of Nursing Graduate Program in Maternal and Newborn Nursing

and Nurse-Midwifery 855 Howard Avenue New Haven, CT 06520 (203) 436-3673 or 3785

CB

CB

CB

MB

MB

MB,R

MB

‘CB

MB

**MB

-*Graduate Credtt Offered **Three-year program for non-nurse college graduates. CB= Certificate Basic Program. Prerequisite is RN. Length is 8 months to 1 year. MB = Master’s Basic Program. Prerequisite is RN plus Bachelor’s De- gree. Length is l-2 years. R = Refresher Program. For nurse-midwives who have not practiced in recent years and want to update their knowledge and clinical practice and/or take the National Certification Exam in order to become a Cer- tified Nurse-Midwife. Length varies according to needs of individual but usually a minimum of 12 weeks is necessary to fulfill requirements for certification. I = Internship. For recent graduates of CB and MB programs who desire additional clinical experience. Length varies according to individual’s needs.

16 Journal of Nurse-Midwifery ?? Vol. 25, No. 3, May/June 1980