SUPPLEMENTAL DIGITAL CONTENT
Nursing Students' Perceptions of Adoption: The Need for Educational Preparation
By Karen J. Foli, Anna Forster, and Eunjung Lim
Journal of Christian Nursing, Volume 31 Issue 4, October/December 2014
ABSTRACT: Adoption is a worldwide practice with the majority of Americans knowing
someone who has been adopted, has adopted a child, or has relinquished a child for adoption.
Most health care professionals, including nurses, will have contact with patients who have a
connection to adoption. This study examined the overall perceptions, current knowledge, and
gaps in a nursing curriculum as reported by undergraduate nursing students.
Specific aims of this study were to:
1) Describe contact nursing students have with members of the adoption triad;
2) Compare student perceptions of members of the adoption triad;
3) Obtain nursing students’ perceptions of overall comfort/competence in caring for the
adoption triad and specific competence through clinical vignettes;
4) List the reported gaps in education in the nursing curriculum; and
5) Through open ended responses, describe themes based on students’ perceptions of the
adoption triad’s needs.
SURVEY: A 29-item, investigator-generated survey, Student Nurses’ Perceptions of Adoption
Survey containing open- and close-ended questions was developed for this study. Global
perceptions of the adoption triad were derived from the literature as well in consultation between
the research team. A draft of the survey was reviewed for face and content validity by faculty
members with experience in pediatrics, postpartum, adult health and foundations of nursing
courses. Comments regarding clarity and ordering of items were integrated into the final survey.
To assess internal reliability, Cronbach’s alphas were calculated for sections of the survey from
participants’ responses:



The three items that measured the students’ self confidence in caring for the adoption
triad were found to have a reliability of 0.72 (Section 2: Items 12, 14, & 16).
The five items that required student responses based on clinical vignettes revealed a
Cronbach’s alpha of 0.79 (Section 3: Items 18-22).
Reliability alphas for the semantic differential/perceptions of the adoption triad (6 items)
were:
o for birth parents: 0.85;
o for adoptive parents: 0.73;
o for the adopted child: 0.79;
o for all three triads (18 items): 0.80 (see Section 4 of the survey).
The online survey which students responded to was created through Qualtrics, web-based survey
software.
ANALYSIS: Descriptive statistics (frequencies, means, standard deviations) were computed to
address Aims 1 and 4. To investigate students’ perceptions of members of the adoption triad, we
performed analyses of covariance (ANCOVA) by a mixed model approach by controlling for
students’ clinical interests and clinical experience (Aim 2). Tukey’s post-hoc tests were then
utilized to compare mean differences between students’ perceptions of members of the adoption
triad. To compare students’ perceptions of competence in caring for the adoption triad through
clinical vignettes, paired t-tests were conducted (Aim 3). All analyses were performed using
Statistical Analysis Software (SAS) Version 9.3 (2008, Cary, NC: SAS Institute Inc.) and p < 0.05
was considered statistically significant.
Results are shown in three tables (below):
1) Demographic Characteristics of Student Participants
2) Undergraduate Students’ Perception of Adoption Triad
3) Self-confidence on Clinical Situations Related to Adoption Triad
Nursing Students’ Perceptions of Adoption: Survey Tool
© Karen J. Foli, PhD, RN, Anna Forster, & Eunjung Lim, PhD
For permission to use this tool in research, please contact Karen Foli at kfoli@purdue.edu
Section 1: Demographics and Previous Experiences
1. What is your gender?
A. Male
B. Female
C. Other (transgender or intersexual)
D. Decline to Answer
2. What is your age?
A. 18 years
B. 19 years
C. 20 years
D. 21 years
E. 22 years
F. 22-24 years
3. What state were you born in?
4. Which racial or ethnic group do you most closely identify with?
A. Caucasian or White American
B. Native American
C. Hispanic American
D. Asian American/Pacific Islander
E. Bi-racial or multi-racial
F. Other
G. Prefer not to answer
5. What year in school are you?
A. Freshman
B. Sophomore
C. Junior
D. Senior
6. Did you enter the School of Nursing_____________
A. Directly from high school
B. As a CODO (transfer from another major)
C. From another college/university
7. In general, how spiritual would you say you are? Are you…
A. Very spiritual
B. Somewhat spiritual
C. Not very spiritual
D. Not at all spiritual
E. Not sure
8. I have clinical experience outside of my nursing education (check all that apply)
A. As a Certified Nursing Assistant (CAN)
B. During the summer(s) as a nurse extern
C. Other_________________
D. No experience
9. What clinical areas interest you (check all that apply)?
A. Critical Care
B. Emergency Department
C. Labor, Delivery or postpartum unit
D. Pediatrics
E. Psychiatric/mental health
F. Operating Room/Recovery Room
G. Medical/Surgical nursing
H. Public/Community health
I. Other_______________
10. As a student nurse, in the past year, I have delivered care to (check all that apply):
A. Birth Parents
B. Adoptive Parents
C. Children who are adopted
D. Adults who are adopted
E. None of the above
F. Don’t know
11. Are you (check all that apply)……
A. A member of an extended family that includes an individual who is adopted
B. A friend of a person who is adopted
C. A member of an adoptive family
D. A person who was adopted
E. A birth parent
F. None of the above
G. Decline to answer
________________________________
Section 2: Confidence with Caring for the Adoption Triad
Again we use the "adoption triad" to describe individuals whose lives have been directly touched
by adoption. The members of this triad are the birth parents, who make a decision to relinquish a
child; the adoptive parents, who parent the child from the ages of infancy to 17 years of age; and
the individual who is adopted. A kinship parent is an individual who is a relative or close family
member who has assumed the care of the child.
Each of these populations has distinct needs from nurses who render care to them. The following
questions pertain to your level of knowledge and comfort as a student nurse who will after
graduation, give care to this patient group.
12. I feel comfortable with my level of knowledge/skills in caring for birth parents.
A. Strongly Agree
B. Agree
C. Neither agree nor disagree
D. Disagree
E. Strongly Disagree
13. What knowledge/skills would be most helpful to you in caring for birth parents? (Open
ended)
14. I feel comfortable with my level of knowledge/skills in caring for adoptive parents.
A. Strongly Agree
B. Agree
C. Neither agree nor disagree
D. Disagree
E. Strongly Disagree
15. What information/skill set would be most helpful to you in caring for the adoptive
parents? (Open ended)
16. I feel comfortable with my level of knowledge/skills in caring for children or adults who
are adopted.
A. Strongly Agree
B. Agree
C. Neither agree nor disagree
D. Disagree
E. Strongly Disagree
17. What information/skill set would be most helpful to you in caring for children or adults
who are adopted? (Open ended)
____________________________________
Section 3: Clinical Vignettes:
Now, we'd like to describe various clinical scenarios that you might encounter as you care for
members of the adoption triad. In each case, answer the statement based on patient care within
the context of adoption.
18. You are caring for a 26-year-old female who has just miscarried in the 12th week of
gestation. She confides to you that she was adopted when she was 2 years of age and is
having feelings of abandonment in her marriage. The miscarriage, she confides to you,
only adds to these feelings. Please answer the following statement related to her
psychosocial needs:
"I would know how to implement the nursing process in this situation, including a plan of
care with interventions."
A.
B.
C.
D.
E.
Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree
19. You are now in your obstetrical clinical rotation and are informed that an adoptive
mother wants to be in the delivery room when the birth mother delivers her baby. She
informs you that this has been discussed and agreed upon by the birth parents.
"I would know how to implement the nursing process in this situation, including a plan of
care with interventions."
A. Strongly Agree
B. Agree
C. Neither agree nor disagree
D. Disagree
E. Strongly Disagree
20. You are in your public health clinical and are following the school nurse at a large high
school. A 14-year-old girl arrives at the nursing office complaining of nausea and
vomiting. She confides to the nurse (and you) that she is 8 weeks pregnant and
considering relinquishing the baby for adoption.
"I would know how to implement the nursing process, including a plan of care with
interventions."
A. Strongly Agree
B. Agree
C. Neither agree nor disagree
D. Disagree
E. Strongly Disagree
21. You are in a nurse-managed clinic, shadowing the pediatric nurse practitioner. A couple
brings their 12-month old child, who is adopted, in for a well-child check. They express
to the PNP and you that they have noticed their 4-year-old biological child is having
trouble bonding with the new baby.
"I would know how to implement the nursing process, including a plan of care with
interventions."
A. Strongly Agree
B. Agree
C. Neither agree nor disagree
D. Disagree
E. Strongly Disagree
22. Your next rotation is on a medical surgical floor where you are caring for patient
with Type 2 diabetes and hypertension. This 55-year-old grandmother has assumed the
care of her 2-year-old granddaughter (as a kinship parent). She confides to you that she
has been feeling overwhelmed, sad, and isn't able to do the self-care necessary to
maintain her health because of the demands of parenting a toddler.
"I would know how to implement the nursing process, including a plan of care with
interventions."
A. Strongly Agree
B. Agree
C. Neither agree nor disagree
D. Disagree
E. Strongly Disagree
___________________________________
Section 4: Semantic Differential Descriptors of Adoption Triad
This section of the survey asks you to describe members of the adoption triad by descriptors that
are antonyms (opposites).
23. For this question, how would you describe an adoptive parent? Click on the
button between the adjectives that you think best describes adoptive parents.
Happy
Responsible
Selfless
Powerful
Stable
Supported
Sad
Irresponsible
Selfish
Powerless
Unstable
Not supported
24. For this question, how would you describe a birth parent? Click on the button between
the adjectives that you think best describes birth parents.
Happy
Responsible
Selfless
Powerful
Stable
Supported
Sad
Irresponsible
Selfish
Powerless
Unstable
Not supported
25. For this question, how would you describe a child who has been adopted? Click on the
button between the adjectives that you think best describes that individual.
Happy
Responsible
Selfless
Powerful
Stable
Supported
Sad
Irresponsible
Selfish
Powerless
Unstable
Not supported
26. For this question, how would you describe an adult who has been adopted? Click on the
button between the adjectives that you think best describes that individual.
Happy
Responsible
Selfless
Sad
Irresponsible
Selfish
Powerful
Stable
Supported
________________________________
Powerless
Unstable
Not supported
Section 5: Need for Information and Education
27. More information regarding adoption (how to care for the adoption triad) should be
offered during your years spent in nursing education?
A.
B.
C.
D.
E.
Strongly Agree
Agree
Neither agree nor disagree
Disagree
Strongly Disagree
28. Which of these topics/educational offerings do you think would be helpful? Check all
that apply.
A.
B.
C.
D.
E.
Legalities of adoption
Counseling birth parents about adoption
Parental postadoption depression
Specific needs of the child who is adopted
Other topics/educational offerings_______________________________
29. Please use the space below to include any additional information, such as experiences
with birth parents, adoptive parents, and/or children who are adopted or comments that
you would like to add.
Demographic Characteristics of Student Participants
Characteristics
Gender
Female
Male
Collage Year
Freshman
Sophomore
Junior
Senior
Race
Caucasian or White
Other
Perceived Spiritualty
Very spiritual
Somewhat spiritual
Not very spiritual
Not at all spiritual
Type of Student
Directly from high school
Internal or external transfer student
Clinical Experience*
Certified Nursing Assistant
Nurse Extern
Other
None
Clinical Interest*
Critical care
Emergency department
Labor, delivery, or postpartum unit
Pediatrics
Psychiatric/mental health
Operating room/recovery room
Medical/surgical nursing
Public/community health
Other
Past Experience in Delivering Care*
Birth parents
Adoptive parents
Adopted child
Adopted adult
None
Don’t know
n (%)
83 (98%)
2 (2%)
13 (15%)
24 (28%)
19 (22%)
29 (34%)
83 (98%)
2 (2%)
34 (40%)
41 (48%)
8 (9%)
2 (2%)
73 (86%)
12 (14%)
16 (19%)
22 (27%)
18 (22%)
33 (40%)
44 (52%)
39 (46%)
54 (64%)
51 (60%)
11 (13%)
19 (22%)
28 (33%)
14 (17%)
18 (22%)
27 (33%)
6 (7%)
8 (10%)
8 (10%)
26 (32%)
29 (36%)
*Multiple answers are possible. Total sample N = 85.
Undergraduate Students’ Perception of Adoption Triad
Domain
Perceived Image
Happy: Sad
Responsible: Irresponsible
Selfless: Selfish
Powerful: Powerless
Stable: Unstable
Supported: Not Supported
Perceived Comfort Caring
for Triad
Knowledge
Birth
Parents
Adoption Triad
Adoptive
Parents
BP vs.
AP
p*
BP vs.
AC
Adopted
Children
AP vs.
AC
2.77 ± 1.06
3.00 ± 0.94
3.65 ± 0.95
2.87 ± 0.88
2.56 ± 0.98
2.73 ± 1.09
4.43 ± 0.70
4.59 ± 0.64
4.09 ± 0.75
3.54 ± 0.77
4.32 ± 0.64
4.29 ± 0.65
3.55 ± 0.78
3.49 ± 0.71
3.31 ± 0.70
3.16 ± 0.64
3.38 ± 0.75
3.84 ± 0.75
<.0001
<.0001
.005
<.0001
<.0001
<.0001
<.0001
.0002
.033
.104
<.0001
<.0001
<.0001
<.0001
<.0001
.005
<.0001
.003
3.60 ± 0.95
3.25 ± 0.83
3.51 ± 0.84
.001
.554
.024
n = 80. The possible range was 1=strongly disagree to 5=strongly agree (scores are reversed
from the original scale).
AP = Adoptive Parents. BP = Birth Parents. AC = Adopted Children.
*Tukey’s post-hoc test was performed.
Self-confidence on Clinical Situations Related to Adoption Triad
Mean ± SD*
#1
#2
#3
#4
#5
Vignette
Miscarriage
Delivery
Pregnancy
Bonding
Kin Parent
n
83
82
81
81
81
3.04 ± 0.99
3.57 ± 0.88
3.43 ± 0.99
2.93 ± 0.96
3.00 ± 0.95
Self-Confidence in
Caring for Birth
Parents
3.60 ± 0.95
t
p
N/A
N/A
-0.30
.763
-1.39
.167
N/A
N/A
N/A
N/A
Self-Confidence in
Caring for Adoptive
Parents
3.25 ± 0.83
t
p
N/A
N/A
3.24
.002
N/A
N/A
-3.12
.003
-2.58
.012
Self-Confidence in
Caring for Adopted
Children/Adults
3.51 ± 0.84
t
p
-3.87
.0002
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N=81~83. Paired t test was performed (Row minus bottom line of each column).
*Same as “Perceived Comfort in Caring for Triad Knowledge” in Table: Undergraduate
Students’ Perception of Adoption Triad
The possible range was 5=strongly agree to 1=strongly disagree (scores are reversed from the
original scale).