Which of the following traits are essential to a profession? choose all that apply

Iran J Nurs Midwifery Res. 2014 Jan-Feb; 19(1): 1–10.

Abstract

Background:

Professionalism is an important feature of the professional jobs. Dynamic nature and the various interpretations of this term lead to multiple definitions of this concept. The aim of this paper is to identify the core attributes of the nursing professionalism.

Materials and Methods:

We followed Rodgers’ evolutionary method of concept analysis. Texts published in scientific databases about nursing professionalism between 1980 and 2011 were assessed. After applying the selection criteria, the final sample consisting of 4 books and 213 articles was selected, examined, and analyzed in depth. Two experts checked the process of analysis and monitored and reviewed them.

Results:

The analysis showed that nursing professionalism is determined by three attributes of cognitive, attitudinal, and psychomotor. In addition, the most important antecedents concepts were demographic, experiential, educational, environmental, and attitudinal factors.

Conclusion:

Nursing professionalism is an inevitable, complex, varied, and dynamic process. In this study, the importance, scope, and concept of professionalism in nursing, the concept of a beginning for further research and development, and expanding the nursing knowledge are explained and clarified.

Keywords: Analysis, concept, Iran, nursing, professional

INTRODUCTION

“Professionalization” is an important characteristic of in-service careers.[1] The concept of professionalization is expressed in the terminology of many job groups and has a long history, especially in social context. Dynamic feature and multiple interpretations of professionalization result in numerous definitions with different functions and nature.[2] Over the years, many people spoke about professionalization in nursing and its features. Therefore, there are multiple definitions and characteristics for professionalization in nursing.[3,4,5] Also, researchers used different methods and tools for its assessment and evaluation.

Nursing profession status is an inter-profession and intra-profession challenge. Whether there is nursing professionalism or not is a challenge among the nurses, sociologists, and historians.[6,7,8,9,10] For many years, other scientists considered nursing as a semi-professional career.[3] Until 1970, nursing profession was considered as a female work and women were considered as barriers to professionalization in nursing due to their high workload and part-time work.[11] At that time, some factors such as slow formation of scientific fundamentals of nursing, disagreement in educational requirements for nurses,[10,12,13] lack of academic education at the entry level of nursing courses, and lack of theory and theory-based research[14] were considered as barriers for nursing as a profession.

Gradually, development of education standards and professional certificates led nursing move to professional status.[3] Having stronger powerful basis for theory and practice and professional education in nursing discipline brought about social cognition. Social understanding about nursing made the society consider nurses as cost–benefit health care providers and independent decision makers. Therefore, nursed could receive more funds and governmental financial aids.[15]

Today's rapid changes in value systems in society caused nursing to encounter more ethical and philosophical challenges at providing care to its clients. These changes also created new nursing environments that require professional nursing. Accordingly, nursing professionalization definition and its attributes need to be clarified and adapted with rapid changes. For this purpose, concept analysis is a suitable method.

Concepts are the building blocks of theories.[16] They have important role in theory development. Concept analysis is one of the strategies in concept development. In this strategy, the basic elements of a concept for understanding its structure and function are assessed. During concept analysis process, a researcher, theorist, or clinician becomes familiar with different attributes and definitions of concept and its function.

Evolutionary approach of Rodgers in concept analysis is based on contemporary philosophical thinking on concepts and their roles in knowledge development. In this approach, dynamic features of concepts over time and different social contexts are emphasized.[17] Form evolutionary perspective, instead of emphasis on “what is it?,” more discovery and assessment are mostly focused. Consequently, this process results in a form of cyclical concept development. With this approach, the final results are the starting point for more concept analysis.[17] Purpose of concept analysis in this approach is to explain the concept and its attributes more clearly for its further development.[18]

Accordingly, the purpose of the current study is assessment of “nursing professionalization” concept to understand more about its attributes, antecedents, and consequences. Since the contemporary nursing believed human and other nursing phenomena have constantly a changing and interrelated context, it seems that nursing professionalization is also better understood in the context. This perspective is congruent with evolutionary approach in concept analysis.

MATERIALS AND METHODS

While there are several methods of concept analysis,[19] an evolutionary approach was selected as the concept of nursing professionalization depends on the context and can be interpreted only when the different parameters appear in a specific context.[17] Although this approach of studying recommends six preliminary activities [Table 1], Rogers believes that many of these activities take place simultaneously during the study. Study process has a non-linear, rotational, and flexible nature. The six stages merely indicate activities that should take place during the study, and it should not be regarded as a continuous process. In this way, Rogers uses inductive approach and detailed analysis and focuses on the collection and analysis of raw data. In this approach, concepts in the specific social and cultural context of a given profession are studied.[17,20]

Table 1

Rodgers’ evolutionary concept analysis process

After identifying the concept of interest, the most important step is determining the scope and range of literature.[20] The scientific databases, PubMed, CINAHL, MEDLINE, ProQuest, and EBM REVIEW, were searched. In a preliminary search, the term “professional nurse” was used. Next, to achieve more precise results, the inclusion criteria were identified. The main criterion for inclusion in the final analysis was the literature published in English from 1980 to 2011 in the context of nursing and health sciences. The exclusion criterion was non-English language articles. Preliminary results of the search gave 250 articles meeting the inclusion criteria, and after deleting the duplicated items (14 items), the number decreased to about 236. In the final stage, 213 articles had the term “professional nurse” in their title or abstract, and their full texts, if available and that too in the nursing field, were chosen. In addition, four books were used in the analysis process to cover the subjects. Books and papers were carefully reviewed and studied. For analyzing, thematic analysis and content analysis were used. All articles in the context of nursing were exactly read, and hints and useful features, antecedents, consequences, related concepts, surrogate terms, and definition of concept were extracted. Then, the data were reviewed several times to allow the researcher to be immersed in, and this enabled deriving key tags and notes to provide clear explanations about every aspect of the concept. Overall, inductive analysis of data was done and themes were identified. Information units consisted of the words and sentences related to the information or responses concerning the following questions: What are the specific characteristics of professional nursing? How do you define nursing professionalization? How do you pretend nursing professionalization? What factors are associated with the incidence of professional nursing? What are the consequences or outcomes of nursing professionalization? Papers based on conceptual analysis of studied information were grouped. In order to ensure impartiality, reliability, and bias reduction, the analysis process was checked by two nursing experts in concept analysis.

RESULTS

Identification of the characteristics of the concept is the first stage of the analysis that leads to the actual definition of the concept.[20,21] Characteristics of a concept, including features and specifications of a concept that have been permanently associated with the concept, help identify the clarity, breadth, and depth of that concept.[19] In this study, the conceptual dimensions of nursing professionalization were identified as cognitive, affective, and psychomotor dimensions.

Cognitive dimension of nursing professionalization

Nursing education should be able to develop professional knowledge.[22] All learners should have a basic cognitive framework for understanding the professionalization. It seems that getting all the essential aspects of professional knowledge in all phases of professionalization must be considered and principles of professionalization must be combined at different levels of professional education.[23] Learner development begins from a basic understanding of the underlying principles of professional conduct and the underlying reasons, and ultimately, the learner should be able to prioritize and make decisions.[24]

Walton et al. (2010) assigned five stages of training to professional nurse education as follows: (1) create a practical fake identity of a professional nurse in students, (2) trial and error, (3) the seriousness of the conduct; (4) transfer to the bedside, and 5) professionalization.[25] Some studies suggest that certain training courses such as ethics, research, or professionalization should be included in the professional training program in nursing.[26] Professional training courses can be temporary and occur during periods of formal or informal education. Professional training in formal programs can be provided with specific workshops and courses of training development modules,[27] working in small groups on problem-solving, use of role play, simulated patients,[28] or clinical courses.[29] On the other hand, usually students learn values ​​and norms in informal trainings.[30,31,32,33,34] For this purpose, there must be a professional learning environment.[35,36,37,38] Role modeling and changing the organizational culture can be effective in non-formal education.[39] Every training program should be designed to meet the expectations concerning professionalization.[40]

In the area of professional learning, continuing education is very important. UKCCN (United Kingdom Central Council for Nursing) states that all nurses should provide a certificate of professional updating every 3 years.[41] However, continuing education cannot be considered as the only criterion and antecedent for professionalization, as until mastery of knowledge is not combined with a personal value system and transferred to action, it cannot have a true function.[42] Making this commitment to continuous learning is the primary task of professional education.[43,44,45]

Attitudinal dimension of nursing professionalization

Values are beliefs and ideals that individuals and groups possess.[46] Professional values ​​are practical standards that create a framework for evaluation of attitudes and ideas influencing behavior in professional clinicians.[47] Acquisition of professional values is the heart of professional development.[48]

Many attitudinal items are discussed in the articles and professional experiences concerning nursing professionalization. Although professionalization is a category related to culture, some of its properties are mentioned as to be autonomous, cooperative, retained jurisdiction, membership in professional organizations and professional development, community service and social services, compliance with codes of nursing, conduct and evaluation of nursing theory.[49,50,51,52,53,54,55] Kim et al. stated that the main features of the nursing professionalization values are classified into three main groups: (1) personal-based features such as the ability to understand the feelings and problems of others, willingness to help others, ability to work with others, tolerance and flexibility in communicating with others; (2) knowledge-based features such as knowledge and skills, scientific accuracy, and ability to research; and (3) state-dependent properties such as willingness to take responsibility and emphasizing on the attractive external appearance.[56] Core values ​set forth by AACN (American Association of Critical-Care Nursing) (1998) include human dignity, integrity, autonomy, altruism, and social justice.[48] These values have also been identified by Horton (2007).[57] Hall (1982, 1968, 1967) formulated five attributes to the most mature professions such as law and medicine, which are use of professional reference agencies, community service, autonomy, self-regulation, and sense of commitment and professionalism.[58,59,60]

In nursing professionalization, the “professional self” is one of the most important attitudinal elements. Professional identity is a secret knowledge that shows the continuation of a profession.[61] Professional attitude is a sense of experiences that makes up a professional identity.[62] Professional self-concept is the result of the university system, skills training, and professional development.[22] Arthur and colleagues (1998) showed that sense of being a professional among graduate students was stronger than among experienced nurses.[63] Finally, we can say professionalization is a framework for identifying a career in a social context, which emphasizes on attitudinal dimension of professionalization showing the importance of attitude within a profession and its professionals.[64]

Psychomotor dimension of nursing professionalization

Studies showed among nurses following the standards of practice and psychomotor competences, there are those who value professionalization.[65] UKCC in 1992, in an article titled “review professional action,” defined the nursing profession by these characteristics: Professional nursing is characterized by clinical working. This view has led to the expansion of the nursing role, so that they allowed getting involved in the therapeutic activities based on their personal qualifications and are actively involved in patient care.[66] So, professionalization is a certain style of management and implementation through which the professionals know about their commitments and obligations. It is also for those who are self-learning and self-controlled. This is consistent with the word “knowledgeable doer” that can be found in new dialogs in nursing.[67]

The definition of nursing professionalization in the clinical area is a difficult issue. Barber (1965) defined four properties for a professional manner: High degree of systematic and public knowledge, awareness about the interests of society rather than the personal interests, a high degree of self-control in behavior through moral codes, and existence of a reward system as a sign for success.[68] In nursing, some scholars have defined codes of professional behavior as: Respecting the dignity, values, and beliefs of the patients, maintaining patients’ trust, making informed decisions, provision of competent and safe care, maintaining standards of activities, presenting the image of nursing, and having a harmony with the law in action.[69] Lui et al. (2007) stated that the use of codes of professional behavior is important, but it is difficult in clinical practice. The main code of professional behavior in their study was “safe and competent care.”[69] This item is considered as the main foundation for nursing professionalization by other nursing associations in the West.[70,71]

From another perspective, nursing professionalization consists of behaviors including commitment, encouragement of the colleagues, peer assessments, and support from collective nature of profession. Focus in this view is on marketing and customer orientation.[72] Mayer (1992) emphasizes that in a modern society, the professions must be of good quality, reasonable, and affordable. He indicates that we can be sure about a professional service when the presented service is market-oriented. Thus, creating an environment where the focus is on value and satisfaction of the customer is important.[73]

Antecedents of nursing professionalization

The next rotational cycle in the developmental processes of evolutionary concept analysis is determining the antecedents and consequences of the concept.[74] Identifying the antecedents and consequences is an important part of the analysis because it provides greater clarity about the concept of interest. Antecedents are the events that happened before the concept occurrence and consequences can occur as a result of them.[17] Professionalization is actually a continuum that occurs during the professional socialization process. Antecedents of nursing professionalization are identified and classified in the following five groups: Demographic factors, factors related to the experience, training-related factors, factors related to the position, and value factors.

Demographic factors

Age is one of the effective factors on nursing professionalization, identified in the studies.[75] Studies have also shown that ethnic differences can have an impact on professional values.[76] Gender differences are also the other factors known to influence the professional values.[76,77]

Factors related to the experience

Length of service,[32] years of experience,[15,75,78] previous experiences,[78] and nursing professional experiences in the health care,[22] shown in several studies, are directly related to the nursing professionalization and professional attitude. It can be said that maturity in professional experiences has a large impact on professional attitude.

Factors related to the education

Degree,[22,72,79,80,81] membership in professional organiza tions,[1,4,15,81,82] having specialized certification,[1,15,78,81] the place where the last degree was issued,[1] political awareness,[83] educational readiness,[78] training and socialization,[72] teachers of nursing,[84,85] and length of the course,[1,86] all have been shown to have a significant relationship with professionalization in academic studies.

Factors related to the position

Position of nurse practitioners,[58,79] type of organization,[87,88,89] organizational culture,[69,90,91] the appearance of nurses in the workplace,[92,93,94,95,96] caregiver employment status,[1] work place,[1] existence of a reward system,[81,97] lack of staffs,[98] increasing the number of patients,[98] the existence of standards of activity,[99] lack of time, having stress and fatigue,[41] patients, clinicians, managers, and co-workers,[84,85] the gap between education and clinical practice,[22] and expectations of health care organizations,[22] all have been mentioned as precursors to professionalization in the reviewed studies.

Value factors

Professional satisfaction and organizational commitment,[4] professional freedom and independence and motivational factors,[78] belonging, knowing, and acknowledging,[100] support and guidance, acceptance, willingness, responsibility, and trust,[101,102,103] altruism,[104,105,106,107,108] and professional identity[93] have shown a significant relationship with professionalization. Studies showed belonging to a team, answering the questions of the patients and their families, and valuing the work do affect the understanding and meaning of students from professionalization.[22,93]

In general, although several internal and external factors are associated with the level of professionalization in nursing, for becoming a true professional, the experience of working and an educational background are very effective factors.

Consequences of nursing professionalization

Consequences of nursing professionalization consist of two components: Compatible and incompatible. Enhancement of patient care quality and improvement of the outcomes of care,[3,109,110,111] satisfaction of staffs, customers, clients, and agencies,[83,91,111,112] enhancement of the professional authority and the power to make decisions,[58] development of training programs to improve educational efficiency,[69] reduction of accidents and mistakes and risk management,[113] non-occurrence of burnout,[114] creating employment standards,[91] socialization, professional development, self-concept development, business retention,[101,102,103] and increased recognition of patients[111] are the compatible consequences that have been discussed in several studies.

Although professionalization can be very positive for professional practice, it can create blind spots in organization and stop vital information flow in uncertain conditions. This is because professional groups form their own subculture, especially in their language and communication habits. Therefore, they tend to be separated, even if they are working with other groups in an organization. On the other hand, as the professional members of the profession must accept responsibility, self-regulation, and control of the market for their services, the foundation of professionalization is based on the competition over resources and power that are divided between the characters and organizations.[113]

Surrogate and related concepts

The term “surrogate” is used for the concepts that express the same meaning of the desired concepts.[20] In other words, the term explains the meaning of a concept.[17] Related terms are used to express concepts that are related to the desired concept but do not have necessarily similar characteristics.[17] Application of related concepts in concept analysis is based on the idea that each concept is a part of a network of concepts. Identifying the related concepts helps us to locate “nursing professionalization” concept in basic knowledge of nursing. During the analysis process, it became clear that the concept of professionalism can be replaced with the words “profession” and “professional.”

Profession and Professor from Latin etymology have the same root (Profess). The meaning of their root is claimed or confessed.[2] From lexical aspect, profession is a vocation required to higher education and intellectual skills. Many authors have searched for the profession and its indicators. Aydellotle (1990) defined a profession as an organized and sophisticated job through which the clinicians obtain their exclusive knowledge in a protracted course for providing an exclusive, essential, or favorite service. He indicates that the essential features of a profession include having extensive and systematic knowledge, focusing on society interests, controlling the behavior through codes of ethics, having relationships with other professions, and existence of a professional reward system.[115] Extensive review of studies suggests that the profession is characterized by a series of factors: (1) the body of knowledge acquired through formal education, (2) a high level of competency, (3) inclusion criteria, (4) professional certification process, and (5) a set of behavioral and attitudinal norms, known as professionalization.[58,116,117,118,119,120]

Overall, a profession is characterized by the use of standardized knowledge that has three components: (1) an action taken based on underlying basic knowledge or discipline, (2) practical knowledge to solve everyday's problems, and (3) the knowledge based on skills and attitudes to serve to the clients. The articles defining the characteristics of the nursing profession list them as: Strong commitment, long-term and regular education, special body of knowledge and skills, ethics, autonomy, power for standard service, valuing and existence of professional associations.

The word “professional” in Aryanpur dictionary means related to a profession or an occupation, or being seasoned, skilled, and experienced. Dictionary of thesaurus lists the synonyms for the word “professional” as: Qualified, trained, skilled, white-collar professional people like doctors and engineers, expert, experienced, finished, skilled, masterly, efficient, etc.[121] Being a professional or being a professor means being a person claiming to have expertise in a specific skill or knowledge.[122] Flexner says professionals are the people who have to adapt to a particular job and have basic and higher education, high intellectual level in performance, sense of responsibility, scientific knowledge based on expertise, interest to develop learning, self-direction, and philanthropy.[123] Qualified members of a profession have ethical codes and a professional organization as a guide. Sacrifice, altruism, accountability, self-regulation, self-determination, and independence are features of the professional values.[7,124] Jarvis defines a professional as a person who is constantly in search of mastery in a branch of learning that is the foundation of his/her career, so as to be able to provide services to his/her clients.[45] Freidson, Cho, and Han expressed some professional qualities such as political autonomy, clinical autonomy, professional excellence and dominance, professional autonomy, clinical thinking, self-regulation and professional ethics.[125,126,127] In nursing articles, the word “professional” is implied to trained clinicians. In fact, professional employees are different. Their activities are associated with their attitudes and social behaviors.[117,128,129] These behaviors and attitudes include a high level of expertise, the freedom to manage work, commitment, knowledge, and a system of peer evaluation for maintaining the ethical standards.[130] From a marketing perspective, we can say that being a professional means to be obliged to do something that is appropriate for the patient and to accept the responsibility to provide services regardless to one's own interest.[58,116]

An appropriate exemplar of the concept

One of the six activities presented in Rodgers’ approach is identifying an exemplar of the concept, if appropriate. Rogers states that providing an example is essential to clarify a practical implementation of the concept related to the context.[17] Examples can be expressed by qualitative studies or specific situations.[131] Despite the strong need felt to provide such an example to clarify the concept further, the complex nature of the concept and features like its multi-dimensionality made it impossible to present a real example. This can be considered as a study limitation.

Interpretation and implications of the concept analysis

The aim of the present study was to assess nursing professionalization in relevant literatures to identify attributes, antecedents, and consequences of the concept. The results showed that nursing professionalization has cognitive, attitudinal, and psychomotor dimensions. Antecedents of nursing professionalization included demographic factors, factors related to education, factors related to experience, factors related to the position, and value factors. Consequences of nursing professionalization included two components of compatible and incompatible mechanisms. Results of the analysis are important because although a lot of literature is available about the nursing professionalization, there is little integration and inference about the concept.

Clinical implications: Professionalization and evolutionary experience

As a special knowledge, professionalization has a skill-oriented and experiential nature. So, focusing on the clinical factors that influence professionalization and providing the perfect context for professional growth and development in clinical practice seems to be one of the essential elements. One of the most important factors in the professionalization was experience, which was confirmed by several studies. Benner in 1984 proposed beginner–expert continuum as a framework for clinical nursing specialty.[132] He suggests five levels at the continuum: Beginner, advanced, competent, proficient, and expert. Different functional levels represent progressiveg stages of acquired skills and experience. Beginner–specialist's theory implies that through evolutionary experience, nurses are moving from one side to the other side of the continuum, but all nurses do not reach the level of expertise. Several studies have tried to explain the difference between a nurse specialist and beginner.[133,134] One of the most important factors discussed in this difference was years of experience. But this division based on years of experience is not a valid classification.[135,136] Benner et al., stated that experience singly does not guarantee specialty. They belived that evolutionary experience is associated with expertise, sufficient and especial experiences.[137]

Implications for research: Professional autonomy path to the professional power

The results of the analysis suggest a variety of researches in future. Although professionalization is not a new concept in nursing, however, studies on this issue seem to have failed to provide a significant step toward a comprehensive solution to achieve it. Therefore, recognition of strategies to achieve professionalization as a major phenomenon among health care providers is essential. The result of the present study suggests professional power and autonomy as a way to achieve nursing professionalization and further researches are considered necessary.

Hall (1982) introduced professional power as the focus on professionalization. He (1968) found that the main features of the professionalization are community service and sense of duty. Meanwhile today, autonomy and membership in professional organizations are most important for nurses.[58,59] He explains the membership in professional organizations as the central reference for self-regulation and professional autonomy at the heart of professionalization. Thereby, it enhances the professional power. One of the main features of nursing professionalization is autonomy. Forsyth and Donisiewics stated that the professions are important, unique, and complex; therefore, professionals should have power to make their own decisions free from external pressures.[138] Bul (1998) stated that one of the main purposes and attractions to move toward professionalization is development of professional autonomy.[139] Autonomy is an important component of professionalization that is effective on personal decision making to achieve the goals and the control on job situations. Autonomy not only acts as a buffer against stress but also acts as a mean to empower and strengthen the sense of the personality and professionalism.

Studies have shown that the most important way to achieve a professional power is autonomy, acquired through membership in professional organizations. Hall states that nurses should strongly support the professional organizations because by connecting to professional organizations, they have a more professional feeling and the organizations grow more to support their members.[58,59] If the nurses do not reach to social maturity as a body, it may influence their attitude and the way they are perceived by others. Also, it can act as a confounding factor to reduce the development of nursing as a profession.[26]

Theoretical implications

This concept analysis is based on an evolutionary approach developed by Rogers. The concept of professionalization is associated with nursing knowledge. This approach with the presentation of a theoretical definition of nursing professionalization is used as a basic starter. This concept analysis is limited based on time and context; therefore, a continuous effort to develop a conceptual framework for the present and future of nursing professionalization is required. Due to the complex nature of the professionalization, various definitions in the literature and the other sciences, especially nursing, are common and expected. According to philosophical foundation of analysis, the result of analysis is not only to reach to what the concept is as a conclusion, but also the basis for further development of the concept. The results of the present analysis can be presented in the definition for the professionalization, as nursing professionalization is a cyclical process, which includes mastery of knowledge, skilful action, and having professional ideology, measured by the top standards. It can promote when excellence is considered as a major criterion for judging actions and attitudes of professionals.

This definition of nursing professionalization not only opens further exploration but also provides the opportunity for further research in order to develop the concept and its application in the field of theory, and research in the fields of education, management, and clinical nursing. On the other hand, acceptance of the above definition is not considered, as acceptance of a unique definition is considered as ignoring other informal factors and variable conditions, which may be a supplement, opposite, or associated with the definition.

DISCUSSION

Professionalization, depending on times, contexts, and disciplines, has variable protests. Literature analysis of nursing professionalization led us to a variety of different meanings. The results of the present study describe the nursing professionalization as a multi-dimensional concept and it introduced cognitive, attitudinal, and psychomotor dimensions as the main features of nursing professionalization. In the review of studies, antecedents of the concept were demographic factors, factors related to experience, factors related to education, factors related to situation, and value-related factors. Consequences of professionalization in nursing are described by two components of compatible and incompatible. Therefore, nursing professionalization is not always associated with a favorable outcome. Hence, understanding of the professionalization characteristics, antecedents, and its consequences can lead to higher promotion of the status and the importance and application of this concept in the nursing profession. Use of assessment tools to evaluate and investigate this concept can result in further research and extension of the body of knowledge in this profession.

CONCLUSION

Finally, it can be concluded that nursing professionalism has a complex nature with multi dimensions. This feature requires theorizing in this area. For this purpose, concept analysis considered the first step.

Footnotes

Source of Support: This article didn’t support by any institution

Conflict of Interest: Nil.

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