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Chapter 3

Nursing’s Pathway to Professionalism

Fayetteville State University PNURS 210

Introduction to Professional Nursing

Sandy Parker, MSN, RN

Characteristics of a Profession

1910: Flexner Report called for medical schools to implement high standards for admission and graduation.

1915: Flexner published a list of criteria that he believed to be characteristic of a profession.

Flexner – sociologist

Flexner’s Criteria of a Profession

1. Is basically intellectual (as opposed to physical) and is accompanied by a high degree of individual responsibility

2. Is based on a body of knowledge that can be learned and is developed and refined through research

3. Is practical, in addition to being theoretical

4. Can be taught through a process of highly specialized professional education

5. Has a strong internal organization of members and a well-developed group consciousness

6. Has practitioners who are motivated by altruism (the desire to help others) and who are responsive to public interests (Figure 3-1)

Characteristics of a Profession

1968: Hall described a professional model with five attributes of professions.

1990: Pharmacy Profession Task Force – found that members of a profession share ten (10) characteristics.

Hall – sociologist

Five Attributes of Professions

1. Use of a professional organization as a primary point of reference

2. Belief in the value of public service

3. Belief in self-regulation

4. Commitment to a profession that goes beyond economic incentives

5. A sense of autonomy in practice

Pharmacy Profession Task Force: 10 Characteristics

1. Prolonged specialized training in a body of abstract knowledge

2. A service orientation

3. An ideology based on the original faith professed by members

4. An ethic that is binding on the practitioners

5. A body of knowledge unique to the members

6. A set of skills that forms the technique of the profession

7. A guild of those entitled to practice the profession

8. Authority granted by society in the form of licensure or certification

9. A recognized setting in which the profession is practiced

10. A theory of societal benefits derived from the ideology

Occupation-Profession Continuum

The Process of Professionalism (Carr-Saunders and Wilson, 1933)

Practitioners performed full-time work in the discipline.

They determined work standards, identified a body of knowledge, and established educational programs in institutions of higher learning.

They promoted organization into effective occupational associations, and then worked to establish legal protection that limited practice of their unique skills by outsiders.

Finally, they established codes of ethics.

Occupation-Profession Continuum

1980: Houle identified characteristics that indicate that an occupation moves along the continuum toward professional status.

Step 1: Defining the group’s mission and foundations of practice

Step 2: Mastery of theoretical knowledge, development of the capacity to solve problems, use of practical knowledge, and self-enhancement (continued learning and development)

Step 3: Development of a collective identity as an occupation evolves into a profession

Houle (1980) – identified a number of characteristics that indicate that an occupational group is moving along the continuum toward professional status.

Signs of a developing collective identity, and hence a profession, include:

Formal training

Credentialing

Creation of a subculture

Legal right to practice

Public acceptance

Ethical practice

Discipline of incompetent/unethical practitioners

Relationship to other practitioners, and

Formalization of the relationship of practitioners of the profession to users of the practitioners’ services

Wynd (2003): A Study of 774 Registered Nurses…

“Professionalism was significantly related to

years of experience as an RN,

having higher degrees,

memberships in professional organizations,

serving the organization of employment as an officer, and holding professional certification.”

Wynd (2003), a study of 774 registered nurses (RNs), found that professionalism was significantly related to years of experience as an RN, having higher degrees, memberships in professional organizations, serving the organization of employment as an officer, and holding professional certification.

Wynd noted that attracting younger persons to nursing as a career and retaining experienced nurses requires recognition of the positive aspects of nursing professionalism.

Professional Preparation

Typically in a college or university. It requires instruction in the specialized body of knowledge and techniques of the profession.

It includes orientation to the beliefs, values, and attitudes expected of the members of the profession, and the standards of practice and ethical considerations (socialization).

Intense preparation enables practitioners to act in a logical, rational manner using scientific knowledge and prescribed ways of thinking through problems rather than relying on simple problem solving, custom, intuition, or trial and error.

Example: nursing process

A profession is different from an occupation in at least two major ways—preparation and commitment.

Professional preparation, typically taking place in a college or university, requires instruction in the specialized body of knowledge and techniques of the profession. In addition to knowledge and skills, professional preparation includes orientation to the beliefs, values, and attitudes expected of the members of the profession, as well as the standards of practice and ethical considerations. These components of professional education are part of the process of socialization into a profession.

This intense preparation enables professional practitioners to act in a logical, rational manner using scientific knowledge and prescribed ways of thinking through problems rather than relying on simple problem solving, custom, intuition, or trial and error.

Example: nursing process – uses scientific knowledge and prescribed ways of thinking through patient problems amenable to nursing care

Professional Commitment

Personal identification is derived from the profession.

Profession as a “calling”

Commitment transcends expectation of material reward.

Strong professional identity – it is less common to change careers than an occupation.

Professionals are:

usually highly committed to their work, deriving much of their personal identification from it, and consider it an integral part of their lives;

some people even refer to their profession as their “calling.”

Historically, professionals’ commitment to their profession has transcended their expectation of material reward.

The strong identity that professionals develop means that it is less common for them to change careers compared with persons involved in occupations, which may not involve such a strong commitment and identity. Several critical differences between occupations and professions are summarized Table 3-1.

OCCUPATION	PROFESSION
Training may occur on the job.	Education takes place in a college or university.
Length of training varies.	Education is prolonged.
Work is largely manual.	Work involves mental creativity.
Decision making is guided largely by experience or by trial and error.	Decision making is based largely on science or theoretical constructs (evidence-based practice).
Values, beliefs, and ethics are not prominent features of preparation.	Values, beliefs, and ethics are an integral part of preparation.
Commitment and personal identification vary.	Commitment and personal identification are strong.
Workers are supervised.	Workers are autonomous.
People often change jobs.	People are unlikely to change professions.
Material reward is main motivation.	Commitment transcends material reward.
Accountability rests primarily with employer.	Accountability rests with individual.

Comparing Occupations and Professions

Interprofessionality

WHO (2010): “It is no longer enough for health workers to be professional. They also need to be interprofessional.”

Definition:

Inter-professionality is a process by which professionals reflect on and develop ways of practicing that provides an integrated and cohesive answer to the needs of the client/family/population.

Nursing’s Pathway to Professionalism

Roy Bixler and Genevieve Bixler were advocates and supporters of nursing. They were not nurses.

Used seven criteria

1959: Re-appraised nursing and noted progress in nursing’s professional development

More recently, nurse leaders have explored the professionalization of nursing.

Kelly’s Criteria: Eight Characteristics of a Profession

Kelly’s (1981) Criteria: Eight Characteristics of a Profession

FIRST: The services provided are vital to humanity and the welfare of society.

Why do students want to become a nurse? “To help people”

Services versus caring

Caring is the core of professional nursing through which nurses intervene for their patients.

Kelly’s (1981) Criteria: Eight Characteristics of a Profession

SECOND: There is a special body of knowledge that is continually enlarged through research.

Research nursing degrees

Nursing is no longer based on simple problem solving but increasingly relies on theory and research as a basis for practice.

Example: Evidence-based practice

Kelly’s (1981) Criteria: Eight Characteristics of a Profession

THIRD: The services involve intellectual activities; individual responsibility (accountability) is a strong feature.

Critical and creative thinking serves as basis for providing nursing care. Example: Nursing process

ANA defines accountability

Accountability is firmly rooted in the ethical principles of “fidelity (faithfulness), loyalty, veracity, beneficence, and respect for the dignity, worth, and self-determination of patients.”

ANA Definition: Accountability

Accountability, according to the ANA Code of Ethics for Nurses, is being answerable to someone for something one has done.

Code of Ethics for Nurses

Provision 4.4: Nurses are accountable and responsible for the assignment or delegation of nursing activities” (ANA, 2015, p. 17).

Accountability is firmly rooted in the ethical principles of “fidelity (faithfulness), loyalty, veracity, beneficence, and respect for the dignity, worth, and self-determination of patients”.

Kelly’s (1981) Criteria: Eight Characteristics of a Profession

FOURTH: Practitioners are educated in institutions of higher learning.

1909: University of Minnesota – first university-based nursing

1965: ANA Position Paper – All nursing education should take place in institutions of higher education.

Debate: Entry level into Practice

Kelly’s (1981) Criteria: Eight Characteristics of a Profession

FIFTH: Practitioners are relatively independent and control their own policies and activities (autonomy).

Autonomy – control over one’s practice.

Licensure and autonomous practice

“Doctor’s orders” connotation

Groups that control nursing practice

Organized nursing

Organized medicine

Health service administration

Magnet Recognition program and survey of nurses

“Organized” in this context refers to the collective professional bodies that are the voice speaking for the interests of their respective professions, specifically the ANA and the American Medical Association (AMA), although other organizations have vested interests in these professions too.

Magnet Recognition program – initiative by American Nurses credentialing Center (ANCC)

It was established to recognize hospitals that attract and retain nurses.

1983: ANCC determined that nursing autonomy and control over practice were crucial characteristics of Magnet Hospitals.

2010: National Survey of Nurses

Nurses in Magnet hospitals rated their workplace organization and participation in shared governance higher than nurses in non-Magnet facilities.

THERE were no difference with respect to influence on decisions related to patient care.

Only 37% of Magnet nurses rated their opportunities to participate in shared governance as very good or excellent.

THUS: significant way to become autonomous and incorporate autonomy into the culture of nursing.

Kelly’s (1981) Criteria: Eight Characteristics of a Profession

SIXTH: Practitioners are motivated by service (altruism) and consider their work an important component of their lives.

Altruism – ideal of service to others

Nurses’ altruism is sometimes questioned when they demand higher compensation and better working conditions.

Collective bargaining

Nursing as “simply a job”

Kelly’s (1981) Criteria: Eight Characteristics of a Profession

SEVENTH: There is a code of ethics to guide the decisions and conduct of practitioners.

ICN and ANA established a Code of Ethics

1893: Nightingale Pledge

Kelly’s (1981) Criteria: Eight Characteristics of a Profession

EIGHTH: There is an organization (association) that encourages and supports high standards of practice.

American Nurses Association (ANA) – official voice of nursing

Purposes

Relatively low percentage of nurses who belong to ANA and the constituent state nurses association

A significant political influence is unrealized for the profession.

Purposes of the ANA are:

To work for the improvement of health standards and the availability of health care services for all people,

To foster high standards of nursing, and

To stimulate and promote the professional development of nurses and advance their economic and general welfare (ANA, 2008).

Miller (1985): The Wheel of Professionalism

It is based on common themes, statements from Nursing’s Social Policy Statement and Code of Ethics for Nurses.

According to Adams and associates (1996):

Each of the eight spokes represents other behaviors deemed necessary in maintaining or increasing nurses’ professionalism. They are competence and continuing education; adherence to the code of ethics; participation in the primary and referent professional organization, i.e., ANA and state constituent member association; publication and communication; orientation toward community services; theory and research development and utilization; and self-regulation and autonomy. (p. 79)

Documents that Guide All Nurses in Their Professional Commitment

Nursing’s Social Policy Statement: The Essence of the Profession – A Contract with Society

Nursing: Scope and Standards of Practice

Code of Ethics for Nurses

Purpose:

It is a statement of ethical values, obligations, duties, and professional ideals of nurses individually and collectively.

It is nursing’s non-negotiable ethical standard.

It expresses nursing’s own understanding of its commitment to society.

Nursing’s Social Policy Statement: The Essence of the Profession – A Contract with Society

It serves as a framework for understanding professional nursing’s relationship with society and nursing’s obligation to those who receive professional nursing care.

ALSO: ANA definition of nursing and pertinent discussions related to the knowledge base of nursing, specialty, and advanced practice , and professional regulation.

Nursing: Scope and Standards of Practice

It outlines the expectations of the professional role within which all RNs must practice and delineates the standards of care and associated competencies for professional nursing.

Code of Ethics for Nurses

ANA designated 2015 – year of Ethics.

It is a tool that guides a group toward professional self-definition and provides evidence of professional legitimacy.

Purpose:

It is a statement of ethical values, obligations, duties, and professional ideals of nurses individually and collectively.

It is nursing’s non-negotiable ethical standard

It expresses nursing’s own understanding of its commitment to society.

Provisions of 2015 Code:

FIRST three provisions – fundamental values and commitments of the nurse

NEXT three provisions – boundaries of duty and loyalty

LAST three provisions – aspects of duties beyond individual patient encounters

Collegiality

Essence of Collegiality – promotion of a supportive and healthy work environment, cooperation, and recognition of interdependence among members of the nursing profession

Professional nurses demonstrate collegiality by sharing with, supporting, assisting, and counseling other nurses and nursing students.

Collegial Behaviors

Examples:

share knowledge with colleagues and students

take part in professional organizations

mentor less-experienced nurses

willingly serve as role models for nursing students

welcome learners and their instructors in the practice setting

assist researchers with data gathering

publish in professional literature, and

support peer-assistance programs for impaired nurses

Unprofessional Behavior

Barriers to Professionalism in Nursing

Varying levels of education for entry into practice

Nursing’s lack of a standardized requirement for a minimum of a BSN, and preferably a master’s degree, stands in sharp contrast with other health care professions requiring more education to practice (David, 2000).

Gender issues

The persistent devaluing of women’s work in our society has created an ongoing struggle for professions such as nursing and teaching to increase the status, increase the compensation, and improve the working conditions.

skilled nursing

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