The really important thing is not to live, but to live well. And to live well meant, along with more enjoyable things in life, to live according to your principles” (Socrates-GoodReads.com).
In this chapter, students will learn
Professional Identity within the Nursing Profession
Professional identity is defined as a sense of one’s self that is characterized by values, beliefs, and standards of the profession (Godfrey and Crigger, 2017). The development of a professional identity is a continuous process that begins when a student is admitted to nursing school and continues throughout their professional practice. That process is fluid and dynamic, allowing for interaction between education and practice. Career development encourages continuous self-reflection, growth, and human flourishing (Larson, Brady, Engelmann, Perkins, and Shultz, 2013). New professionals begin this process right away as the old identity dismantles.
The ANA sets the standards and scope for general nursing practice which include ten domains: Ethics, education, evidence-based practice and research, quality of practice, communication, leadership, collaboration, professional practice evaluation, resources, and environmental health (ANA, 2010). This e-text introduces the student to each of these standards.
Definitions and scope of practice
So, how is nursing identity defined? Florence Nightingale stated that nurses must “put the patient in the best condition for nature to act upon him” (p. 133, 1859). The American Nurses Association describes nursing duties and aspirations as “the protection, promotion, and restoration of health and well-being, the prevention of illness and injury; and the alleviation of suffering, in the care of individuals, families, groups, communities, and populations.…Nurses act to change those aspects of social structure that detract from health and well-being” (Fowler, p. xvi, 2015).
Several definitions can also be found in the literature. Nursing is an art and science where the careful and compassionate application of scientific knowledge is blended into high-quality nursing care (Potter, Perry, Stockert, and Hall, 2017). "Nursing is not simply a collection of specific skills…Nursing is a profession" (Potter, Perry, Stockert, and Hall, p.1, 2017). Other authors state that nursing practice is defined by society's expectations and needs and continues to evolve as knowledge and technology increase (Harding, 2017). Nursing could be summarized as a profession that helps people maintain health, recover from illness, and attain optimal health in chronic conditions.
During nursing education, students learn that professional identity development is a life-long process “of learning, refining, and integrating values and behaviors” (NLN, p. 23, 2010). Professional identity is an essential transition for nursing students (Browne, Wall, Batt, and Bennett, 2018). The move from a layperson mindset toward a professional identity takes time, effort, and education. Students must make a crucial transition which includes appearance, performance of roles, connection with others, and self-care. A strong professional identity is essential for future job satisfaction (Browne, Wall, Batt, and Bennett, 2018).
Registered nurses continue to evolve as professionals who adhere to standards and ethics and who have the courage to improve care for patients, families, and communities (NLN, P. 23, 2010). Professional identity evolves as the nurse advances through higher levels of education and as new evidence and technology advance the profession’s fund of knowledge (NLN, 2010).
Characteristics of professional identity
Professional identity encompasses five categories: Doing, being, acting ethically, flourishing, and changing identities (Godfrey and Crigger, 2017). This section discusses each of these attributes.
Doing. The act of “doing” encompasses the codes and standards of the nursing discipline and society’s expectations. Understanding how one functions as a member of this group is central to learning nursing skills – the “doing” part of nursing. Every student must accomplish this major task: The careful and safe application of nursing skills. This “doing” component is an essential part of nursing education but does not fully explain how laypersons become professional nurses. As students learn skills, instructors role model professional behaviors that accompany every nurse-patient encounter.
Being. Expert nurses develop a personal mindset that comes from “a desire to do what is good” and this internal drive is called “being” (Godfrey and Crigger, p.380, 2017). This attribute is demonstrated through attitudes and behaviors that reflect thinking, feeling, and acting as a professional. Being is informed by social and professional rules, principles, laws, codes, and standards. This personal sense of behaving as-a-nurse is developed within the culture of the profession and shapes how one thinks as a nurse.
Acting Ethically. Nurses have been voted the most trusted profession in Gallop’s ethics survey for over 17 consecutive years (American Hospital Association, 2019). Nurses make decisions each day that advocate for patient care and safety and must always ‘do the right thing’. A strong sense of professional identity can guide nurses through ethical dilemmas. For example, a patient wants to stop life support for a terminal illness, but the family does not agree. Nurses work with the patient and family to reach a satisfactory solution. See Chapter 3.
Flourishing. Flourishing is necessary for the formation and maintenance of professional identity (Godfrey and Crigger, 2017). Expert nurses develop five key qualities for life-long learning that foster a sense of thriving, promote striving for excellence, and sustain professional life. Colby and Sullivan (2008) describe these qualities:
1. Deeply engage with the profession’s purposes and derive meaning and satisfaction from the work
2. Develop a strong identity where nursing standards are essential features of one's view of oneself as a member of the profession
3. Habitually interpret and understand complex situations in terms of the profession’s moral purposes and standards
4. Consistently respond to patients, families, co-workers, and supervisors in alignment with professional ideals rather than from self-interest
5. Contribute courageously to ethical structures and practice of the profession
Flourishing is an important component in forming and fostering a professional identity and can be viewed as a stair-step process toward professional transformation. Crigger (n.d.) identified a process where experts move through phases of "growth and slips" between one's professional ideal and meeting social expectations. This process continues throughout a nursing career. Image retrieved from Crigger, N. (n.d.). From the inside out: Forming professional identity an inclusive transformation.
Changing Identities. Most people develop new identities throughout life. For example, a child becomes an adolescent, or a middle-aged adult becomes a retired elder. The process can be challenging when gaining a professional identity. A stage of disequilibrium is common. Some students struggle with adaption to professional rigor and expectations. However, recognition of various stages can help a student transition toward the final step of professional identity.
Professional identity development
Developing a professional identity involves the internalization of core nursing values (Larson, Brady, Engelmann, Perkins, and Shultz, 2013). The National League for Nursing (NLN, 2010) describes seven core values: Caring, diversity, excellence, integrity, ethics, holism, and patient-centeredness. Students internalize these values during nursing education, and these “become evident as the nurse learns, gains experience, and grows in the profession” (NLN, p. 68, 2010). “Professional identity is evident in the lived experience of the nurse in his or her ways of ‘being’, ‘knowing’, and ‘doing’” (NLN, p. 68, 2010).
Benner’s professional development model. Patricia Benner developed a model to explain the developmental process of clinical expertise in nursing (1984). She describes five stages: novice, advanced beginner, competent, proficient, and expert.
The novice has no prior experience or knowledge regarding professional expectations and situations. Nursing programs expose students to the classroom and clinical experiences that build knowledge, skills, and professional attitudes from simple to complex situations. Rules are emphasized without context to guide actions.
The advanced beginner can demonstrate basic acceptable behaviors in a few carefully chosen situations such as clinical skills labs, simulation labs, and care of patients with non-complex conditions. The student and new nurse graduate continuously build upon prior experience to solve problems in new situations.
The competent nurse has been on the job for two to three years and begins to look to the future with long-range goals. These goals include patient outcomes and the nurse’s career goals. The nurse moves from reaction to responding with a plan for high quality, organized care. Time management is well-honed, and priorities are set based upon patient needs. This nurse is not as flexible and quick as an expert nurse but is moving in that direction.
The proficient nurse can see an entire situation as well as the parts and is more flexible than competent nurses. Proficient nurses learn from experience and can modify patient care based on needs that might not be noticed by less experienced nurses. This level of performance is achieved when nurses work with similar patients and conditions for about three to five years. A key element, perception, is “not thought out but ‘presents itself’ based upon experience and recent events” (Benner, p. 27, 1984).
The expert nurse does not rely on analytical processes to respond to patient needs. Vast experience results in an intuitive grasp that zeroes in on problems without wasting time (Benner, 1984). The expert nurse can size up a situation quickly and masterfully, leaving a novice nurse wondering how decisions were made. Expert nurses “feel and know” things about patient care at a level that can be difficult to describe. The years of experience provide layers of knowing that build upon each other.
Context within healthcare
As has been addressed, the development of a professional nursing identity can be a challenge and needs context in which to flourish. Students grow professionally through practice, exposure to clinical settings, professional role modeling, and relinquishment of preconceptions about the professional role and rigors of nursing school. Students also need clear expectations, supportive environments, and opportunities for self-reflection (Godfrey and Crigger, 2017).
The development of a professional nurse identity is an essential transition that involves how students see themselves within the profession, and that perception is shaped by the media, educational experiences, and role modeling (Browne, Wall, Batt, and Bennett, 2018). Student nurses are encouraged to socialize within the profession to develop a personal sense of identity as a nurse (Potter, Perry, Stockert, and Hall, 2017). A strong professional identity can protect a nurse from common abuses in the healthcare setting such as incivility and secondary traumatic stress (Thompson, 2012). The ANA provides tools and tips for creating healthy workplaces at https://www.nursingworld.org/ practice-policy/work-environment/violence-incivility-bullying/.
Professional identity is strengthened through connections between nurses and other members of the healthcare. Interprofessional teamwork can enhance a sense of respect for one’s profession as students learn about, from, and with each other (Interprofessional Education Collaborative [IPEC], 2011). Nurses do not work in silos. In fact, excellent patient care is enhanced through collaboration between all disciplines (IPEC, 2011). Chapter seven provides more information interprofessional teamwork.
The NLN states that professional identity “involves the internalization of core values and perspectives recognized as integral to the art and science of nursing” (NLN, p. 35, 2010). The following exemplars discuss aspects of professional identity.
“Integrity is the practice of being honest and showing a consistent and uncompromising adherence to strong moral and ethical principles and values” (Wikipedia, n.d.). Integrity is a character trait that manifests through nursing actions that agree with what a nurse says he or she will do. It also means respecting the dignity of each person. It is the basis for trust with patients, families, and co-workers; and a breach can erode that trust. For example, a nurse who answers a call light promptly demonstrates integrity, whereas, a nurse who fails to contact a healthcare provider about a critical laboratory value demonstrates a lack of integrity.
Caring in nursing is “promoting health, healing, and hope in response to the human condition” (NLN, p. 65, 2010). Professional nurses show concern for the whole person and create caring cultures where patient-centered care is practiced. Caring nurses understand spoken and unspoken needs and act in the patient’s best interest. For example, a nurse might notice restlessness and adjust the patient’s position or understands that a frown indicates a need to talk.
Advocacy is an action that protects patients’ rights – human and legal – and/or aids in securing these rights. Nurses speak up about patient preferences for health care, provide information about treatment decisions, and work to change policy when care is adversely affected. Examples include discovering creative ways for patients to implement self-care, locating affordable medication and services, and supporting a patient’s decision on whether to have surgery.
Nurses are taught to be caregivers, educators, and role models. But who takes care of the nurses? As flight attendants remind airline passengers to put the oxygen mask on oneself before helping others, nurses must care for themselves so that the best care can be provided for patients. Nurses know the importance of a healthy lifestyle, but that knowledge is not always evident (Ross, Bevans, Brooks, Gibbons, and Wallen, 2017). Multiple studies have found that nurses do not follow a healthy lifestyle (James, Troped, Hart, Joshu, Colditz, Bronson, and Laden, 2013; Letvak, Ruhm, and Gupta, 2012; Nahm, Warren, Zhu, An, and Brown, 2012; Perry, Gallagher, and Duffield, 2015). As professionals, nurses need to acknowledge personal needs, stresses, and limitations to be successful caregivers (Duarte, et al., 2016).
Why is self-care important? Nurses must be "intentionally present" and "centered" and able to use all five senses with every patient encounter (University of Texas, Arlington, 2016). Alert nurses observe patient trends such as raising or lowering blood pressure and whether a patient is ready to sit up or must continue bed rest. Nurses who practice self-care are better able to use these observations to make good clinical judgments and reduce errors. When providing care, nurses frequently offer lifestyle education to improve health outcomes. Credibility can be affected by the nurse’s lifestyle choices (Perry, Gallagher, and Duffield, 2015).
The shortage of nurses can cause increased stress levels, lower job satisfaction, and high turnover rates. Lack of nurse retention after years of training, negatively impacts a nurse’s quality of life, patient care, and the amount of time spent with each patient. Lack of time with patients can lead to safety issues addressed in Chapter 4 (AACN, 2017).
The lack of self-care can lead to errors on the job, fatigue, burnout, health problems, and a decreased quality of life which could be detrimental to both patients and nurses (University of Texas Arlington, 2016). Taking care of oneself may seem selfish but if not done, there is very little caring or compassion left for patients (Duarte, Gouveia, and Cruz, 2016). Nurses who work in hospitals witness prolonged suffering which can result in anger, sadness, guilt, or anxiety (Potter, Perry, Stockert, and Hall, 2017). Self-care practices can buffer these ill-effects while a lack of self-care can lead to physical, mental and emotional depletion (Potter, Perry, Stockert, and Hall, 2017). Sometimes, nurses decide to leave nursing. For one nurse’s story, go to the Sigma Theta Tau online publication Reflections on Nursing Leadership at https://www.reflectionsonnursingleadership.org/features/more-features/i-left-nursing-because-of-secondary-traumatic-stress.
Nursing students must also practice self-care. They manage academic stress, heavy assignment workloads, new clinical situations, family obligations and in some cases, work hours that interfere with study time. Ashcroft and Gatto (2015) found that students' self-care practices declined during nursing school. The downward trend in self-care occurred as the intensity of academic and clinical responsibilities increased.
Self-care starts with an awareness of personal needs and methods to meet those needs. Occupational stresses include increased paperwork, protection of patient rights, decreased management support, staffing patterns, lack of power, role ambiguity, conflict, and workplace violence. To buffer these stresses and increase the quality of life, the nurse can eat a nutritious diet, increase physical activity, obtain adequate restful sleep, and practice mindfulness, and other stress-reduction techniques. Stress reduction activities include play, meditation, taking work breaks, socializing, decompression time, aromatherapy, and visual imagery. For more tips, go to Purdue University Online at https://www.purdueglobal.edu/blog/nursing/self-care-for-nurses/.
Importance of self-care
Nurses must be “present” for each nurse-patient encounter. Presence creates “a sense of closeness and caring” (Potter, Perry, Stockert, and Hall, p. 84, 2017). To be present on a continual basis, nurses must practice self-care or suffer burnout and compassion fatigue which can lead to decreased quality of life. The following exemplars discuss three consequences of poor self-care.
Compassion fatigue is difficult to identify which makes it a challenge to recognize in oneself according to Coetzee and Klopper (2010). These researchers found that three stages of compassion fatigue are progressive and accumulative: Compassion discomfort, compassion stress, and compassion fatigue. Stage three results in burnout, accidents, breakdowns, apathy, a desire to quit, unresponsiveness, callousness, and indifference. If compassion fatigue is not identified early, nurses might not be able to recover. A nurse in the last stage places the nurse and patient at risk for poor outcomes.
For example, a nurse with compassion fatigue arrives at work having lost sleep and decides to go for a coffee break before making rounds. The nurse misses a crucial assessment finding and a patient choked on orange juice. The nursing assistant discovered the problem and called the Rapid Response Team. The patient lost consciousness, required a breathing tube and machine-assisted breathing, and was sent to the intensive care unit. The nurse's compassion fatigue was made obvious in her unwillingness to provide routine care in a timely manner.
Compassion satisfaction (CS), however, is the positive aspect of quality of life and can be increased through excellent self-care. This state of mind promotes pleasure derived from caring for others. Nurses with CS experience positive feelings about colleagues, patients, and self. This sense of satisfaction fuels the nurse and does not deplete personal reserves. A nurse with CS will care for patients, co-workers, and self while maintaining a good work-life balance.
Secondary traumatic stress (STS) comes from the stress of witnessing repeated human tragedy and traumas (Cieslak, Shoji, Douglas, Melville, Luszczynska, and Benight, 2014). Nurses who work in acute care settings can be exposed daily to secondary traumatic stress (Potter, Perry, Stockert, and Hall, 2017). Symptoms resemble compassion fatigue and include intrusive thoughts, re-experiencing the episode, and avoiding situations that trigger the memory (Shoji, et al., 2015). STS can lead to disruptions in home life and negatively impact work performance. Some nurses decide to leave the profession when STS is not well managed.
For example, a young nurse witnessed the death of an infant who had suffocated due to a house fire. The child had been resuscitated but died a day later. As the nurse performed post mortem care on the tiny soft body, she became distraught. This was the first child she had cared for and the experience caused her to lose sleep and remember how the body felt in her arms. She worked with her nurse mentors to stop the intrusive thinking, but still to this day, she can viscerally feel that baby's body. She works only with older adults.
Burnout is a negative outcome of caring more for others than for oneself. This state of physical and mental distress includes three dimensions: Emotional exhaustion, depersonalization, and a lack of personal accomplishment. It can occur when nurses lack social and managerial support and self-care. Burnout can lead to irritation, restlessness, an inability to focus on or engage with patients, and disengagement with work in general (Shoji, et al., 2015). If not reversed, burnout can lead to uncivil behaviors such as absenteeism and lateral violence or bullying (Potter, Perry, Stockert, and Hall, 2017; Thompson, R., 2012).
Image source: ProQOL.org
For example, an older nurse who had cared for the same type of patient for many years became increasingly frustrated with healthcare reform limitations. In the past, nurses were allowed plenty of time to provide excellent bedside care. However, changes in healthcare finance and patient demographics made nursing care more stressful. Workloads increased, staffing decreased, and patient acuity worsened. Nursing was no longer enjoyable, and irritations grew over petty issues. This nurse had reached burnout.
Resilience comes from successful experience with adversity and results in hardiness, mental toughness, and emotional stability (Kumpfer, 1999; Luthar, Cicchetti, and Becker, 2000). Simply defined, personal resilience is the ability to bounce back, adapt, and become more resourceful or stronger after an adverse event, major challenge, or tragedy (Earvolino-Ramirez, 2007; Hart et al., 2014). Nurses must develop personal resilience that sustains wellbeing. Training can enhance nurse resilience in acute care settings (Mealer, Conrad, Evans, Jooste, Solyntjes, Rothbaum, and Moss, 2014; Mealer, Jones, Newman, McFann, Rothbaum, and Moss, 2012).
A resilient nurse would experience stress, be affected by it, and find a way to bounce back and regulate emotions (Halter, 2018). Resilient nurses learn how to thrive in modern healthcare settings (Mealer, Jones, Newman, McFann, Rothbaum, and Moss, 2012). To take a personal resilience quiz, go to page 196 in the research article by Smith, Dalen, Wiggins, Tooley, Christopher, and Bernard (2008) at https://www.researchgate.net/publication/23164897_The_Brief_Resilience_Scale_Assessing_the_Ability_to_Bounce_Back.
The ANA named 2017 as the “Year of the Healthy Nurse” to raise awareness that nurses must attend to self-care and improve quality of life and health. As role models and patient educators, over three million nurses could greatly impact the health of the nation. The organization defined a healthy nurse as “one who actively focuses on creating and maintaining a balance and synergy of physical, intellectual, emotional, social, spiritual, personal, and professional wellbeing” (ANA, 2017).
For more information on the Healthy Nurse, Healthy Nation Grand Challenge and development of health nurse lifestyles, go to these links:
In this chapter, students learned about: