Professionalism in Nursing
Cheryl Donelan, R.N. BSN
Professionalism in Nursing
Purpose: Upon completion of this learning
module, the nurse will have an overview of
nursing professionalism in practice. This
activity will explore what nursing
professionalism is, how it impacts nursing
practice, and how to advance
professionalism in the community. The
module includes information on the Kansas
State Board of Nursing’s definition of
incompetence, The Code of Ethics from the
Kansas State Nurses Association and
accountability within the profession.
Objectives: Upon completion of the learning
module, the nurse should be able to:
–Define the meaning of nursing
–Describe three factors which enhance
–Describe situations reflective of
accountability in the nursing profession.
Nurses Week 2004
The nursing profession began with a
genuine desire to serve and care for others,
combined with a sense of compassion and
commitment. Nurses are special people. It is
with awe and reverence that the nation
pauses this week to celebrate and thank all
those in the nursing profession for the
tireless hours of giving and care bestowed
upon the suffering.
To be a nurse is a calling and difficult to
describe in words. Who can say why a
person would want to do a nurses
work, but those who do will tell you
there is nothing as fulfilling or
rewarding. Nurses stay by the side of
those they serve through the worst
times and celebrate with patients and
families in the best times.
There is an intimacy nurses and
patients share which is understood.
The essence of nursing is an
unconditional love for mankind. To
be called a nurse is an honor – a
profession of the highest realm.
Founder of Nursing
Florence Nightingale is called the mother of
modern secular nursing. Born in 1820 in
Florence, Italy, this intelligent, upper-class
woman made dramatic and universal
changes in health care. At age 16,
Nightingale was called by God to minister to
With her social connections she was able to
secure an appointment as a healthcare
professional at a hospital for women in
London in 1853. Nightingale was asked to
bring nurses to care for the wounded British
soldiers in Scutari during the Crimea War in
Nightingale viewed nursing as an art as well as a
“Nursing is an art, and, if it is to be made an art,
requires as exclusive a devotion, as hard a
preparation, as any painter’s or sculptor’s work; for
what is the having to do with dead canvas or cold
marble, compared with having to do with the living
body- the temple of God’s spirit? It is one of the
fine Arts; I had almost said, the finest of the Fine
The Florence Nightingale Pledge
I solemnly pledge myself before God
and in the presence of this assembly to
pass my life in purity and to practice my
I will abstain from whatever is
deleterious and mischievous and will not
take or knowingly administer any harmful
I will do all in my power to maintain and
elevate the standard of my profession
and will hold in confidence all personal
matters committed to my keeping and all
family affairs coming to my knowledge in
the practice of my calling.
With loyalty will I endeavor to aid the
physician in his work and devote myself
to the welfare of those committed to my
In 1859, Florence Nightingale wrote: “No
man, not even a doctor, ever gives any other
definition of what a nurse should be than
this – “devoted and obedient” “ This
definition would do just as well for a porter. It
might even do for a horse. It would not do
for a policeman” (Nightingale, 1860).
Nursing has come a long way in 145 years.
Nightingale established the fundamentals of
patient management, care, and cleanliness
that has been taught in nursing schools ever
since. Her true legacy is far greater, as she
elevated nursing to a higher degree of
respectability and professionalism than ever
before. As we celebrate Nurse’s Week, May
6-12, 2004 let us reflect on what
professional nursing is and our vision for the
Definition of Professional Nursing
The Kansas State Board of Nursing provides this definition
on professional nursing:
(1) The practice of professional nursing as performed by a
registered professional nurse for compensation or
gratuitously means the process in which substantial
specialized knowledge derived from the biological,
physical, and behavioral sciences is applied to: the care,
diagnosis, treatment, counsel and health teaching of
persons who are experiencing changes in the normal
health processes or who require assistance in the
maintenance of health or the prevention or management of
illness, injury or infirmity; administration, supervision or
teaching of the process as defined in this section; and the
execution of the medical regimen as prescribed by a
person licensed to practice medicine and surgery or a
person licensed to practice dentistry (KSBN, 2003).
Definition of Licensed Practical
(2) The practice of nursing as a licensed practical
nurse means the performance for compensation or
gratuitously of tasks and responsibilities defined in
part (1) which tasks and responsibilities are based
on acceptable educational preparation within the
framework of supportive and restorative care
under the direction of a registered professional
nurse, a person licensed to practice medicine and
surgery or a person licensed to practice dentistry
A profession is defined as a calling or
vocation, especially one that involves some
branch of advanced learning or science. The
essence of professionalism is both having a
unique or special knowledge and the self-
imposed obligation to serve the community.
Until recently this has been an unwritten
contract. For these reasons, society holds
the professional in higher esteem than it
does a technician, blue-collar worker, or
businessman, people who traditionally are
interested in the benefits of their
employment rather than the occupation
Professionals are expected to show a
degree of special attainment, altruism, and
self-sacrifice in their dealings with the rest of
the community and in return receive
privileges both in the workplace and at large
(Bryan-Brown, et al. 2003).
In order to emphasize professionalism within
nursing, each nurse needs to understand
the opportunities, responsibilities and
concerns that are integral to the nursing
profession. The Kansas State Nurses
Association, 2003, Code of Ethics for
Nurses with Interpretive Statements defines
ANA Code Of Ethics
The nurse participates in the
advancement of the profession through
contributions to practice, education,
administration, and knowledge
7.1 Advancing the profession through
active involvement in nursing and in
Nurses should advance their profession by
contributing in some way to the leadership,
activities, and the viability of their professional
organizations. Nurses can also advance the
profession by serving in leadership or mentorship
roles or on committees within their places of
employment. Nurses who are self-employed can
advance the profession by serving as role models
for professional integrity. Nurses can also advance
the profession through participation in civic
activities related to health care or through local,
state, national, or international initiatives.
Nurse educators have a specific
responsibility to enhance students’
commitment of professional and civic
values. Nurse administrators have a
responsibility to foster an employment
environment that facilitates nurses’ ethical
integrity and professionalism, and nurse
researchers are responsible for active
contribution to the body of knowledge
supporting and advancing nursing practice.
7.2 Advancing the profession by
developing, maintaining, and implementing
professional standards in clinical,
administrative, and educational practice.
Standards and guidelines reflect the practice
of nursing grounded in ethical commitments
and a body of knowledge. Professional
standards and guidelines for nurses must be
developed by nurses and reflect nursing’s
responsibility to society.
It is the responsibility of nurses to identify
their own scope of practice as permitted by
professional practice standards and
guidelines, by state and federal laws, by
relevant societal values, and by the Code of
The nurse as administrator or manager must
establish, maintain, and promote conditions
of employment that enable nurses within
that organization or community setting to
practice in accord with accepted standards
of nursing practice and provide a nursing
and health care work environment that
meets the standards and guidelines of
Professional autonomy and self regulation in
the control of conditions of practice are
necessary for implementing nursing
standards and guidelines and assuring
quality care for those whom nursing serves.
The nurse educator is responsible for
promoting and maintaining optimum
standards of both nursing education and of
nursing practice in any settings where
planned learning activities occur. Nurse
educators must also ensure that only those
students who possess the knowledge, skills,
and competencies that are essential to
nursing graduate from their nursing
7.3 Advancing the profession through
knowledge development, dissemination, and
application to practice
The nursing profession should engage in
scholarly inquiry to identify, evaluate, refine,
and expand the body of knowledge that
forms the foundation of its discipline and
In addition, nursing knowledge is derived
from the sciences and from the humanities.
Ongoing scholarly activities are essential to
fulfilling a profession’s obligations to society.
All nurses working alone or in collaboration
with others can participate in the
advancement of the profession through the
development, evaluation, dissemination, and
application of knowledge in practice.
However, an organizational climate and
infrastructure conducive to scholarly inquiry
must be valued and implemented for this to
The nursing profession is characterized by
the continuing pursuit of knowledge, a sense
of responsibility for human concerns,
preparation through higher education, peer
accountability, autonomy, and altruism.
Nursing theory provides knowledge to
improve practice by describing, explaining,
predicting, and controlling phenomena.
Theory provides professional autonomy by
guiding the practice, education, and
research functions of the profession. Theory
also helps develop analytical skills,
challenge thinking, clarify values and
assumptions, and determine purposes for
nursing practice, education, and research
Career trajectory, in systems thinking, refers to
the series of successive states through which a
system or career proceeds over time. It may be
said to represent the long-term behavior of the
system. Nursing is often referred to as a young
profession, in that it is around 150 years old. A
review of nursing’s history clearly shows growth in
theory, evidence-based practice, image and
VCRMC Survey on Professionalism
In the winter of 2003, a random survey of
licensed nurses was conducted at Via
Christi Regional Medical Center. The survey
asked nurses throughout the organization to
name three characteristics that expressed
what professionalism was to them.
The top eight responses of over 300
surveys were as follows:
Knowledge (78) Respect for others (51)
Competence (53) Integrity (35)
Appearance (48) Positive Attitude (28)
Teamwork (27) Compassion (18)
The following discussion will focus on the
results and how nurses can build on the
characteristics identified by peers to
exemplify professional nursing.
Participants in the Via Christi study
indicated that knowledge and continuing
education were very important to them. The
desire to continue learning is relevant to the
nurse’s ability to develop competence and
professionalism in the provision of nursing
care. With knowledge acquired, nurses can
focus on the quality and performance of
nursing care rather than merely successful
completion of tasks.
Several factors enhance the utilization and
acquisition of knowledge. These factors are:
In-house educational programs
Research evidence-based practice.
Orientation generally includes a brief
employee orientation about the hospital’s
mission, vision and values as well as
organizational policies and procedures.
Further orientation for licensed personnel is
focused on patient care policies and issues.
Specific orientation programs for varying
lengths of time are developed to address
skills and expectations for patient care in
each department. Some nurses may require
a longer orientation time than others
because learning is individualized.
Preceptoring/ Co-worker Support
Mentoring or precepting is a crucial activity
that enhances the development of
professionals. Experienced practicing
nurses mentor others by being competent
role models and by providing a safety net as
nurses attempt to master new skills.
Strong mentors provide a positive
introduction to the nursing profession and,
depending on their beliefs, can foster
professionalism among those they guide
(Cameron-Jones & O’Hara, 1996; Ehrich,
Tennent, & Hansford, 2002; Lo & Brown,
Mentoring involves two parties and occurs
when the senior person in terms of maturity
and experience- the mentor- provides
information, advice, and emotional support
for the junior person – the “mentee” or
protégé. Mentors are people with advanced
job-related experience, knowledge, and
power in their organizations.
The beliefs of altruism, self-sacrifice,
advanced learning and above all else
honesty are required in order to be a
mentor and serve as a role-model for the
profession of nursing. To find a good
mentor look for someone with a positive
attitude and caring approach to others. The
individual should be a good communicator
and someone trustworthy (Restifo, 2004).
Preceptors are key elements in the
success of a nurse’s professional
development. Alspach (2000) published a
Preceptor’s Bill of Rights which follows.
Preceptors have the right to:
–A clear definition of their role.
–A clearly stated set of expectations for
–A clear delineation of their responsibilities
to the preceptee.
–A clear distinction for their responsibilities
in relation to others who are involved in
the orientation program.
–A clear statement of all expected
outcomes for the orientation program.
–Valid and reliable evaluation tools to
appraise preceptee performance.
–The resources necessary to fulfill their
–Continuing and responsive support
systems for fulfillment of their
–Adequate preparation for integration of
the preceptor role.
–Adequate training in the knowledge, skills,
and attitudes necessary to fulfill their
responsibilities (Alspach, 2000).
Preceptor Development Classes and
programs help define and support the
preceptor role. With the increased
complexity of healthcare systems this clearly
is an identified need for the nursing
Students and new nurses working closely
with experienced staff nurses have the
opportunity for role socialization as well as
increasing clinical skills, knowledge,
competence, and confidence.
Precepting student nurses and graduate
nurses has shown to be effective in reducing
lengthy and costly orientation programs,
enhancing recruitment and increasing
In-house Educational Programs
Nurses are required to maintain and develop
their professional knowledge and
competence in the many years of practice
that may follow registration. They are
expected to have knowledge,
communication skills and the ability to offer
effective, safe, evidence-based nursing in
their field of practice.
In order to facilitate and encourage this level
of professionalism, in-house educational
programs should be offered. Accordingly,
higher education, certification in advanced
practice, support for professional
organizations and research should be
Nursing competency ranked second in
the Via Christi survey. Some key features of
nursing competency are as follow:
The ability to recognize common factors that
contribute to, and adversely affect, the
physical, mental and social well-being of
patients and clients, and be able to take
The use of relevant literature and research
to inform the practice of nursing.
An appreciation of the influence of social,
political and cultural factors in relation to
An understanding of the ethics of health
care and the nursing profession and the
responsibilities these impose on the nurse’s
The ability to identify the physical,
psychological, social and spiritual needs of
the patient or client.
The use of appropriate channels of referral
for matters not within the nurse’s sphere of
Professional Incompetence Defined
Professional Incompetence is defined in
the Kansas Nurse Practice Act (2004) 65-
e. Professional incompetence defined;
As used in this section, “professional
1) one or more instances involving failure
to adhere to the applicable standard of care
to a degree which constitutes gross
negligence, as determined by the board;
2) repeated instances involving failure to
adhere to the applicable standard of care to
a degree which constitutes ordinary
negligence, as determined by the board; or
3) a pattern of practice or other behavior
which demonstrates a manifest incapacity or
incompetence to practice nursing.
It is every nurses responsibility to
understand the definition of incompetent
proactice. In addition, it is the responsibility
of those within the profession to monitor and
report acts of incompetence.
A standard is an authoritative statement
defined and promoted by the profession by
which the quality of practice, service, or
education can be evaluated.
These standards are used by Peer Review
Committees to evaluate peer practice and
determine if certain situations meet the
criteria of a reportable incident according to
the Kansas Risk Management laws.
The Kansas State Board of Nursing
provides standard of care determinations
which are based on the following criteria:
Standard of Care Determinations
Level I Standard of care met
Level II Standard of care not met, but
no reasonable probability of
Level III Reportable; standard of care
not met, with injury occurring
or reasonable probable.
Level IV Reportable; grounds for
disciplinary action by the
appropriate licensing agency
The nursing survey identified appearance as
important as professionalism. The issue of
appearance and attire is important in
creating a positive perception and
communicating an attitude of competence
and professionalism (Huber, 2000).
Research has shown that consumers
prefer white uniforms with a skirt and a cap
as a nurse’s uniform. This has possibly
occurred because of the persistence of
traditional views and images of nursing. As
the health care field becomes more
competitive some institutions may begin to
implement dress codes which capitalize on
the preference of “the customer”.
While caps and white starched uniforms are
not functional, nurses must realize that the
way one dresses symbolizes role identity,
authority, professional image, and
confidence - as well as the way the nurse
feels about themselves (Mangum, et al.,
Clothing is a form of nonverbal
communication that stimulates judgmental
responses from others and as a professional
nurse it is inappropriate to dress casual,
soiled, disheveled or seductive. Dressing
with a professional image in mind is a
simple act which carries the power to
An institutional policy on nursing dress code
is as follows:
Nurses are asked to set an example of
neatness and cleanliness in personal
appearance during work hours/shifts. Daily
grooming and appropriate appearance are
essential and set the image of the hospital.
Nurses customarily dress in uniform
specified by the departments. Hair, beards,
and sideburns must be neatly groomed,
clean and present a professional
appearance. Excessive use of cosmetics,
fragrances and other accessories should be
avoided. Facial jewelry, such as eye, nose,
lip or tongue jewelry is prohibited.
Other attire considered inappropriate includes:
Stained, wrinkled, tight, frayed, or revealing
Leggings, stretch pants, or capris
Sweatpants/tops or wind suits
T-shirts, tank tops, tube tops, crop tops or
Shirts with inappropriate slogans and/or
The last characteristic identified through to
2003 survey relates to teamwork. Nurses
work in multidisciplinary professional teams
with doctors and therapists. The goal of
these teams is to promote and provide
treatments which improve patient outcomes.
Nurses have been working with doctors for
many years attempting to strengthen mutual
understanding of each other professionalism
Definition of Teamwork
Teamwork in nursing practice refers to
interdisciplinary practice or collaboration
defined as a joint decision-making and
communication process with the goal of
satisfying the needs of the patient. This
includes respecting the unique abilities of
each professional involved in the care.
Today’s best integrated health delivery
systems are evolving toward a model of
care in which interdisciplinary teams of
providers manage the care of complex
As nurses have expanded their roles in
the community, it is important to understand
the contributions of unlicensed assistive
personnel. As the nursing shortage looms
upon us, the nursing profession may need to
divide labor with unlicensed staff,
particularly in non-acute care where team
working has existed for many years.
As professionals, nurses must not forget the
greatest consideration – that of the patient
rather than the provider. We cannot function
without our unlicensed assistants and owe
them mutual respect and courtesy. Their job
is also to provide comfort, care, love and
compassion to the sick.
Teamwork Improves Safety
As stated in the Hallmarks of the
Professional Nursing Practice Environment
(2002), in 1999, the Institute of Medicine
(IOM) issued a comprehensive report, To Err
is Human; Building a Safer Health System,
summarizing problems of patient safety in
the U.S. health system (IOM, 1999).
One important recommendation was to
create improved safety systems inside
health care through implementation of safe
practices at the delivery level, including
interdisciplinary clinical practice among
Attributes of interdisciplinary collaboration
include trust, knowledge, mutual respect,
good communication, cooperation,
coordination, share responsibility, and
The Fear Factor
The Institute for Safe Medication Practices
recently released a report on a survey
concerning the role that intimidation plays in the
safe administration of medications.
75% of the survey participants were nurses.
The questions were inquiring of how frequently
problems were encountered regarding
>Reluctance or refusal to answer your questions,
return phone calls or pages: 39% three to 10
times, and 21% more than 10 times.
>Condescending language or voice intonation:
40% three to 10 times, and 30% more than 10
>Impatience with questions: 42% three to 10
times, and 27% more than 10 times.
>”Just give what I ordered”: 24% three to 10 times,
and 10% more than 10 times (Ulrich, 2004).
This data identifies the problem of
intimidating behavior in regard to clarifying
orders and answering questions. Many
professional education programs for
medical, nursing, and allied health students
now require curricula that support
interdisciplinary practice in a variety of
These programs should emphasize
teamwork, conflict resolution, and the use of
informatics to promote collaboration in
patient care planning and implementation
(Wakefield & O’Grady, 2000).
Though problems of intimidation exist, the
registered nurse is personally accountable
for his/her own practice – not a senior
member of staff, physician or other health
care professional. Remember the saying
“but he/she told me to do it” is never
justification for poor practice.
Nurses cannot blame anyone else for
mistakes – they are accountable,
answerable, and liable for their own actions,
the completion of the assigned task, and
acts of delegation. Accountability cannot
Past studies of environments that support
collaboration among physicians, nurses and allied
health professionals have shown evidence of
improved outcomes for both acutely and
chronically ill patients. The professional nurse
should always remain calm and respectful of
others. Perhaps the best advice is to remember
the golden rule “do unto others as you would have
them do unto you.”
The most common dilemma regarding
accountability is created by the assignment of
responsibility and the granting of authority. Some
common examples of a mismatch of authority to
responsibility is when nurses are placed in what
they consider inadequate staffing situations,
disagreements with physician orders which may
not reflect best practice or instructions to carry out
tasks outside the scope of practice or the nurses’
Suggestions for avoiding the mismatch of
authority to responsibility include clear and
explicit communication, coupled with
negotiation strategies (Huber, 2000). Every
nurse has a responsibility to know the chain
of command and the person to turn to when
these occasions occur.
Respect, Integrity and Positive
Respect for others, integrity and a positive
attitude also ranked high in the nursing
survey. This finding is not surprising, as it
correlates to Gallup’s 2003 annual survey in
which nurses were on the top for honesty
and ethics among various professions,
followed by other medical professionals like
doctors, pharmacists, veterinarians and
Americans, in the November 14-16, 2003
CNN/USA Today/Gallup Poll, were asked to
rate the honesty and ethical standards of
people in 23 different professions as very
high, high, average, low, or very low.
As has been the case in four out of the five
times they have been included in the poll,
nurses ranked higher than any other
profession, with 83% of respondents saying
honesty and ethical standards of nurses are
“very high” or “high” (Carroll, 2003).
Future of Nursing
As nurses embrace the future, what is your
vision for the nursing profession? This
author believes it will be interactions that
nourish our human spirits in the places we
live and work. Nurses must be deliberate
with time, energy and resources as the
profession works toward the goal of quality
New modalities of delivering care are yet
to be envisioned and coordinated – not only
for patients being served, but for each other.
Fundamental to the nursing professions’
future is our ability to honor, respect and
value each other, as well as the inter-
personal and inter-professional
To know even one life has breathed
easier because you have lived – this
is to have succeeded (unknown author).
Happy Nurses Week!
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