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Professionalism in Nursing

Nurses Week 2004 By Cheryl Donelan, R.N. BSN

Professionalism in Nursing Learning Module

 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 Nursings 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 professionalism. Describe three factors which enhance professionalism. 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 upperwoman made dramatic and universal changes in health care. At age 16, Nightingale was called by God to minister to the sick.

 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 1854.

 Nightingale viewed nursing as an art as well as a science.  Nursing is an art, and, if it is to be made an art, requires as exclusive a devotion, as hard a preparation, as any painters or sculptors work; for what is the having to do with dead canvas or cold marble, compared with having to do with the living bodybody- the temple of Gods spirit? It is one of the fine Arts; I had almost said, the finest of the Fine Arts (Nightingale,1868).

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 profession faithfully.  I will abstain from whatever is deleterious and mischievous and will not take or knowingly administer any harmful drug.

 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 care (Nightingale,1860).

 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 Nurses Week, May 6-12, 2004 let us reflect on what professional nursing is and our vision for the future.

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 Nurse

(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 (KSBN,2003).

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 selfselfimposed 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 bluebusinessman, people who traditionally are interested in the benefits of their employment rather than the occupation itself.

Professionals are expected to show a degree of special attainment, altruism, and selfself-sacrifice in their dealings with the rest of the community and in return receive privileges both in the workplace and at large (Bryan(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 these concepts:

ANA Code Of Ethics

Provision 7  The nurse participates in the advancement of the profession through contributions to practice, education, administration, and knowledge development. 7.1 Advancing the profession through active involvement in nursing and in healthcare policy. policy.

 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 selfadvance 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 nursings 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 Ethics.

 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 nursing practice.

 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 programs.

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 practice.

 In addition, nursing knowledge is derived from the sciences and from the humanities. Ongoing scholarly activities are essential to fulfilling a professions 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 occur.

 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 (Tomey, 2002).

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 longsystem. Nursing is often referred to as a young profession, in that it is around 150 years old. A review of nursings history clearly shows growth in theory, evidence-based practice, image and evidenceautonomy.

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.

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The top eight responses of over 300 surveys were as follows: Professional Personal
    Knowledge (78) Competence (53) Appearance (48) Teamwork (27) Respect for others (51) Integrity (35) Positive Attitude (28) 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 nurses 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: Orientation Preceptor/coPreceptor/co-worker support In-house educational programs InAdvanced certification Research evidence-based practice. evidence-

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 Orientation generally includes a brief employee orientation about the hospitals 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 Co 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(Cameron-Jones & OHara, 1996; Ehrich, Tennent, & Hansford, 2002; Lo & Brown, 2000).

 Mentoring involves two parties and occurs when the senior person in terms of maturity and experience- the mentor- provides experiencementorinformation, advice, and emotional support for the junior person the mentee or protg. Mentors are people with advanced jobjob-related experience, knowledge, and power in their organizations.

 The beliefs of altruism, self-sacrifice, selfadvanced learning and above all else honesty are required in order to be a mentor and serve as a role-model for the roleprofession 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 nurses professional development. Alspach (2000) published a Preceptors Bill of Rights which follows. Preceptors have the right to: A clear definition of their role. A clearly stated set of expectations for their performance.

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 responsibilities.

Continuing and responsive support systems for fulfillment of their responsibilities. 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 profession.

 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 retention.

In-house Educational Programs In 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 evidencetheir field of practice.

 In order to facilitate and encourage this level of professionalism, in-house educational inprograms should be offered. Accordingly, higher education, certification in advanced practice, support for professional organizations and research should be supported.

Nursing Competency
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 wellpatients and clients, and be able to take appropriate action.

 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 health care.

 An understanding of the ethics of health care and the nursing profession and the responsibilities these impose on the nurses professional practice.

 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 nurses sphere of competence

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Professional Incompetence Defined

 Professional Incompetence is defined in the Kansas Nurse Practice Act (2004) 65651120  e. Professional incompetence defined; As used in this section, professional incompetence means:  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  Level II  Level III  Level IV
Standard of care met Standard of care not met, but no reasonable probability of causing injury Reportable; standard of care not met, with injury occurring or reasonable probable. 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 nurses 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., 1991).

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 advance professionalism.

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 clothing  Jeans  Shorts  Leggings, stretch pants, or capris  Sweatpants/tops or wind suits

 T-shirts, tank tops, tube tops, crop tops or halter tops  Hats  Sleeveless clothing  Shirts with inappropriate slogans and/or designs.  Artificial nails  Open-toed shoes Open-

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 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 and ability.

Definition of Teamwork
 Teamwork in nursing practice refers to interdisciplinary practice or collaboration defined as a joint decision-making and decisioncommunication process with the goal of satisfying the needs of the patient. This includes respecting the unique abilities of each professional involved in the care.

 Todays best integrated health delivery systems are evolving toward a model of care in which interdisciplinary teams of providers manage the care of complex patients.

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 nonworking 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 health professionals.

 Attributes of interdisciplinary collaboration include trust, knowledge, mutual respect, good communication, cooperation, coordination, share responsibility, and optimism.

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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 intimidating behaviors:

 >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 times.  >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 clinical settings.

 These programs should emphasize teamwork, conflict resolution, and the use of informatics to promote collaboration in patient care planning and implementation (Wakefield & OGrady, 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 be delegated.

 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 competency base.

 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 Attitude

 Respect for others, integrity and a positive attitude also ranked high in the nursing survey. This finding is not surprising, as it correlates to Gallups 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 dentists.

 Americans, in the November 14-16, 2003 14CNN/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).

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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 nursing care.

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 interinterpersonal and inter-professional interrelationships.

 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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