Chapter 3: The Professionalization of Nursing

1. Chapter 3: The Professionalization of Nursing Bonnie M. Wivell, MS, RN, CNS

2. History of Professions • Historically only professions were: • Ministry (first ever) • Medicine • Law • So how is profession defined?

3. Abraham Flexner • The Flexner Report provided the impetus for reform to medical education • Published a list of criteria that he believed were characteristic of all true professions • Basically intellectual; accompanied by individual responsibility • Based on a body of knowledge that can be learned and refreshed and refined through research • Is practical as well as theoretical • Can be taught through specialized professional education • Has a strong internal organization of members with group consciousness • Has practitioners who are motivated by altruism and are responsive to public interests

4. Richard H. Hall • Published work on professionalism in 1968 • Described a professional model • 5 indicators of an individual’s attitude toward professionalism • Recommended that each profession needed to develop its own methods of measuring professionalism

5. Major Similarities • 3 Criteria that consistently appear • Service/Altruism: a sense of calling or mission; responsibility to the public • Specialized knowledge: special education including theory and skill • Autonomy/Ethics: control over one’s own practice; having a code of ethics governing conduct

6. Professionalization • Perform full time work in the discipline • Determine work standards, ID a body of knowledge, and establish educational programs of higher learning • Promote organization into effective occupational associations • Legal protection that limits practice • Establish a code of ethics

7. Occupation to Profession • 9 characteristics identified by Houle (1980) that an occupation is developing a collective identity • Formal training • Credentialing • Creation of a subculture • Legal right to practice • Public acceptance • Ethical practice • Discipline of incompetent/unethical practitioners • Relationship to other practitioners • Relationship to users of services

8. “Occupation” vs.“Profession” Occupation: “What occupies or engages one’s time; business; employment” (Webster) Profession: “A calling, vocation or form of employment that provides a needed service to society, possesses expertise, autonomy, long academic preparation, commitment, & responsibility” (Huber)

9. 5 Core Competencies • IOM Summit in 2003 identified core competencies that all health professions should acquire • Provide patient-centered care • Work in interdisciplinary teams • Employ EBP • Apply quality improvement principles • Utilize informatics

10. Profession College/university preparation Usually 4 or more years Values, beliefs, ethics always present (code of ethics) Commitment & personal ID always present (mentoring) Independent, autonomous Work stable, rarely change profession Individual accountability Occupation On the job, trade school, community college prep Shorter prep time Values, beliefs, ethics not always present Commitment & personal IDnot always present Supervised by others Often change jobs Accountability usually rests with employer Characteristics of Profession vs. Occupation

11. Profession Overview Preparation in college or university Skills & unique body of knowledge that grows with research Oriented to beliefs, values, and attitudes of its members Decisions are based on standards of practice with ethical considerations Strong commitment to the profession, considered a “calling”

12. Barriers to Professionalism in Nursing Variability in educational preparation: no other profession allows entry at less than baccalaureate level Gender issues: perceived mainly as female Historical connections with religious orders and military: unquestioning obedience to orders run counter to autonomy External conflicts with medicine, strive for collaboration Internal conflicts among subgroups and rivalry among levels of educational preparation

13. Nursing’s Pathway to Professionalism • Bixler & Bixler (1945, 1959) 1. Well defined body of specialized knowledge, intellectual 2. Enlargement of body of knowledge & improves techniques of education & service 3. Education in institution of higher learning 4. Applies body of knowledge vital to human & social welfare 5. Functions autonomously 6. Attracts those who exalt service above personal gain 7. Compensates its practitioners by providing freedom of action, opportunity for professional growth & economic security.

14. Kelly’s Criteria 8 Characteristics of a Profession 1. Services provided vital to humanity/society 2. Specialized knowledge enlarged with research 3. Intellectual activities, accountability 4. Education in higher learning institution 5. Autonomy—independent, control own policies and activities 6. Motivated by service; important part of their lives 7. Code of ethics guide decisions and conduct 8. There is an organization (association) that encourages and supports high standards of practice

15. How does nursing measure up? Commitment strong—a “calling”, caring Nursing education: higher learning institutions Nursing unique knowledge, research—reliance on evidence-based practice. Nursing process of critical & creative thinking that standardizes nursing diagnoses, interventions, outcomes Code of ethics regularly updated (Hallmark is accountability) Accountability--each nurse responsible for own action Autonomy of nurses is controversial. Remains dependent on medicine in many areas. Nursing scope of practice defined by nursing practice act of each state and varies Majority of nurses are not members of any professional organization which impedes progress for the profession and reduces political influence (encourage and support higher standards of practice)

16. Miller’s Wheel of Professionalism • Center represents the essential foundation of nursing education • Eight spokes • Competence and Continuing Education • Adherence to the code of ethics • Participation in professional organization • Community Service • Publication and Communication • Theory and research development and utilization • Self-regulation and autonomy

17. Nursing’s Contract with Society • Obligation to those who receive nursing care—Nursing’s Social Policy Statement (2003) addresses social context of nursing, values & assumptions of support, definition of nursing, knowledge base for nursing practice, scope of practice, and professional, legal, and self-regulation of nursing practice. • Code of Ethics (2001)—written public document outlines professional responsibilities of nurse, values, commitment, boundaries of duty and loyalty to patient & profession. (See back cover of text)

18. Behaviors of a Professional Nurse Develops own philosophy of nursing Uses self-determination Uses critical thinking Collaborates & communicates with other professionals Demonstrates accountability for self & others Committed to life long learning Active in professional organizations Mentors aspiring professionals Recognizes own limitations: seeks necessary help

19. Behaviors of a Professional Nurse Contributes to expansion of nursing’s body of knowledge Provides leadership Uses principles of time management Delegates responsibility wisely Represents the profession to the public Models altruism Possesses self-awareness Demonstrates commitment to the profession Models healthy coping behaviors Demonstrates collegiality

20. Self-Assessment • Which characteristics do you already possess? • Which characteristics do you think will be easily gained during the educational process? • Which characteristics do you think will be somewhat difficult to achieve? (Check out Box 3-2)

21. Chapter 6: Becoming a Nurse: Defining Nursing & Socialization into Professional Practice Bonnie M. Wivell, MS, RN, CNS

22. Defining Nursing: Harder than it Seems • Why define nursing? What are the benefits? • Provides framework for nursing practice & curriculum development • Identifies boundaries and clarifies purpose and function of nursing • Guides nursing research and theory development • Differentiates nursing from allied health professions and unlicensed assistive personnel • Policymakers need to understand role of nursing to make health care policy decisions

23. Norma Lang’s Quote • “If we cannot name it, we cannot control it, finance it, research it, teach it, or put it into public policy. It’s just that blunt!”

24. Early Nursing vs Contemporary Definitions • Florence Nightingale • “Put the patient in the best condition for nature to act upon him.” • Her definition of nursing foreshadowed contemporary nursing’s focus on • Therapeutic environment • Health promotion • Health maintenance • Virginia Henderson (1939): “Nursing…service to an individual that helps him to attain or maintain a healthy state of mind or body.”

25. Early Nursing vs Contemporary Definitions Hildegard Peplau (1952) “Nursing is a significant, therapeutic, interpersonal process…an educative instrument…that aims to promote forward movement of personality…” Patient seen as active collaborator in his/her own care Dorothea Orem (1959) “Nursing…giving of direct assistance to a person because of inabilities in self-care…”

26. Virginia Henderson (1960) • Adopted by International Council of Nurses: “ The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible.”

27. Other Nursing Definitions Martha Rogers: “Nursing aims to assist people in achieving their maximum health potential.” American Nurses Association: “Nursing encompasses the prevention of illness, alleviation of suffering, and the protection, promotion, and restoration of health in the care of individuals, families, groups, and communities.” ANA: Six features of caring relationship, response to health & illness, integrate objective and subjective data, apply scientific knowledge, scholarly inquiry, influence social and public policy to promote social justice. Definition of nursing is defined in Nurse Practice Act of each state and constitutes the legal definition of nursing in that state.

28. Commonalities in Definitions of Nursing Patient-centered & holisitic Caring-oriented Combination of science and humanism (caring) Therapeutic interpersonal process Concerned with patient responses to illness and disability Practice-based profession Focused on enhancing patient’s health Collaborative, with nurses sharing responsibility for care

29. Shaping Your Professional Identity Initial images idealized & expect to work with sick patients immediately, make things better for patients, & be treated with respect May expect to easily adopt nursing roles & behaviors and instead find new behaviors challenging or difficult Necessity of prerequisite courses before clinical, expected to defer to experienced nurses, patient cannot always be cured, and may experience anxiety & discomfort while learning new roles

30. Formal & Informal Socialization Formal socialization: lessons taught in nursing program, skills, communication, nursing theorists Informal socialization: lessons that occur incidentally by observing other professionals and absorbing the culture of nursing.

31. Factors that Influence Professional Socialization External: values, beliefs, and behaviors of significant people (faculty, practicing nurses) possess around the new professional and what they project as being important Internal: personal feelings and beliefs that influence the individual (religion, personal beliefs, moral values, ethics, and beliefs about social and health matters).

32. Cohen’s Model Stage I: Unilateral dependence = Reliant on external authority; limited questioning or critical analysis Stage II: Negativity/independence = student’s ability to engage in critical thinking expands and may begin to question authority; cognitive rebellion Stage III: Dependency/mutuality = students learn to test concepts, ideas, & models and to accept some and reject others…ability to share jointly with others; reasoned appraisal Stage IV: Interdependence = students develop capacity to make decision collaboratively & develop a professional role identity that is professionally acceptable

33. Benner’s Stages of Nursing Proficiency Novice/Stage I: students enter nursing school & have little background. They depend on rules & expectations because practical skills limited Advanced Beginner/Stage II: learners have become marginally competent, can use theory & principles, may have difficulty setting priorities Competent Practitioners/Stage III: learners have 2-3 year’s experience, begin to feel organized & efficient most of the time. Mastered planning & goal-setting skill, think abstractly & analytically. Able to coordinate several complex demands simultaneously. Proficient Practitioners/Stage IV: learners begin to view patients holistically, recognize subtle changes in patient condition, set priorities with ease, focus on long term goals, not merely task at hand Expert Practitioners/Stage V: learners perform fluidly, grasp patient needs automatically, responses are integrated with actions, expertise comes naturally, have a “sense” of what needs to be done based on knowledge and prior experience.

34. Purpose of Models These models are aids to student awareness during socialization to the profession Change and growth to be expected and may not always be comfortable. Awareness of anxiety-producing aspects of socialization assists to recognize it for what it is—a predictable process—and make decisions as how to cope

35. Whose responsibility? Nursing Program—plan, implement, evaluate the program of formal socialization and provide for good role models. Student’s—participate actively in the socialization process, know what to expect (models), select role models, practice the roles & behaviors of nurses, become proficient in skills, develop knowledge base necessary to meet course objectives, develop values & ethics expected by the profession

36. Strategies to Ease Transition Recognize schools cannot provide enough clinical experience to make graduates comfortable the first days as new nurses Obtain additional practical work experience outside of school without jeopardizing academic preparedness Enter the preceptor program if available. Seek out experiences in employment that pair new grad with experienced nurses Work on time management skills Seek out a mentor Continue to read and learn Take care of yourself, stay strong & healthy in body, mind, and spirit. Recognize that you are responsible for your lifelong professional growth and development.

37. How do you define nursing? Write a definition of nursing Write what you expect of the DSN nursing curriculum Write why you think is it important for you to understand the process of socialization in the profession of nursing How do you plan to increase your comfort and facilitate your socialization into nursing?

38. Chapter 15 (Pages 363-366): Professional Organizations Bonnie M. Wivell, MS, RN, CNS

39. Why Join? • Network with colleagues • Pursue continuing education • Certification opportunities • Stay informed on professional issues • Develop leadership skills • Influence health policy • Practice guidelines and position statements

40. Why Nurses Don’t Join • High cost of dues • Lack of time • Lack of interest • Different expectations and interests amon the generations

41. Types of Associations • Broad purpose professional associations • ANA: professional organization for all nurses regardless of practice setting or level of practice • NSNA: for student nurses • Specialty practice associations • Focus only on standards of practice or professional needs of the particular specialty • 66 are represented in the Nursing Organizations Alliance • Special interest associations • Sigma Theta Tau International • The Honor Society of Nursing • Must be invited to join

42. Mission Statements • Organizational activities are derived from the mission statement • Defines the association’s area of focus as: • Practice standards • A code of ethical conduct • Continuing education and conferences • Collective action around workplace issues

43. Role Associations Play Serve society: Standards of practice & code of ethics and enforce these Serve members of the profession: Provide political power by collective action Keep standards high; credentialing; support for impaired nurses Communicate: Newsletters, journals. Computer access via databases