Chapter 3: The
Professionalization of Nursing
Bonnie M. Wivell, MS, RN, CNS
History of Professions
• Historically only professions were:
– Ministry (first ever)
– Medicine
– Law
• So how is profession defined?
Abraham Flexner
• The Flexner Report provided the impetus for
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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
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
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
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
Occupation to Profession
• 9 characteristics identified by Houle (1980) that
an occupation is developing a collective identity
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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
“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)
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
Characteristics of
Profession vs. Occupation
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 ID
not always present
• Supervised by others
• Often change jobs
• Accountability usually rests
with employer
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”
Barriers to Professionalism in
Nursing
• Variability in educational preparation: no other
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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
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.
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
How does nursing measure up?
• Commitment strong—a “calling”, caring
• Nursing education: higher learning institutions
• Nursing unique knowledge, research—reliance on evidence•
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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)
Miller’s Wheel of Professionalism
• Center represents the essential foundation of
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nursing education
Eight spokes
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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
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 selfregulation 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)
Behaviors of a Professional Nurse
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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
Behaviors of a Professional Nurse
• Contributes to expansion of nursing’s body of
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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
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)
Chapter 6: Becoming a Nurse:
Defining Nursing & Socialization into
Professional Practice
Bonnie M. Wivell, MS, RN, CNS
Defining Nursing: Harder than it
Seems
• Why define nursing? What are the benefits?
• Provides framework for nursing practice &
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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
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!”
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.”
Early Nursing vs Contemporary
Definitions
• Hildegard Peplau (1952) “Nursing is a
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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…”
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.”
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.
Commonalities in Definitions
of Nursing
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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
Shaping Your Professional Identity
• Initial images idealized & expect to work with
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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
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.
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).
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
Benner’s Stages of Nursing
Proficiency
• Novice/Stage I: students enter nursing school & have little background.
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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.
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
Whose responsibility?
• Nursing Program—plan, implement, evaluate
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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
Strategies to Ease Transition
• Recognize schools cannot provide enough clinical experience
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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.
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?
Chapter 15 (Pages 363-366):
Professional Organizations
Bonnie M. Wivell, MS, RN, CNS
Why Join?
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Network with colleagues
Pursue continuing education
Certification opportunities
Stay informed on professional issues
Develop leadership skills
Influence health policy
Practice guidelines and position statements
Why Nurses Don’t Join
• High cost of dues
• Lack of time
• Lack of interest
• Different expectations and interests amon
the generations
Types of Associations
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Broad purpose professional associations
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ANA: professional organization for all nurses
regardless of practice setting or level of practice
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Specialty practice associations
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NSNA: for student nurses
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Focus only on standards of practice or professional needs of
the particular specialty
66 are represented in the Nursing Organizations Alliance
Special interest associations
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Sigma Theta Tau International
The Honor Society of Nursing
Must be invited to join
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
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