The Journal of Continuing Education in Nursing

Original Article 

Factors Influencing Registered Nurses' Perceptions of Their Professional Identity: An Integrative Literature Review

Philippa Rasmussen, PhD, MN, Grad DipPsych St, Grad Cert CAMHN, BN, RN, MHN; Ann Henderson, PhD, MEd, BEd, Dip T, Dip Bus, RN, RM; Nicky Andrew, Prof D, RN; Tiffany Conroy, MNSc, BN, RN, FACN

Abstract

Background:

This review synthesizes contemporary research investigating the factors influencing RNs' perceptions of their professional identity.

Method:

The method used was an integrative literature review.

Results:

Factors influencing RNs' perceptions of their professional identity were synthesized into three categories: the self, the role, and the context. The self is the nurse who enacts the role in practice, and the context is the practice setting. Poor alignment of these categories leads to stress, tension, and uncertainty affecting work-force retention. Strong alignment leads to satisfaction with the nursing role, increased staff retention, and improved quality of care and patient outcomes. These three categories should be considered when planning nursing professional development activities.

Conclusion:

This integrative review identified a lack of research addressing how nurses' perceptions of their professional identity change over time. A deeper understanding of their perspective is needed to establish whether career longevity and continued professional development are influences.

J Contin Educ Nurs. 2018;49(5):225–232.

Abstract

Background:

This review synthesizes contemporary research investigating the factors influencing RNs' perceptions of their professional identity.

Method:

The method used was an integrative literature review.

Results:

Factors influencing RNs' perceptions of their professional identity were synthesized into three categories: the self, the role, and the context. The self is the nurse who enacts the role in practice, and the context is the practice setting. Poor alignment of these categories leads to stress, tension, and uncertainty affecting work-force retention. Strong alignment leads to satisfaction with the nursing role, increased staff retention, and improved quality of care and patient outcomes. These three categories should be considered when planning nursing professional development activities.

Conclusion:

This integrative review identified a lack of research addressing how nurses' perceptions of their professional identity change over time. A deeper understanding of their perspective is needed to establish whether career longevity and continued professional development are influences.

J Contin Educ Nurs. 2018;49(5):225–232.

Professional identity is grounded in the individual practitioner's perception of what it means to be, and to act, as a nurse (Fagermoen, 1997). A strong, yet flexible, professional identity is regarded as central to the quality of nursing care, recruitment of nursing students, and retention of existing staff (Johnson, Cowin, Wilson, & Young, 2012; Sabanciogullari & Dogan, 2015; Shahidi, Vahidi, Mahram, Areshtanab, & Zarghi, 2014). The way nurses view their scope of practice may be limited or enriched by their perception of professional identity and the factors that influence its development.

Professional identities begin to emerge at the point of entry into nursing education and are reconstructed through ongoing exposure to practice and continuing professional development. These experiences support both development and maturation of professional identity (Andrew, 2013; Johnson et al., 2012; Larson, Brady, Engelmann, Perkins, & Schultz, 2013). The perception of professional identity varies among individuals, as experience and understanding is unique to each practitioner. Being able to ascribe to a professional identity allows an individual to better understand his or her role within their area of practice (Rasmussen, 2015). Although professional development activities may not focus on developing professional identity per se, professional development is designed to help nurses be clear about their role within an organization.

Health care is constantly evolving and the roles that nurses perform change accordingly. Over time, rising incomes, health expenditure, new technologies, migration, and international influences have increased the expectations for the quality and scope of nursing care, with subsequent impacts on health care service delivery (Johnson et al., 2012; World Health Organization [WHO], 2016). Nursing is being influenced by changing demographics, aging populations, and increasing globalization (WHO, 2016). This is associated with a demand for health care services reform and, therefore, changing skill sets and scopes of practice for nursing (Johnson et al., 2012; WHO, 2016). Addressing these twenty-first century challenges requires the appropriate clinical skills, critical thinking, innovation, adaptability, and flexibility (Miskelly & Duncan, 2014; WHO, 2016). These revised perceptions and expectations of the nursing role can lead to reconstruction of professional identity (Johnson et al., 2012).

Two previous literature reviews on professional identity were conducted by Johnson et al. (2012) and ten Hoeve, Jansen, and Roodbol (2014). The theoretical paper by Johnson et al. (2012) explored the construct of professional identity and suggested further research was needed on the factors that influenced the development of this construct. ten Hoeve et al. (2014) linked the public image of nurses to their professional identity and concluded that this image needed to be more visible to the public and other health professionals. These reviews although systematic in their search strategy were both conducted prior to 2010. This integrative review synthesizes the recent literature and adds an additional level of rigor by using a formalized search strategy with predefined inclusion criteria, and undertaking an assessment of the credibility of the findings from the included studies, prior to their being included in the synthesis.

Aim and Objectives

The overall aim of this integrative literature review was to identify and describe factors influencing RNs' perceptions of their professional identity. The specific objectives were to identify the evidence for:

  • Factors that influenced RNs' perceptions of their professional identity.
  • How these perceptions may change over time.

This review considered studies that explored factors influencing RNs' perceptions of their professional identity. Studies that used either quantitative or qualitative research methods were considered for inclusion. These study designs included, but were not limited to, experimental and quasi-experimental studies, phenomenology, grounded theory, ethnography, action research, historical research, case studies, and feminist research.

Types of Participants

This review considered studies that included RNs who had any exposure to practice in any type of clinical environment.

Search Strategy and Method

An integrative review method was used as it facilitated the inclusion of both qualitative and quantitative research designs. This wider inclusive perspective has the potential to enhance current understanding of nurses' professional identity (Whittemore & Knafl, 2005). A comprehensive search of existing literature was conducted of the following databases: PubMed®, CINAHL®, EMBASE, and Scopus®. The search was undertaken using the following key terms: professional identity, nursing, nursing practice, perception, characteristics, factors, relevance, self-concept, professional self, meaning, registered nurse, and qualified nurse. To ensure data reflected contemporary practice and research, the review was limited to articles published between 2012 and 2017. Research published in English was considered for inclusion.

The title and abstract of all articles identified in the search were examined by two reviewers (P.R., A.H.) to determine their relevance to the inclusion criteria for this review. Original Article that met the inclusion criteria were retrieved in full text and their reference lists were reviewed to find additional references not identified during the database search.

Data Extraction and Results

The total number of articles retrieved from the search was 548. Forty-three additional records were located from reference lists. Duplicate papers were identified (n = 136) and removed. After screening the title and abstract, 403 articles were excluded because they did not meet the inclusion criteria. The remaining 52 articles were retrieved in full text and reassessed for their relevance to the aim and objectives of the review. Forty-three articles were then excluded for the following reasons:

  • The article was not research (n = 16).
  • The population referred to in the study was not RNs (n = 13).
  • The focus of research was not professional identity (n = 14).

A total of nine studies (eight qualitative and one quantitative) were included in this review. Figure 1 illustrates the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart of the results.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) diagram.

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) diagram.

Study Characteristics

Data extracted from the studies included author names, year of publication, country where the study was conducted, study aim, population and sample size, research type and method, and results. The bibliographic details and main characteristics of the nine included studies are presented in Table 1. The methodologies of the studies were focused ethnography (n = 1), grounded theory (n = 1), phenomenology (n = 1), longitudinal study (n = 1), case study (n = 2), qualitative interview (n = 1), life history interview (n = 1), and quasi-experimental (n = 1). The included studies were conducted in Denmark (n = 2), Norway (n = 2), United States (n = 1), Singapore (n = 1), Turkey (n = 1), China (n = 1), and Iran (n = 1). Two studies examined new graduates and their transition to practice and effect on professional identity. The professional identity of RNs working in public health, anesthesia, and expanded or extended practice roles were evident in four studies. Two studies investigated personal and professional experiences of nurses to gain an understanding of their professional socialization and professional identity. The quasi-experimental study evaluated the impact of an educational program on professional identity development. Methods of data collection included structured, semi-structured and unstructured interviews, observations, focus group discussions, reflective journal entries, and questionnaires. Analysis of data ranged between descriptive and inferential statistics, thematic analysis, and case analysis.

Characteristics of Included Studies

Table 1:

Characteristics of Included Studies

Data Synthesis

The findings from each of the included studies were extracted. The credibility of each extracted qualitative finding was assessed according to the levels of credibility defined by the Joanna Briggs Institute Qualitative Assessment and Review Instrument: unequivocal (U), credible (C) or not supported (NS) (Joanna Briggs Institute, 2017). All findings were assessed as unequivocal as they were supported by illustrations, such as direct quotations or fieldwork observations. The quantitative study was quasi-experimental due to the intervention not being blinded to both groups. The intervention was clearly described and all participant data were complete, with no loss to follow up. A synthesis of the findings from each included study was then undertaken to generate a single set of synthesized findings.

Results

Findings that related to factors influencing RNs' perceptions of their professional identity were extracted and synthesized into three main categories: the self, the role, and the context. The self refers to the person or nurse (“who I am”) who enacts the role (“what I do”) in professional practice, and the context (“where I do it”) is the setting where the nurse practices. Although these synthesized findings are presented separately, there are necessary interrelationships between them. Figure 2 represents the categories and their interrelationship to professional identity. The findings, synthesized findings, and the relevant included studies are presented in Table 2.

Synthesized findings related to professional identity.

Figure 2.

Synthesized findings related to professional identity.

Initial Findings, Synthesized Findings, and Related Studies

Table 2:

Initial Findings, Synthesized Findings, and Related Studies

The Self (Who I Am)

Identifying the self is an important aspect of professional identity (Aagaard, Sørensen, Rasmussen, & Laursen, 2017). RNs need to adapt, adjust (Leong & Crossman, 2015; Zhang, Wu, Fang, Zhang, & Wong, 2017) and be flexible (Seo & Kim, 2017) about expectations of their work (Leong & Crossman, 2015). Uncertainty about the self can lead to stress and tension (Dahl & Clancy, 2015; Leong & Crossman, 2015). The sense of belonging (Zarshenas et al., 2014) and fitting in (Leong & Crossman, 2015) can lead to feelings of job satisfaction (Piil, Kolbaek, Ottmann, & Rasmussen, 2012; Seo & Kim, 2017) and a positive professional identity, whereas feeling as if they do not belong (Zhang et al., 2017) can have a negative effect. Feelings of achievement and being valued (Seo & Kim, 2017) contribute to self-esteem and therefore confidence (Piil et al., 2012), which influences coping strategies (Dahl & Clancy, 2015). Personal experiences and the exploration of the self contributes to a heightened self-awareness and the internalization of professional identity (Ramvi, 2015).

The Role (What I Do) in Professional Practice

Who I am as a nurse influences what I do in the nursing role. Changes in the boundaries of practice may lead to more autonomous roles and responsibilities (Piil et al., 2012), which enhance confidence, promote feelings of empowerment (Dahl & Clancy, 2015), and bolster professional identity. Provision of patient-centered care is core to professional nursing practice (Aagaard et al., 2017). Comprehensive nursing care (Dahl & Clancy, 2015) involves an alignment of theory and practice (Zarshenas et al., 2014) and the use of a broad range of skills, including sound clinical judgment and problem solving, leading to positive patient outcomes (Dahl & Clancy, 2015). The ability to multitask (Aagaard et al., 2017) varies depending on the complexity of the task and the level of experience and independence of the nurse (Aagaard et al., 2017). Contemporary professional practice within the health care team requires the nurse to communicate clearly (Piil et al., 2012; Zarshenas et al., 2014) and collaborate effectively with peers, colleagues, and patients (Piil et al., 2012). Clarity and confidence related to the role of the nurse contributes to a well-defined professional identity.

The Context (Where I Do It)

The context in which nurses perform their role impacts on their understanding and perception of professional identity. The context of practice, affects the role and the self “because where I do it affects what I do and who I am.” The three categories are interconnected. Professional and organizational policies, protocols and guidelines provide a framework for practice (Dahl et al., 2014; Seo & Kim, 2017). The structure and resources (Aagaard et al., 2017) provided by an organization, such as orientation, preceptorship (Leong & Crossman, 2015), role models (Zarshenas et al., 2014), technology (Aagaard et al., 2017), professional development, and education (Sabanciogurri & Dogan, 2015), provide support for nurses when enacting their role, and enculturation (Seo & Kim, 2017) into nursing practice (Seo & Kim, 2017; Zhang et al., 2017). The support nurses feel in their work context leads to a sense of belonging, improved confidence, and self-motivation (Piil et al., 2012; Zarshenas et al., 2014). These are factors that affect the formation and reconstruction of professional identity.

Discussion

This integrative literature review provides evidence that professional identity is composed of many factors within the categories of the self, the role, and the context of nursing practice. Professional identity may be defined as how an individual views himself or herself as a nurse who can provide quality care in a responsible manner (Leong & Crossman, 2015; ten Hoeve et al., 2014). The studies within this review support that professional identity is developed through experience and socialization in the nursing role (Aagaard et al., 2017; Dahl & Clancy, 2015; Ramvi, 2015; Sabanciogurri & Dogan, 2015; Zarshenas et al., 2014).

New graduates experience a period of transition or enculturation into their new workplace (Aagaard et al., 2017; Leong & Crossman, 2015). Expectations are high that they should quickly take on their new role and integrate themselves into the realm of nursing practice (Cowin, Johnson, & Wilson, 2013). Zhang et al. (2017) suggested that professional identity is adjusted as a result of this socialization and integration. Following transition to nursing practice, adjustments are made to professional identity as experiences accumulate (Aagaard et al., 2017). This process starts with orientation to an organization and continues through various professional experiences, including the education provided.

Nurses' working lives can involve consolidation of theory and practice, expanded or extended roles, and new practice settings, along with health care changes and education. Accumulation of experience continues to affect their perceptions of the nursing role (Miro-Bonet, Bover-Bover, Moreno-Mulet, & Zaforteza-Lallemand, 2014) and challenge their professional identity (Faulk, Parker, & Morris, 2010; ten Hoeve et al., 2014). Some argue that extended or expanded roles can lead to innovative nursing practice where nurses are satisfied in their work, collaborate widely with colleagues and other health professionals, and have a positive impact on patient outcomes (Piil et al., 2012). Practicing in an evidence-based manner contributes to the provision of sensitive and effective nursing care internationally (Feo et al., 2017). Nurses may respond to the globalization of the health care workforce with a reconstruction of their professional identity due to their adjustment to new cultures, new roles, and new settings (Seo & Kim, 2017; WHO, 2016).

Some evidence supports the notion that continuous professional development may influence nurses' perceptions of their professional identity. Sabancioigullari and Dogan (2015) indicated that a hospital-based educational program focused on developing professional identity in nurses had a positive impact on the self and the role of nursing practice. An evaluation of an in-house education program aimed at developing leadership capacity conducted by Miskelly and Duncan (2014) found this provided opportunities for nurses to improve their personal skills, role performance, and satisfaction with the clinical work environment. In addition, mentorship programs that provided support for new nurses improved job satisfaction and retention rates and positively affected professional identity (Chen & Lou, 2014). Thus, the context of nurses' practice is a characteristic that affects professional identity. Deliberative efforts to support professional identity for nurses can be enhanced through the educational process within an organization.

The categories of the self, the role, and the context of practice need to be in alignment for a strong construction or reconstruction of professional identity. A poor alignment of these categories can lead to stress, tension, and uncertainty, with poor retention in the nursing workforce. The influence of self or personal factors on job satisfaction may influence patient care outcomes (Leong & Crossman, 2015; Ramvi, 2015). Conversely, when there is a strong alignment of these three categories, self-satisfaction, self-confidence, and self-motivation develops, which can lead to satisfaction within the nursing role, retention in the nursing profession, provision of high-quality of care, and improved patient outcomes (Pill et al., 2012; Zarshenas et al., 2014). These three categories should be considered when planning nursing professional development activities, as they influence nurses' perceptions of their professional identity.

This review sought to explore the factors influencing RNs' perceptions of their professional identity and how these may change over time. Few of the included studies evaluated these perceptions over time or addressed how theses perceptions may be influenced by continuing professional development. Further research is required to develop a deeper understanding of these potential influences.

Limitations

The literature search was extensive; however, despite the effort to capture all relevant studies, it is possible that some may have not been identified.

Conclusions and Implications

This integrative review focused on the identification, description, and synthesis of the factors that influenced professional identity in RNs. Although studies addressed professional identity in general, a dearth of research addressed how these factors and perceptions changed over time. A deeper understanding of professional identity is needed from the RN's perspective to establish whether this changes with career longevity and continued professional development. Further research to address the gap identified in the literature is required.

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Characteristics of Included Studies

Study and CountryStudy AimPopulation and Sample SizeResearch Type and MethodsResults
Sabanciogullari & Dogan (2015), TurkeyEvaluate the effect of a professional identify development program on the professional identity, job satisfaction and burnout levels of RNs216 RNsQuasi-experimentalThe program had a positive impact on professional identity.
Aagaard et al. (2016), DenmarkExplore the professional identity of RN anesthetists (RNAs) and explore RNAs' expectations of their professional self and the expectations RNAs meet from interdisciplinary team members when preparing patients for general anesthetics10 RNsFocused ethnographyOne core and two subcore variables were identified as affecting professional identity. The core variable was “identifying the professional self” and the two subcore variables were “gliding between tasks and structures” and “depending on independence.”
Ramvi (2015), NorwayInvestigate how personal and professional experiences form selfunderstanding of a nurse and the influence on professional practice1 RNSingle case approachProfessional practice of a nurse was informed by self-understanding.
Piil et al. (2012), NorwayExplore the concept of professional identity of Danish nurses working in expanded practice5 RNs (advanced practice nurses with a master's degree)Case studyAutonomy self-esteem and confidence had a positive impact on professional identity.
Dahl et al. (2014), DenmarkIlluminate public health nurses' (PHN) experiences of being ethically charged and reflect on how experiences influence professional identity23 PHNsPhenomenologyFour themes were identified. Value conflicts mobilize courage and affects professional identity and the quality of nursing work.
Zhang et al. (2017), ChinaExamine the longitudinal change of intention to leave and identify the potential factors of intention to leave in the first year343 RNsQuantitative longitudinal studyHigh stress levels and poor professional identity development predicted an intention to leave the nursing professional. Nurse managers should provide support to neophyte nurses to reduce their stress and enhance their professional identity.
Leong et al. (2015), SingaporeExplore the perceptions of new graduates of their experiences of role transition26 RNsGrounded theoryNew graduates adapted to the expectations of others to acquire personal identity and professional identity.
Zarshenas et al. (2014), IranIncrease understanding of professional socialization in nursing43 RNsQualitative interviewsA sense of belonging and professional identity contributes to professional socialization.
Seo & Kim (2017), United StatesExplore the career characteristics of Korean nurse immigrants who became nurse practitioners (NPs) in the United States7 NPsA qualitative design using the life history research methodFive themes were identified regarding their professional identity as NPs: patient-centered thinking, responsibility for patient care, dedicated life, diligence, and feelings of achievement.

Initial Findings, Synthesized Findings, and Related Studies

Initial Findings (Factors)Synthesized FindingsRelevant Studies
AdaptingThe self—who I amDahl et al. (2014)
AdjustingLeong et al. (2015)
FlexibilityPiil et al. (2012)
Expectations of their workRamvi (2015)
Uncertainty and stressSeo & Kim (2017)
Sense of belongingZarshenas et al. (2014)
Fitting inZhang et al. (2017)
Feelings of achievement
Self-esteem and confidence
Personal experiences
Exploration of self
Raised self-awareness
Tension
Job satisfaction
Coping
Self motivation
Being valued
Autonomous roles and responsibilitiesThe role—what I doAagaard et al. (2016)
Confidence and feelings of empowermentDahl et al. (2014)
Patient care is central to practice (patient-centered care)Piil et al. (2012)
Comprehensive nursing careRamvi (2015)
Alignment of theory and practiceZarshenas et al. (2014)
Broad range of skills
Clinical judgment and problem solving
Positive patient outcomes
Multitasking
Complexity of task
Level of experience and independence
Contemporary practice
Good communication skills
Collaboration with peers, colleagues, and patients.
Changing boundaries and roles
Professional and organizational policies and guidelinesThe contex—where I do itAagaard et al. (2016)
Organizational structure and resourcesDahl et al. (2014)
PreceptorshipLeong et al. (2015)
Role modelsPiil et al. (2012)
TechnologySabanciogurri & Dogan (2015)
SupportSeo & Kim (2017)
AcculturationZarshenas et al. (2014)
Poor retention in nursingZhang et al. (2017)
Knowledge development and sharing
Authors

Dr. Rasmussen is Master of Nursing Science Program Coordinator and Internationalisation Lead, Dr. Henderson is Adjunct Senior Lecturer, and Ms. Conroy is Lecturer, Adelaide Nursing School, University of Adelaide, Adelaide, South Australia, Australia; Dr. Andrew is Head of Academic Quality and Education Research Lead, Glasgow Caledonian University, Glasgow, Scotland.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Philippa Rasmussen, PhD, MN, Grad Dip-Psych St, Grad Cert CAMHN, BN, RN, MHN, Master of Nursing Science Program Coordinator and Internationalisation Lead, Adelaide Nursing School, University of Adelaide, Corner of North Terrace & George Street, Adelaide, South Australia 5005, Australia; e-mail: philippa.rasmussen@adelaide.edu.au.

Received: December 03, 2017
Accepted: February 21, 2018

10.3928/00220124-20180417-08

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