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.
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
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.
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.
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.
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.
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 Country||Study Aim||Population and Sample Size||Research Type and Methods||Results|
|Sabanciogullari & Dogan (2015), Turkey||Evaluate the effect of a professional identify development program on the professional identity, job satisfaction and burnout levels of RNs||216 RNs||Quasi-experimental||The program had a positive impact on professional identity.|
|Aagaard et al. (2016), Denmark||Explore 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 anesthetics||10 RNs||Focused ethnography||One 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), Norway||Investigate how personal and professional experiences form selfunderstanding of a nurse and the influence on professional practice||1 RN||Single case approach||Professional practice of a nurse was informed by self-understanding.|
|Piil et al. (2012), Norway||Explore the concept of professional identity of Danish nurses working in expanded practice||5 RNs (advanced practice nurses with a master's degree)||Case study||Autonomy self-esteem and confidence had a positive impact on professional identity.|
|Dahl et al. (2014), Denmark||Illuminate public health nurses' (PHN) experiences of being ethically charged and reflect on how experiences influence professional identity||23 PHNs||Phenomenology||Four themes were identified. Value conflicts mobilize courage and affects professional identity and the quality of nursing work.|
|Zhang et al. (2017), China||Examine the longitudinal change of intention to leave and identify the potential factors of intention to leave in the first year||343 RNs||Quantitative longitudinal study||High 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), Singapore||Explore the perceptions of new graduates of their experiences of role transition||26 RNs||Grounded theory||New graduates adapted to the expectations of others to acquire personal identity and professional identity.|
|Zarshenas et al. (2014), Iran||Increase understanding of professional socialization in nursing||43 RNs||Qualitative interviews||A sense of belonging and professional identity contributes to professional socialization.|
|Seo & Kim (2017), United States||Explore the career characteristics of Korean nurse immigrants who became nurse practitioners (NPs) in the United States||7 NPs||A qualitative design using the life history research method||Five 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 Findings||Relevant Studies|
|Adapting||The self—who I am||Dahl et al. (2014)|
|Adjusting||Leong et al. (2015)|
|Flexibility||Piil et al. (2012)|
|Expectations of their work||Ramvi (2015)|
|Uncertainty and stress||Seo & Kim (2017)|
|Sense of belonging||Zarshenas et al. (2014)|
|Fitting in||Zhang et al. (2017)|
|Feelings of achievement|
|Self-esteem and confidence|
|Exploration of self|
|Autonomous roles and responsibilities||The role—what I do||Aagaard et al. (2016)|
|Confidence and feelings of empowerment||Dahl et al. (2014)|
|Patient care is central to practice (patient-centered care)||Piil et al. (2012)|
|Comprehensive nursing care||Ramvi (2015)|
|Alignment of theory and practice||Zarshenas et al. (2014)|
|Broad range of skills|
|Clinical judgment and problem solving|
|Positive patient outcomes|
|Complexity of task|
|Level of experience and independence|
|Good communication skills|
|Collaboration with peers, colleagues, and patients.|
|Changing boundaries and roles|
|Professional and organizational policies and guidelines||The contex—where I do it||Aagaard et al. (2016)|
|Organizational structure and resources||Dahl et al. (2014)|
|Preceptorship||Leong et al. (2015)|
|Role models||Piil et al. (2012)|
|Technology||Sabanciogurri & Dogan (2015)|
|Support||Seo & Kim (2017)|
|Acculturation||Zarshenas et al. (2014)|
|Poor retention in nursing||Zhang et al. (2017)|
|Knowledge development and sharing|