Journal of Nursing Education

Major Article 

Professional Identity in Graduating Nursing Students

Anita Fitzgerald, PhD, APRN, CNE; Lory Clukey, PhD, PsyD, RN, CNS

Abstract

Background:

This research examines the meaning of nursing professional identity development from the perspectives of both associate degree nursing students and baccalaureate degree nursing students in their final semester. It provides insight into the student's understanding of nursing professional identity and the factors students identified as supporting or detracting from it.

Method:

Participants were guided through individual interviews using semistructured interview questions and later invited to focus groups with other students to clarify and elaborate on previous comments.

Results:

Results demonstrated both groups shared many descriptions of what it means to be a nursing professional, including knowledge, caring, team-work, and integrity. Good communication, confidence, competence, critical thinking, advocacy, and leadership were concepts the participants frequently used to describe the professional nurse.

Conclusion:

This research helps to further the understanding of this significant topic in nursing education and to serve as a basis for student activities that help foster nursing professional identity formation. [J Nurs Educ. 2021;60(2):74–80.]

Abstract

Background:

This research examines the meaning of nursing professional identity development from the perspectives of both associate degree nursing students and baccalaureate degree nursing students in their final semester. It provides insight into the student's understanding of nursing professional identity and the factors students identified as supporting or detracting from it.

Method:

Participants were guided through individual interviews using semistructured interview questions and later invited to focus groups with other students to clarify and elaborate on previous comments.

Results:

Results demonstrated both groups shared many descriptions of what it means to be a nursing professional, including knowledge, caring, team-work, and integrity. Good communication, confidence, competence, critical thinking, advocacy, and leadership were concepts the participants frequently used to describe the professional nurse.

Conclusion:

This research helps to further the understanding of this significant topic in nursing education and to serve as a basis for student activities that help foster nursing professional identity formation. [J Nurs Educ. 2021;60(2):74–80.]

Nursing professional identity is, in its essence, a perception of what it means to be a nurse (Rasmussen et al., 2018). Yet, this simple definition belies the importance of a distinct and positive self-perception within the context of medicine, where the unique contributions of nursing are still too often devalued.

Researchers describe the process of nursing professional development as starting before nursing school with personal values and beliefs (Lyneham & Levett-Jones, 2016), which are then developed through experience and socialization to the nursing role (Browne et al., 2018; Crigger & Godfrey, 2014; Neishabouri et al., 2017; Rasmussen et al., 2018; Thompson et al., 2018). Studies describe the purposeful and active role that instructors and mentors must play in a student's professional development (Fernandes et al., 2018; Crigger & Godfrey, 2014; Fisher, 2014; Heldal et al., 2019; Zarshenas, 2014) or they risk a superficial commitment to professionalism, leading to poor quality nursing care (Crigger & Godfrey, 2014; Neishabouri et al., 2017; Rasmussen et al., 2018), moral distress and values dissonance (Lyneham & Levett-Jones, 2016), difficulties with recruitment and retention (Browne et al., 2018; Goddard et al., 2019; Hercelinskyj et al., 2014; Neishabouri et al., 2016; Sun et al., 2016; Thompson et al., 2018), and allowing others to define the profession (Hercelinskyj et al., 2014).

This research sought to describe the meaning of nursing professional identity from the perspective of nursing students in their final semester of study. Developing a more robust understanding of how students describe a professional nurse will form the groundwork for the development of students' professional identity. It can help educators to understand what students believe about nursing professionalism and how they see themselves developing their own nursing identity.

Literature Review

Given that professional identity includes entry into the community of practice, professional identity cannot be easily separated from social identity (Bochatay, 2018; Crigger & Godfrey, 2014; Heldal et al., 2019; Sun et al., 2016). Nursing professional identity is therefore defined as both personal and social. It is social in that it involves the definition of the group (Best & Williams, 2019; Browne et al., 2018; Crigger & Godfrey, 2014; Heldal et al., 2019; Hercelinskyj et al., 2014; Mariet, 2016; McLean, 2017; Thompson et al., 2017). At the same time, it is personal because of the self-identification one has as a member of that group (Best & Williams, 2019; Browne et al., 2018; Crigger & Godfrey, 2014; Dikmen et al., 2016; Goddard et al., 2019; Hercelinskyj et al., 2014; McLean, 2017; Neishabouri et al., 2017; Rasmussen et al., 2018; Thompson et al., 2017; Zarshenas et al., 2014).

Many nursing-related studies define nursing professional identity based on the uniqueness of the group, or what makes nursing different from other professions (Bochatay, 2018; Dahl & Clancy, 2015; Sun et al., 2016). Some studies define nursing professional identity by what nurses do—the behaviors and activities (Best & Williams, 2019; Dahl & Clancy, 2015; Dikmen et al., 2016; Mariet, 2016; Neishabouri et al., 2017; Seo & Kim, 2017; Thompson et al., 2018; Traynor & Buus, 2016; Zarshenas et al., 2014)—whereas others define it by what nurses know—their knowledge and skills (Browne et al., 2018; Dikmen et al., 2016; Heldal et al., 2019; Hercelinskyj et al., 2014; Matthews et al., 2019; Mariet, 2016; Neishabouri et al., 2017; Seo & Kim, 2017; Thompson et al., 2018). Many studies refer to values, ethics, and norms as essential to nursing professional identity (Best & Williams, 2019; Browne et al., 2018; Dikmen et al., 2016; Goddard et al., 2019; Mariet, 2016; Matthews et al., 2019; Neishbouri et al., 2017; Song, 2016; Traynor & Buus, 2016; Woods et al., 2016).

Method

Design

This research sought to create a composite description of the meaning of professional identity as defined by two groups of graduating nursing students. Students were selected based on having experiences in a nursing program, their proximity to graduation, and the fact that they were willing and able to participate.

Sample

The sample of nursing students was recruited from two large public institutions in the western United States: (a) a state university that offers a baccalaureate nursing degree (BSN), and (b) a public community college that offers an associate nursing degree (ADN). Twenty-two participants were included in the study: 10 from the community college, and 12 from the state university. The ages of the participants ranged from early 20s to over 40. There were 17 women and five men. All students were in their final semester of study in their nursing program, so they would have adequate nursing school experience from which to draw in answering questions, and all participants were older than 18 years of age. Each student participated in a one-to-one interview lasting anywhere from 30 to 75 minutes. In addition, all 10 of the ADN students and three of the 12 BSN students participated in separate follow-up focus groups.

Protection of Human Subjects

Access to the academic sites and the participants was arranged through the directors of undergraduate nursing in each location. Institutional review board approval was obtained from both agencies where data were collected and the university where the researchers were affiliated. Each participant was asked to sign a consent form that explained that participation in the research was purely voluntary and had a description of efforts to protect confidentiality, including the use of pseudonyms and removal of identifying information. The consent included an agreement to be audiotaped, a description of the data collection process, and the risks and benefits of participation in the research.

Data Analysis

The process of data analysis for this research followed the method developed by Clark Moustakas (1994), a modification of the Van Kaam method of analysis of phenomenological data. Analysis of the data was done in a systematic way: looking for consistency, verifiability of the process, sequential understanding of the data, and continuous reflection. The researcher analyzed individual responses in relation to other participants and the group context. Field notes were used to enrich the data from the transcripts and give a broader perspective and context to the spoken word. Concepts and ideas were examined for repetition, for their relationship to one another, for concurrence, and for sequencing. The intent in this qualitative research was not to generalize the information but to reveal the particular: the specific experience of the participants. Careful records of research methods and tracking of data ensured the results reflected what was actually said and experienced and helped to limit researcher bias. The ultimate goal of this study's analysis was to give the researcher the essence of the experience using data from the individual interviews and each of the focus groups.

Theoretical Framework

The theoretical framework for this research is the concept of constructivism, particularly as expressed by Jerome Bruner (1996). His theory posited that learning is an active process in which learners construct understanding based on previous experiences and knowledge, awareness of one's own thinking, and the context in which the learning occurs (Bruner, 1996). According to Bruner (1996), learning is not an attempt to get at pure scientific facts; rather, it is a way to make sense of the environment and relate it to new inputs. In this way, the acquisition of knowledge is personally constructed but socially mediated. Professional identity is developed through social interaction, vicarious observation, and adopting behaviors as one's own. A new understanding of the role of the nurse is developed, which is shaped by the meaning the learner gives to it. This describes the process participants underwent in their understanding of nursing professional identity.

Results

The interviews demonstrated that both groups shared many characterizations of a nursing professional; primary among them were knowledge, caring, teamwork, and integrity. Participants also frequently discussed communication, confidence, competence, critical thinking, advocacy, and leadership as important descriptors of what it means to be a professional nurse. In the individual interviews and the focus groups, participants spoke of nursing professional identity as a concept and as demonstrated by the nursing professionals they encountered during nursing school. Participants talked of the importance of nursing defining itself as a profession. One BSN participant stated, “We have to view ourselves as professionals and a profession before anyone else does…promoting nursing in the community and promoting nursing as a profession, being a representative of nursing when I make decisions, even in my personal life.” Their descriptions showed an understanding of the complexity of nursing professionalism and the various elements that compose it.

The nurses who participants saw as having a strong nursing professional identity cared about their work and their patients, had knowledge, and integrated this in the work they did. They performed with professional integrity and saw themselves as part of a team. Professional nurse examples held themselves to high standards and saw this as a reflection of their status as a nurse, not just their personal reputation. This suggests participants saw professional nurses as part of an identified group rather than as singular individuals completing a task.

Participants also described nurses they encountered who did not demonstrate nursing professional identity. Concepts these unprofessional nurses failed to demonstrate were caring, a professional demeanor, integrity, and trust. Many participants saw these nurses as negative role models or examples of how not to develop as a professional. Another BSN participant stated, “You walk away at least knowing how you don't want to be…. It's actually great to have at least one bad nurse here and there, so at least you know, that's what I don't want to be like.”

Knowledge

Knowledge was the most often mentioned concept in the study. Participants described the concept of knowledge as important to professional identity and to good nursing care. One ADN participant described the nursing professional as:

someone who would go out of their way to know everything they need to know about a particular topic. If they come upon a situation with a patient and they don't understand the diagnosis, then they're going to take that moment to look it up and research it and not take a step forward without knowing all that information.

Participants described knowledge as a sign that they were developing as a nursing professional. An ADN participant said, “I felt more like a nurse than any other semester because I think I gained enough experience and I have prepared myself enough with knowledge, I would say.” Knowledge prepared them with the ability to perform nursing interventions with minimal guidance. According to a BSN participant, “Just being able to know that and independently be able to carry it out and verify that all the medications are meeting [the patient's] needs. It just makes me feel like I got this.”

Caring

Participants often started the conversation talking about caring, as stated by an ADN participant: “A nursing professional means just being there for your patients, caring for them.” They talked about caring as descriptive of the profession and essential to the concept of nursing professionalism. Another ADN participant stated:

Probably the single-most important characteristic is caring because that's what really makes the difference with patients is trying to show them that you care about their well-being and you're there to support them through whatever they're going through.

Caring informed nursing professional identity in many ways: as a descriptor; as a commitment to the profession; as the basis for holistic nursing practice; as a form of communication; and as a way of knowing the patient in their context, rather than as a body in a bed. Many participants were emphatic when talking about the importance of caring to the professional nurse. An ADN participant stated, “I think that they really have to show that they care, that they truly, legitimately care. It's not just going into another job and saying, ‘Okay, I'm going to go just show up to work today.’” Although novices in the profession, participants in this current study were able to describe a sophisticated and comprehensive understanding of the importance of caring. Participants recognized the uniqueness of their patients and that they had to attend to more than their medical needs.

Confidence

Many participants described the lack of confidence they felt early in the program and how they felt they could harm a patient. One ADN participant stated, “It's sometimes like a place of doubt. You just feel like you aren't an authority and you don't yet know how things work or you don't feel confident in your own ideas and you have to be reassured about everything.” As they developed, participants described confidence as allowing them to make clinical decisions independently, which in turn enhanced their professional identity development: “This time I just felt that something needed to be done, and I had the knowledge to go and ask and not feel like I was out of place to do that.”

Competence

Similar to confidence, increased competence feeds on itself. Participants described having the experience of a good shift or a successful patient encounter as making them eager to take on more responsibility, which gave them the opportunity to increase their competence. An ADN participant said, “So that was really a good experience for me, where I knew what things were expected and everything. Well, not everything [laughs] but everything as far as that unit goes.” And with competence comes the feeling of being a nursing professional. A BSN participant stated, “For me it means feeling competent, feeling prepared, feeling like you are ready to start your profession.”

Integrity

Participants described integrity in many different ways, including responsibility, being ethical or accountable, not “cutting corners,” and being honest. Their views were remarkably similar across the two groups, whether in an individual interview or in the focus groups. In particular, the topic of integrity brought about animated conversation in each of the follow-up focus groups. Participants emphasized integrity as an essential character trait, not an optional aspect of a professional identity. In one focus group, a participant summed it up in this way: “I think, for me, it's every aspect of your life, how you live your life, as far as are you honest in all your actions. How do you behave when no one's looking?” Participants from both schools identified integrity as most important for safe patient care. An ADN participant stated it this way: “I would say integrity; you need integrity with everything you do. Doing everything right by your patients, for the safety of your patients.” A BSN participant described it similarly: “I think that integrity, that's something that's instilled…. It's just something that you should know to do and to live by as you give care. You always want to do the right thing and do the best for your patients.” The way participants described integrity echoes a Gallup® Poll that for the past 18 years has cited nursing as the most trusted profession (Reinhart, 2020).

Teamwork

Teamwork was another concept participants frequently used to describe the professional nurse: “We're professionals individually, but we also have to think that we're not single players, we're team players.” Participants described not only how the work is done collaboratively but how each member of the team affects the patient outcome and each other. A BSN participant stated, “There are so many aspects to the medical profession and there are so many people that support a patient's journey to wellness and recovery that if one person is off, it kind of throws off the process.” In defining how teamwork shaped the nursing professional, participants described it as not just helping others but being helped by others and being able to ask for help. An ADN participant said, “Things are going to happen where you might do something wrong sometimes, but don't be afraid to say, ‘Oh I don't know, can somebody help me?’”

Participants acknowledged teamwork sometimes came with conflict but handling that too was part of being a nursing professional. One participant in the ADN focus group said, “We're always going to come into someone that we have a personality conflict with, but that shouldn't affect the way that we work. We just have to find a way to work together with them; that was my challenge.” Participants defined nurses with professional identity as being team players, both with other nurses and in an interdisciplinary team.

A BSN participant said:

She tells the CNA [certified nursing assistant] thank you for your help, she tells the respiratory therapist thank you for giving my patient a breathing treatment. She tells everybody thank you for helping me as a team instead of like, ‘Oh well, that's your job.’”

Communication

Good communication skills were something participants saw in nursing professionals. Participants identified these as an important but sometimes neglected part of being a nursing professional. According to a BSN participant:

That to me is excellent. And I think whenever the nurse can, they should be able to take that little extra time and explain things like Henry [a staff nurse identified as a nursing professional] does and what I have been trying to do, [to] keep the patient updated.

Critical Thinking

Critical thinking was also seen as an important skill for the nursing professional as the incorporation of science and best practice. An ADN participant said, “Caring is the human side of nursing, but there's also a scientific side where you have to be organized and critically think and you have to be able to put the puzzle pieces together. That's…what nursing is.”

Advocacy and Leadership

Advocacy and leadership were also described by participants as characteristics of the professional nurse. A BSN participant said, “At this point in my educational career, at the end of it, I understand that as a nurse it's basically or primarily my role to be the patient advocate, and that dictates everything that I do.” When participants were able to engage in patient advocacy, they described it as feeling like a professional nurse. Another BSN participant said, “I was just really happy that I was able to make a contribution and be the patient advocate at the same time. So that was really exciting for me.” Participants described this change as part of their development as nursing professionals: “My mental scope, my attitude, my perspective, my paradigm shift went from I'm a follower to I'm a leader; a completely different perspective.”

Discussion

Knowledge

Similar to the perspective of the National League for Nursing (2010), participants in this study identified that knowledge alone is insufficient; professionalism includes internalizing the core values and beliefs of the profession, as well as understanding the context of the practice. In this way, knowledge went beyond simply having the information and the know-how to applying and adapting the knowledge to unique patient care situations. Williams and Burke (2015) described the concept of knowing, which includes having the appropriate information and using it to promote better patient health, as a way to develop professional nursing identity. Similarly, Lyneham and Levett-Jones (2016) described behaviors demonstrating professional values as “being knowledgeable and sharing one's knowledge” (p. 89).

Caring

In a small qualitative study of first-year nursing students in New Zealand, all participants described caring as the basis of their understanding of professional identity (Sun, 2016). Personal experiences of caring gave them confidence in their learning and allowed them to see themselves as a future nursing professional. Lyneham and Levett-Jones (2016) described caring as one of the four main values identified in their study. Nurses who exhibited caring behaviors toward their patients were admired and seen as positive role models. Similarly, in a 2016 study in the United Kingdom, nursing students identified caring as an innate characteristic of the profession (Traynor & Buus, 2016). Participants in the current study discussed caring as an approach unique to nursing and as central to the profession. One BSN participant said, “If your goal in nursing is to heal the person and to increase or improve their level of health, then your attitude is different.”

Confidence

Rasmussen et al. (2018), in their very comprehensive literature review, found that uncertainty, or a lack of confidence, can lead to stress and tension, leading to decreasing job satisfaction. Confidence was seen as a positive coping strategy, leading to self-awareness and an internalization of nursing professional identity (Rasmussen et al., 2018). St-Martin et al. (2015) described how confidence allows new graduate nurses to master their role and is an important part of a well-developed nursing identity. Zarshenas et al. (2014) described a momentum that starts with internal motivation, which leads to increased knowledge, which leads to confidence, which results in professional identity.

Competence

Research has also described competence as being important to the development of nursing professionalism (Rasmussen el al., 2018), as a way to support nursing professional practices (Spector et al., 2015), as an element of professional self-assessment (Yoder, 2017), and as a contributor to confidence (Neishabouri et al., 2017; Williams & Burke, 2015) and job satisfaction (Spector et al., 2015).

Integrity

According to Krautscheid (2014), professional accountability supports congruence between nursing action and standards for the profession. This is similar to the way participants identified the internalization of nursing integrity and identification with the profession. These ideas also arose when participants described times they did not feel like a professional. According to an ADN participant:

Nothing bad happened that day but I really felt like I should be a transporter, a medical transporter that second, because that's how much I knew about my patient; absolutely nothing. It was definitely a situation where I didn't know what my role was as a nurse.

To a person, participants identified that there was a role, or a persona, they must take on to perform or to feel like a professional. Such comments are supported by the literature in an expectation that professional nurses' behavior met an expected standard or level of integrity (Dikmen et al., 2016; Hercelinskyj et al., 2014; Neishabouri et al., 2017; ten Hoeve et al., 2014).

Teamwork

Best and Williams (2019) found that working in teams, particularly interprofessional teams, supports nursing professional identity by giving the nurse a sense of belonging. Bochatay (2018) found that rituals such as the nurses' shift report were an important form of socialization and helped new nurses strengthen their professional identity. Hensel (2014) found that there was strong agreement among nursing students that teamwork was critical to patient safety. She labeled one group of participants “collaborators” who found teamwork to be essential and who enjoyed collaborating with all members of a team.

Communication

Similar to the current study, participants in a Turkish study of nursing students and instructors (Aydin Er et al., 2017) described interpersonal relations and communication as qualities of a good nurse. Effective communication has been described as important to civility (Woodworth, 2016), to establishing and maintaining therapeutic relationships (Akhtar-Danesh et al., 2013), and as a means of developing confidence (Williams & Burke, 2015).

Critical Thinking

Ward and Morris (2016) described critical thinking as a nurse's ways of knowing, thinking, and decision making, and as the basis of effective nursing care. Kabeel and Eisa (2016) found evidence of a positive correlation between critical thinking and effective assessment, which gives students satisfaction and competency. Participants in this study described times when they felt like a professional nurse when they had the opportunity to use their critical thinking skills in the clinical setting.

Advocacy and Leadership

Waite et al. (2014) described how leadership development is important during nursing formation as an essential ability, not an add-on skill. In the current research, the concept of leadership was discussed in both focus groups as a part of the definition of a professional nurse. The complexity of leadership and leadership development was described by Linderman et al. (2015), who found inexperience and a lack of career wisdom as obstacles to leadership development in students and early career nurses. Participants in the current study talked about feeling like a nursing professional when they were able to engage in advocacy. Beal and Riley (2015) described advocacy as an unchanging element of nursing professionalism despite the ongoing and rapid changes in the nursing work environment, and as an essential element of nursing that needed to be adapted to new environments, not altered in its essence. This finding supported what both ADN and BSN participants in the current study described as an important trait for a nursing professional.

ADN and BSN Preparation

The decision to study both ADN and BSN participants was made to strengthen the research with a variety of student experiences and to allow differences or similarities between the two groups to emerge. The link between curricula and professional identity formation is not well-developed. Previous research has shown a strong correlation between patient care outcomes and baccalaureate education (Aiken et al., 2012; Harrison et al., 2019), yet no similar link has been found with professional identity. It could be argued that better patient outcomes come from confident, knowledgeable, competent nurses who are critical thinkers. All are attributes of a nursing professional, but that link has not been demonstrated in the literature.

Conclusion

This study adds to a limited body of literature on the definition of nursing professional identity. In particular, it helps to fill the gap in research about how nursing students define what it means to be a nursing professional. Participants attributed the ingrained traits of knowledge, caring, teamwork, and integrity to the identification of a nursing professional. They also described the professional nurse as displaying good communication, confidence, competence, critical thinking, advocacy, and leadership. These findings relate closely to research studies on professional identity, despite the fact that many of these previous studies lacked a focus on the definition of nursing professional identity. This research gives support to recommendations from the National League for Nursing (2010), the American Association of Colleges of Nursing (2008), and other nursing governing bodies about professional identity as a focus of nursing education. The significance of how the participants described the nurse with a strong professional identity was the emphasis on personal characteristics or ingrained traits and not on actions or skills. The students described someone who cares about the patient, who has integrity, and who is able to work as part of a team.

Limitations

One limitation of this study was the difference in the focus group participation between the ADN and BSN participants. All ADN participants had an opportunity to further the discussion with their peers. Only three BSN participants attended their focus group, a function of the fact that it took place after graduation. The three BSN participants who did attend might not represent the views of all 12 members of that group. The geographic location and sites of this study limited the research. This study used only two sites—one BSN and one ADN school of nursing in the same geographic region. The fact that these schools recruit students from the same catchment area could account for the similarity in results between the two groups. Recruiting students from a more diverse geographic and academic environment could further develop the results of this study and support the generalizability of these results.

Implications for Nurse Educators

As with any educational endeavor, knowing the student's starting point helps in the creation of effective environments of learning. Nurse educators can better support a strong foundation for nursing students' professional identity by developing a shared understanding of what it means to be a nursing professional. Participants in this study showed that as students near graduation, they have gained sufficient knowledge, had enough exposure to role models, and had experienced enough nursing environments to develop a concept of nursing professional identity. A fuller understanding of what this concept means to students helps nurse educators create environments for the development of professional attitudes of care along with nursing skills and knowledge.

Future Research

More remains to be developed in the study of nursing professional identity formation, particularly from the perspective of nursing students. Research using students from all levels of study and from different types of programs in different geographic regions, and research involving nursing faculty could further develop our understanding of the development of professional identity. More research is warranted on the relationship between academic degree and professional identity and on the relationship between professional identity and patient outcomes. This research provided an important perspective on nursing professional identity by adding depth and a fresh perspective to further our understanding of this significant topic in nursing education.

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Authors

Dr. Fitzgerald is Assistant Professor, School of Nursing, California State University Long Beach, Long Beach, California; and Dr. Clukey is Professor Emerita, School of Nursing, University of Northern Colorado, Greeley, Colorado.

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

Address correspondence to Anita Fitzgerald, PhD, APRN, CNE, Assistant Professor, School of Nursing, California State University Long Beach, 1250 Bellflower Boulevard, Long Beach, CA 90840; email: anita. fitzgerald@csulb.edu.

Received: November 09, 2019
Accepted: May 04, 2020

10.3928/01484834-20210120-04

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