HAVING DESIGNATED 2020 as the Year of the Nurse and Midwife, the World Health Organization extended the designation through 2021 to honor these age-old professions during the COVID-19 pandemic.1 As the most trusted profession, nursing is built on care, compassion, empathy, and knowledge.2 But how did it evolve into the profession it is today? To comprehend what it means to be a nurse requires an understanding of the career spectrum from nursing students to veteran experts in the field.
This article describes the Building Your Nursing Legacy project developed by the authors. It was based on a qualitative research study designed to focus on legacy building in the nursing profession as nurses progress from students to experts in their field. The project was inspired by a Presidential Call to Action that tasked chapters of the nursing honor society, Sigma Theta Tau International, also called Sigma, with developing strategies for establishing a living legacy.3
What is a legacy?
In the literature, legacy is often associated with end-of-career accomplishments or monetary awards in honor of individuals who have passed away, but building a legacy in nursing is more than financial donations. Everything an individual contributes to the profession supports an avenue for others to follow.4-8
More recently, nurses have been looking at legacy as an investment in future nurses in which every interaction with friends, colleagues, students, and patients provides opportunity to promote and advance the profession.6,9-11 This would redefine legacy as “a meaningful, lasting contribution to the people you touch by serving a greater cause” that “drive[s] results that have long value.”6,9
Establishing a living legacy
The Building Your Nursing Legacy project described in this article was developed by researchers in a chapter of Sigma, which has focused on scholarship, service, and excellence for almost a century. A Presidential Call to Action communicated a core strategic value of establishing a living legacy and tasked chapters with its development. The project showcased legacy as more than just monetary donations or end-of-career objectives.12,13
Nurses today continue to value the same qualities that Florence Nightingale did more than 160 years ago: courage, tenacity, and competence to improve patient care and serve as agents of change.14 A nurse's legacy can help forge paths to impact healthcare both locally and globally.15 For example, in a 2016 study, Newton and Jones found that legacy can provide insight into cultural differences.16 Similarly, in 2014, Kennedy pointed out that new nurses do not simply learn job skills, but instead join “a profession with a legacy of service and social commitment.”17
Many nurse leaders have posed the question, “What will be your nursing legacy?” However, research on this topic has been almost nonexistent.18-21 One study on the legacy of mentor relationships found that, while experienced nurses had a lot to offer new nurses, their relationship was often reciprocal and benefited the experienced nurses as well.22 Building a legacy has a positive impact on nurses from all generations, regardless of their years of experience.
Legacy building fosters nursing engagement and leadership development.23 By nature, nursing is a caring profession. Feeling a sense of purpose and developing a personal and professional legacy is important for nurses to gain meaning from their work.
In 2015, Hinds and colleagues developed a career legacy map to help nurses maintain meaningfulness in their work and achieve positive career outcomes.24 This map is intended as a guide for nurses to achieve goals through meaningful and purposeful work. It helps them determine how to leave a legacy through education and change in healthcare. It uses two main questions: “What do you want to be better in nursing because of you and your efforts?” and “What would you like best to be known for by others?”24
Initiating the project
Although some research has been conducted on nursing legacies, this qualitative research study is the first to focus on legacy building in the nursing profession as nurses progress from students to experts in their field. It was approved by the Institutional Review Board at the authors' university. A group of novice and experienced nurses, both pre- and postlicensure, developed and reviewed a survey designed to address the larger question, “What does building a legacy mean to the nursing profession?”
All survey questions were verified by a doctoral-level nurse with expertise in legacy initiatives. Five open-ended questions were developed to examine how the participating nurses viewed their personal legacy and how engagement has influenced their career paths over time (see Nursing legacy survey). The inclusion criteria included adults over age 18 who were either in nursing school or were currently licensed, and who could read and write English.
The study participants were not asked to provide in-depth demographic information related to age, gender, race, or ethnicity, as the focus was on the responses to the open-ended questions regarding legacy. Although no demographic data were collected, the participants' graduating years ranged from 1973 to current nursing students. Of 47 participants who reported their credentials, 31 (66%) identified as nursing students.
Qualitative data were collected between 2014 and 2017 at local and national Sigma events, including membership appreciation events, membership inductions, outreach events, and evidence-based practice dinners. Participants were asked to respond anonymously to five open-ended questions related to legacy building, and membership in Sigma was not a criterion for inclusion. The question topics covered memorable nursing and patient moments, the future of nursing, the qualities of a nurse, and advice for new or novice nurses. A convenience sample of 84 nurses completed the survey, ranging from students to BSN-, MSN-, and PhD-level nurses.
These data were transcribed verbatim from the surveys and reviewed for errors using a double-check system before analysis. The analysis was performed by three researchers, who reviewed the data to gain general impressions and identify emerging themes. Using an iterative process, the researchers defined and named themes found in the data.
The researchers analyzed the data using Braun and Clarke's six-phase process for thematic analysis, a widely used approach that defines and describes how to report patterns and themes in qualitative research.25
- In the first phase, the researchers familiarized themselves by transcribing the data and reading the transcripts.
- In the second phase, they generated initial codes based on data that appeared meaningful or interesting.
- In the third phase, they searched for initial themes and examined the codes as they related to those themes.
- In the fourth phase, they reviewed the data to combine themes and collapse generated subthemes.
- In the fifth phase, they composed working definitions of the identified themes, leading to a unified story.
- The sixth and final phase used direct quotes related to each theme. Three themes were identified: who nurses are, who nurses help, and who nurses become.
Who nurses are
When nurses attempt to define themselves, they often recall significant moments in their career to highlight the quintessential aspects of what it means to be a nurse.20,21,23 Despite varying careers and subspecialties, nurses often discuss similar characteristics related to the field. While each nurse has a personal story, the participant responses in this study revealed similar journeys. They defined nurses as “compassionate” and “competent” members of the healthcare team, who pursue their “passion” and uphold “professional integrity” in their career.
Although nurses possess many positive qualities, the concept of compassion related to empathy, kindness, and understanding resonated throughout the survey responses. One participant reported that “compassion is just as important, if not more important, than all technical skills learned in school.” Additionally, the participants noted that nurses are supportive, with one describing having a role in supporting patients' families during crises as a memorable moment.
Compassion may have been the focal point of many responses, but the participants also noted the importance of competence and knowledge of critical skills in nursing. For example, one participant noted that some memorable moments involved high-acuity skills such as first hospital codes, first defibrillations, administering I.V. adenosine, administering tissue plasminogen activator to patients experiencing a stroke, and treating patients who may have been exposed to rabies. As another participant stated, “hopefully the nursing profession will become a more autonomous one. Nurses have so much knowledge that can make a difference.”
Other crucial characteristics included professional integrity and passion. One participant described an interaction with the mother of an 18-year-old patient who had experienced a brain aneurysm. The mother told this nurse, “You fought for me [and my child], and I will always continue to fight for you.” The survey responses emphasized the importance of honesty, integrity, professionalism, ethics, and trust in nursing.
Who nurses help
The participants described how they had helped patients and their families through both joyous and somber events. Nurses often recall their most memorable moments as being related to patient care. Although the study participants ranged from student to expert, they all identified the same characteristics. For example, they discussed the importance of “collaboration” and “comprehensive care” in order to be patient advocates. Additionally, they noted “connecting with patients,” including “faith/spiritual aspects of care,” as crucial to being there for patients during good times and bad.
Sometimes nursing involves being present at the bedside to hold a patient's hand during childbirth or “helping patients and their families experience peaceful transitions from this life.” The participants described memorable moments in which they acted as a source of comfort for patients at some of their worst times, such as when facing death. One participant described such a patient: “I sat with him most of my shift because he had no family there...it was very powerful.” Nurses working in health promotion also collaborate with patients by “achieving health goals and being able to make an impact on patients' lives.”
Nurses are traditionally depicted in acute care settings, but this impression has evolved as nurses impact healthcare in the political, educational, judicial, and research arenas. For example, nurses work with police officers and forensic scientists, with one participant describing caring and providing emotional support for victims of crimes. Many nurses also travel outside the US to provide care for people in need. As one nurse reported: “When I was abroad in Tanzania, a community outside of Moshi had over 300 people come to our mobile clinic. Regardless of the language barrier, I was able to connect with them and see how thankful they were for the care they received.”
Who nurses become
Nursing, meaning “to nurture,” is grounded in developing not only future generations of nurses, but also in fostering professional development personally and in peers.26 Throughout their career, nurses become role models for nursing students, colleagues, patients, families, and the community.
They can also inspire and foster growth intellectually and socially. The participants described nurses as “confident” and “autonomous” individuals, who become “lifelong learners” with many accomplishments beyond their academic degree. They noted major achievements such as developing leadership programs, earning special certifications, and winning professional awards.
Mentoring and role modeling are essential and should begin in nursing school.22,24 One nursing student described the bond that developed with an ICU nurse after they were paired for rotations and problem-solving: “She allowed me to take the lead in critical thinking and told me how she thought I was going to be a great nurse, which [I will] never forget.” A nursing professor discussed a former student who had been inspired by the professor to go into nursing research.
Additionally, as nurses become expert analytical thinkers, they promote and guide changes to improve healthcare and nursing. As one participant reported, “I see the nursing profession changing by continuing to use evidence-based practice and becoming more involved with technology.”
Most of the limited literature related to legacy building in nursing focuses on expert nurses.10,22,24 This study explored legacy building in experienced professionals, novice nurses, and nursing students in the early stages of their career. It is the first study aimed at understanding the impact of legacy in nursing from participants of varying experience levels. As such, the emerging themes should not be limited only to expert nurses. Increased efforts in early legacy building may promote career purposefulness and direction and reinforce the long-term influence nurses have on those they serve.21-24
The first theme focused on who nurses are and their characteristics. Nursing students begin to develop a professional identity during nursing school and throughout the transition to professional practice. Although nursing students and newly graduated nurses are frequently asked about their 5- or 10-year plans and any long-term career ambitions, these questions are often centered on personal aspirations. Increased awareness, dialogue, and programs on legacy building may support individuals in framing their identity as nurses in terms of the population they serve and the legacy they wish to leave behind. Nurses can have a local and global impact on healthcare, so a focus on cultivating meaningful legacies is crucial at all stages of a nurse's career.15,16
In the second theme, the participants emphasized the integral role of nurses in patient, family, and community outcomes. Nurses are involved directly and indirectly with care across a patient's lifespan, advocating and promoting evidence-based change.4,6,17 The study participants also noted that nursing extends beyond the bedside with research, health promotion, and healthcare reform at local and global levels.
In the final theme, participants emphasized the role of education in their professional development. As lifelong learners and educators, nurses educate patients and families and eventually become role models for future generations within the profession.6,9-11 For example, some Sigma chapters have established Leader Intern Programs that promote mentorship and leadership development among nursing students. These programs foster a foundation of legacy building for emerging nurses and cultivate a living legacy shared by nursing students, experienced nurses, and nurse leaders within the chapter.
The study limitations included a self-selected convenience sample, so the results may not be generalized to other healthcare professions. Additionally, the lack of demographic data hindered the authors' ability to describe participants in the sample comprehensively. As this was the first study focused on building nursing legacy from students to expert nurses, future research should include demographic data, explore what legacy means to individual nurses, and detail challenges for new nurses, and it should be conducted over a longer period of time to compare results.
An additional theme to consider in future research would be how nurses are viewed by others. Additionally, future studies should focus on understanding the complexities of shared legacies between nursing students and their mentors through programs similar to Sigma's Leader Intern Program. The recent influx of BSN-to-PhD programs has also allowed for research longevity in emerging nurse scientists. As more nurses obtain doctoral degrees, research longevity and the legacy of nurse researchers should be further explored in nursing.
Enhancing nurse legacies
This was the first qualitative study on legacy building and the journey that leads to a career in nursing. The participants described nurses as “trustworthy,” “autonomous,” “honest,” “collaborative,” and “mak[ing] a difference.” These responses revealed that nurses' identity and understanding of who they are and who they help contributes to their career legacy and who they become. Strong nursing legacies pave the way to a successful career. Legacy building fosters engagement and leadership development. In the meantime, nurses can continue to enhance their legacy with gratitude, time, and expertise to make a difference.
Nursing legacy survey
- Describe your most memorable moment in nursing.
- What was your most memorable patient moment?
- What change do you expect in the nursing profession?
- What thoughts would you like to share with a novice, graduating nurse?
- What do you believe are the most important qualities of a nurse?
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