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Department: Professional Enrichment

Professionalism in the critical care setting

A concept analysis

Byars, Michael BSN, RN, CCRN; Camacho, Melissa BSN, RN, CCRN; Earley, Donovan DNP, CRNA; Harrington, Linda PhD, DNP, RN-BC, CNS

Author Information
doi: 10.1097/01.CCN.0000515987.70483.8d
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In Brief

The concept of professionalism is gaining momentum as nurses achieve higher levels of education, autonomy, and respect. What is professionalism? Why is it important? To answer these questions, this article provides a concept analysis for understanding professionalism in the critical care setting.

A concept analysis begins with defining a concept and identifying critical attributes or characteristics of a concept.1 Empirical referents serve to measure critical attributes. Antecedents describe specific factors that must be present for the concept to be present. The intended and unintended consequences of professionalism highlight the importance of understanding the concept. The concept is then demonstrated in case examples that enhance understanding.

A concept analysis creates a mutual understanding among individuals in a discipline so it can be explored in practice, education, and research. This exercise will guide readers in applying professionalism to their nursing practice.

Background

The definition of professionalism has evolved over the years. Professionalism was originally a commitment to learned pursuits.2 The Latin root of the word professionalism means to “profess” or “vow.” This refers to the medieval practice of surrendering personal gain to the religious community.3

The root word of professionalism, profession, helps develop a context for understanding the concept of professionalism. A profession is “a calling requiring specialized knowledge and often long and intensive academic preparation.”4 A professional is a person who belongs to a learned profession, and therefore professionalism is the behavior expected from a professional.5,6

Professionalism consists of various traits, characteristics, and behaviors that are attributed to people held in high esteem.7 Professionalism is the skill, good judgment, and polite behavior that is expected from a trained person to do a job well. It is the conduct, aims, or qualities that characterize a profession or a professional person.8 Professionalism is something individuals “know when they see it.”9

Professionalism develops as a result of a social contract between the profession and society.10 This contract allows for a monopoly over a knowledge base, autonomy, prestige, and financial rewards. The profession must be altruistic, demonstrate honesty and integrity, assure practitioner competency, and be devoted to public good.

However, these ideas of what the concept of professionalism embodies are inexplicit, and the literature lacks consistently used adjectives describing the concept. Read on for clarification of the concept and how it applies to the field of nursing.

Refining the definition for nursing and critical care

The authors developed a more precise definition of the concept after a review of the literature surrounding professionalism in healthcare. This review focused on the most common elements to create an operational definition. Ultimately, professionalism in the critical care setting is the integration and use of skills, behaviors, and qualities by an individual whom society deems valuable. Nursing professionalism, specifically, can be correlated with years of experience, higher educational attainment, specialty certifications, and consistent devotion to continuing education.11

The critical attributes are demonstration of specialized knowledge obtained through education and/or training, good judgment, and polite behavior. Examples of these qualities include honesty and punctuality. The implementation of these skills is a practice in good judgment; for example, the nurse should convey a polite demeanor despite stressful circumstances.

This operational definition of professionalism can be taught throughout all healthcare fields. Nurses who share a common definition of professionalism have the potential to alter the profession in positive ways. An operational definition enhances collaboration among nurses, clarifies expectations, and strengthens nursing services.

Modeling professionalism

Barbara Miller created the Wheel of Professionalism in Nursing model that depicts the essential characteristics and behaviors of a nursing professional.12 The eight spokes of the wheel represent professional behaviors and include participation in professional organizations; self-regulation or autonomy; developing, using, and evaluating research; maintaining competence through continuing education; involvement in community service; developing, using, and evaluating theory; following a Code of Ethics for Nurses; and publishing.12

Miller and colleagues then used the model to develop the Behavioral Inventory for Professionalism in Nursing (BIPN).13 The tool provides a consistent method of measuring professional behavior and identifying opportunities for improvement. An initial study following the development of the BIPN involving 515 nurses in eight states reported the highest achievement of professional behaviors in continuing education, certification, and reading and subscribing to professional journals.12

Two recent studies used the BIPN to measure professionalism in clinical nurses. One study focused on 89 nurses working in a public hospital in Turkey, finding the highest numbers of professional behaviors were in continuing education and lowest in autonomy, publication, and research.14 Another descriptive study of 1,501 nurses in Japan reported low levels of professionalism overall, with the highest levels related to higher educational preparation, years of nursing experience, and current role as administrator or faculty.15 Findings from such studies can be used to guide interventions targeting the improvement of professionalism.

Measuring critical attributes

Empirical referents are phenomena that demonstrate the existence of a concept.1 They are used to measure the critical attributes of professionalism in critical care: specialized skill obtained through education and training, good judgment, and polite behavior. Nurse competency and skill level can be measured through attainment of specialty certifications, ability to manage critical situations, scores on continuing education exams, and years of experience. Nurses with higher levels of professionalism often pursue continuing education and participate in autonomous quality improvement projects and community service.13

Good judgment can be measured based on the results of peer and case review studies. These studies can determine if good or poor outcomes resulted from the nurse's judgment and subsequent decision to take action or not to take action. The nurse's judgment and subsequent actions can be measured based on which actions are taken. Poor judgment can lead to wrong actions. Rationales that support the decision can be discussed and new knowledge can be gained. Further research can determine if judgment patterns improved post intervention and education.

Polite behavior can be measured through compliment and complaint reporting systems as well as patient and family satisfaction surveys. The amount and types of feedback nurses receive reflect how others view them.

Antecedents

Antecedents are the factors that must occur in order for professionalism to be present. First, a situation must arise that requires professionalism, such as interdisciplinary collaboration and nurse-to-nurse interactions. The individual must understand the values of honesty and accountability for professionalism to develop. Society should be able to identify and find value in the service the professional offers. The professional should also effectively utilize education or training to serve others.

Consequences

Intended consequences of professionalism include respect, trust, autonomy, and skill mastery. Individuals will gain respect and trust if they exhibit professionalism. These characteristics can lead to increased autonomy and skill mastery within their field.

Unintended consequences of professionalism include increased job satisfaction, quality of care, and patient safety.16 While some concepts have negative consequences, the unintended consequences of professionalism are highly desirable. Nurses can improve quality of care and patient safety by further developing professional behaviors through continuing education, collaboration with other nurses as leaders of interdisciplinary task forces, and participation in quality improvement programs.

Using the identified critical attributes, the following cases are constructed to illuminate what professionalism is and is not. The model case is the ideal case.

Model case

A critical care nurse with 15 years of experience has successfully completed an American Heart Association Advanced Cardiovascular Life Support course and obtained specialty certification as a CCRN® (Adult). She is polite, honest, and builds rapport with her patient and his family. Her patient complains of chest pain. Based on her experience, she quickly implements the chest pain protocol and notifies his primary care provider while beginning a focused assessment. She also notifies the respiratory therapist because the patient shows signs of respiratory distress. The patient develops pulseless ventricular tachycardia and the nurse activates the code team, provides high-quality CPR, and effectively participates in additional resuscitation efforts. The patient is successfully resuscitated and the patient's family has a newfound respect for her.

This is a model case because the nurse exhibits all of the critical attributes of professionalism in critical care. She is polite and able to build a rapport with her patient and the family. She demonstrates good judgment by delegating tasks and understands what to do in this situation. Her specialized skill set allows her to intervene and save her patient's life.

Borderline case

One of the critical care nurse's patients is diagnosed with diabetic ketoacidosis (DKA). This is the patient's fourth admission for DKA in the last 3 months. The nurse tells a coworker, “This patient is hopeless!” She carefully follows the DKA protocol and informs the healthcare provider of the patient's lab results and physical assessment findings.

This is an example of a borderline case because the nurse demonstrates some of the critical attributes of professionalism. The nurse has a specialized skill set for managing the critically ill patient. The nurse exercises good judgment by keeping the healthcare provider informed and following the DKA protocol. However, she is unprofessional and impolite while interacting with her coworker.

Related case

An RN arrives for work on time and is dressed appropriately. His polite behavior turns into frustration as the day progresses. He fails to appropriately delegate tasks despite being overwhelmed. This results in a patient medication error. He informs the appropriate personnel of his error and completes an event report as per facility policy.

Here, the RN exhibits qualities that are similar to professionalism but lack all of the critical attributes. Professionals are appropriately dressed, reliable, and honest, as this RN demonstrates. However, he doesn't utilize the specialized skill of delegating tasks. He demonstrates poor judgment by not asking for help. He demonstrates a lack of professionalism through his behavior, which ultimately results in a medication error.

Contrary case

A practicing nurse new to critical care complains to coworkers and patients about staffing and pay. She receives orders to discharge a patient who was treated for DKA. His blood glucose levels are elevated and he is confused. She documents the patient's confusion and blood glucose results before discharging him. He is readmitted that evening.

This is an example of a contrary case because none of the critical attributes of professionalism are met in this scenario. The nurse shows a lack of skill and good judgment when caring for the patient. Her complaints to patients and staff demonstrate poor professionalism.

Implications for nursing practice, education, and research

Professionalism in nursing practice is essential to gain respect, credibility, and trust. The evolution of nursing practice has led to increased responsibility and autonomy. The expanded decision-making power of nurses makes measuring and defining professionalism a significant area for research.15

Establishing the concept of professionalism in education is important because academic and clinical educators are early sources from which nurses develop their idea of professional behavior. There is inconsistent introduction and application of the concept of professionalism across nursing curricula.11 A clear definition enables educators to assess students' understanding, facilitate their socialization and transition into the professional role of nursing, and promotes homogeneity across nursing curricula.

With this operational definition, interventions to improve professional behavior can be measured. The assessment of professionalism should focus on initial perceptions of professionalism and how those perceptions change after education and training.17 This type of research can identify nurses who need education and training in professionalism.

Clinical monitoring is significantly different among nurses with varying levels of professionalism.18 Different levels of professionalism among nurses can impact patient safety. Therefore, efforts to optimize patient safety should focus on developing nursing professionalism.18

Nurse work satisfaction is another important area of focus regarding professionalism. A statistically significant relationship between professionalism and work satisfaction exists.16 Job satisfaction can be increased by developing professionalism. Improved nursing satisfaction increases retention, career longevity, and overall improvement in the profession of nursing.16

Conclusion

Professionalism is the integration and use of skills, behaviors, and qualities by an individual whom society deems valuable. This operational definition includes the necessary antecedents of honesty and accountability with consequences such as respect, trust, autonomy, and skill mastery. This concept analysis of professionalism can improve patient outcomes, nursing satisfaction, and the nursing profession.

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