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Nurse Education in Practice 13 (2013) 18e22

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Nurse Education in Practice

journal homepage: www.elsevier .com/nepr

An exploratory study: Student nurses’ perceptions of professionalism

June Keeling*, Jenni Templeman 1

Faculty of Health and Social Care, University of Chester, Riverside Campus, Castle Drive, Chester CH1 1SL, United Kingdom

a r t i c l e i n f o

Article history:Accepted 13 May 2012

Keywords:ProfessionalismStudent nursesPracticeRole modelling

* Corresponding author. Tel.: þ44 (0) 1925 53 4065E-mail addresses: j.keeling@chester.ac.uk (J

chester.ac.uk (J. Templeman).1 Tel.: þ44 (0) 1925 534226.

1471-5953/$ e see front matter � 2012 Elsevier Ltd.doi:10.1016/j.nepr.2012.05.008

a b s t r a c t

Aim of the study: To explore final year nursing students’ perceptions of professionalism using a reflectiveapproach.Design: A phenomenological approach informed the study, and data was collected by a focus group andfive individual semi-structured interviews.Subjects: Participants were ten final year student nurses studying on the adult nursing education pro-gramme in the United Kingdom.Data analysis: Thematic analysis resulted in an extensive list of general statements or ’units of meaning’,from which meaningful categories describing a phenomenon evolved.Results: The findings revealed that student nurse’s perceived vulnerability, symbolic representation, rolemodelling, discontent and professional development as elements that informed their own profession-alism. Additionally, being able to observe the behaviours of registered nurses appeared to be significantto the student in the development of their own sense of professional identity, using positive and negativerole models constructively.Conclusions: It appears that final year student nurses are cognisant of the impact of practice scenarios andobservational influences, affecting their own perceptions of professionalism. They are able to clearlyidentify and make sense of experiences in practice, and constructively use this knowledge to positivelyinform their practice.

� 2012 Elsevier Ltd. All rights reserved.

Introduction

Defining professions and professionalism has been a contem-porary and contentious issue that has merited the concern ofsociologists throughout the ages (Noordegraaf, 2007). Historically,nurses in the Nightingale era were seen as ‘attendants of the sick’,whilst in the twenty-first century nurses assume diverse roleswithin a complex healthcare system in response to changes insocial, political and demographic trends, medical and technologicaladvancement, and the perceptions of nurses themselves (Yam,2004).

The nursing profession has only relatively recently been affor-ded and recognised with a professional status (Shaw and Degazon,2008). This status through, appears to be confused and vacillating(Schlotfeldt, 2011). Whilst the term ‘Professionalism’ is a globalterm used to describe many professions with a nonspecific focus,when applied to nursing, it alludes to nurses’ behaviours such as

.. Keeling), j.templeman@

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autonomy and self-regulation, belief in public service, and a senseof vocation (Wynd, 2003), and further, accountability (Carryer et al.,2007).

The attrition of experienced nurses leaving the National HealthService is leaving a void and creating a crisis in the healthcaresystem (Wynd, 2003). The fissure that has developed betweenlosing experienced nurses, and the development of newly regis-tered nurses, affords an opportunity to reassess nursing in thecontext of contemporary society. Thus, this gap has provided anopportunity to explore the next generation of nurses’ perceptionsof professionalism within the context of contemporary society.

Background

Over the past century, the essence and evolution of nursing haschanged dramatically from the Nightingale style of apprenticeshiptraining to a professional discipline that has fervently striven toidentify itself as a profession (Yam, 2004). In the early 1950s, therewas increased discontent amongst nurses about their roles, a situ-ation that led to a concerted effort to shed the historical shacklesand to argue their claim to professional status (Yam, 2004).

Prior sociological enquiry on the professions concentrated ondefinitions of professions and their salient characteristics with the

J. Keeling, J. Templeman / Nurse Education in Practice 13 (2013) 18e22 19

sociological meaning of the term, ‘profession‘, being the subject ofconsiderable debate (Modarresi et al., 2001). The sociological studyof professions as a special category of occupations is a long-standing field of academic research with historical and distinctivecomparative modes of analysis (Evetts, 1999).

The conceptual framework of a profession has also not beentheorised adequately, and is therefore unable to provide definitiveparameters. However, according to Nagla (1993), professionalism isbest viewed as a state of mind, because it is a way of thinking aboutthe cognitive aspects of a profession and the characteristics thattypify a professional. Towards a dimensional model or theory ofprofessionalism, a different trajectory has been proposed, identi-fying knowledge, education and training, skills, autonomy, values,ethics and reward as integral to this model (Sachs, 2003; Winch,2004). These components, considered to encapsulate profession-alism, have been identified as knowledge, education and training,skills, autonomy, values, ethics and reward (Sachs, 2003; Winch,2004). Nursing however, has been categorized as a semi-profession due to the traditional apprenticeship training system(Cody, 2011).

Methods

A qualitative paradigmwas chosen to explore the perceptions ofprofessionalism from the student nurses’ perspective. Prior tocommencement of the study, ethical approval was obtained by theauthors’ academic institution. Confidentiality was maintained bythe use of a pseudonym.

Sample

The sample consisted of ten final year nursing students studyingon the diploma or degree programme of adult nursing at an Englishuniversity. Participant information sheets were given to allstudents who met this inclusion criterion, regardless of gender.Only female students responded. Recruitment was by voluntaryparticipation; student’s e-mailed the primary researcher if theychose to participate. A mutually convenient time and place to meetwas then arranged. The decision to include student nurses on boththe diploma and degree programme was based on having an equaldistribution of these students on the programme that could providerich data from differing perspectives and levels of knowledge.

Data collection

Five initial individual interviews were conducted followed byone focus group consisting of five students. Semi-structuredinterviews enabled the individual’s experiences to be explored,whilst the focus group brought together students to share theirthoughts and experiences on the research topic. This triangulatedapproach sought to enhance the depth of data collected. Theinterviews and the focus group lasted for up to 1 h in duration andwere audio recorded with the participants’ permission. To ensureconfidentiality between focus group members was maintained,a verbal agreement was negotiated prior to commencement. Anobservation of the groups’ interaction and contribution was recor-ded by the primary researcher at the time of the focus group, toassist in the data analysis.

Data analysis

The focus group and semi-structured interviews were taperecorded and transcribed verbatim, with copies of the transcriptoffer to participants for member checking. The fifteen phases tothematic analysis as detailed by Dey (1993) were used and initial

codes were generated manually and applied to segments of datathat were identified as significant. The iterative process of databeing categorised continued until data saturation. Codes were thencollated and developed into potential themes and in a continuousand iterative process were checked for their relevance to the codeddata and entire data set.

Findings

The findings are presented as five themes, supported byexcerpts from the interviews.

Vulnerability

Many of the participants expressed feelings of professionalvulnerability. They reflect on their increasing awareness ofimpending responsibility and identify the connection betweenresponsibility and the professional implications they associatedwith this.

Since I have been in placement the responsibility is terrific and Ithink it’s just that in away you are on you’re own.as a secretaryif youmake a mistake well I would go and correct it. If you makea mistake here [pause] you’re on you’re own and you areresponsible for that error and you will be called into account[pause] and I found that quite scary sometimes (Student NurseJones)

I think the one thing that has impacted on me the most is theamount of knowledge nurses seem to have and the confidencethat they seem to have doing the job, because it is a hugeresponsibility and that in itself can be very overwhelming(Student Nurse Smith)

You can’t just have 3 years training, have your mentor standingright behind you and then suddenly you are let out on your own,I think that is a big responsibility (Focus Group)

The students revealed their feelings of vulnerability, com-pounded by feelings of fear and responsibility. Student Nurse Jonesrevealed feelings of isolation stating ‘on you’re own’ suggestinga burden of responsibility was located on her, leading to increasedfeelings of vulnerability. Pask (2005) elicits nurses’ desire towardsintrinsic value inevitably involves their vulnerability and isa necessary and self-transcending aspect of a nurses’ professionalself. The excerpts revealed the student nurse’s perception of feelingvulnerable in their new role and professionally accountability. Theauthors suggest that nurses who see intrinsic value are shown to bevulnerable to self-sacrifice in their inclination to work for the goodof their patients, at the expense of themselves. Yet an ability to puttheir own needs second to patients in this way remains a necessaryaspect of a nurse’s professional self, which requires nurture andsupport through nurse education (Pask, 2005).

Symbolic representation

The student’s perceptions of the symbolism of nursing wereexpressed clearly. They articulated the broader perspectives ofbeing a nurse, embracing nursing as a ‘way of life’, which impactson their social being in conjunction with the professionalaccountability.

You couldn’t just say when you left the building you are nota nurse. You are a nurse. That’s it. And until you choose to leavethe profession and even if you do leave the profession I thinkyou are under a moral obligation if you can help someone andyou know you have the skills to do so safely.once you are

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a nurse. they see you as a nurse rather than as a person(Student Nurse Jones)

You do have to think about your registration and that you area responsible professional person and you have to think aboutyour actions when you are outside the work (Student NurseSmith)

I feel people ask you a lot more questions if they have a personalproblem, the nurse in the family is the first to have the phonecall and I know it has changed my family a lot and I have hadnumerous calls.I would say you never stop being a nurse(Student Nurse Brown)

These excerpts reveal feelings that appear to have a significantvalue for the participants, with an acceptance that their role asa nurse is a permanent identity, both within clinical practice and inthe social context. Wenger (1998) suggests that learning cannot bedesigned and that it ultimately belongs to the realm of experienceand practice. Central to social learning theory are the concepts ofknowledge, knowledge construction, meaning, interpretation andbelonging with situated learning being based on our socially con-structed environment and related to meaning which is culturallyand professionally group specific (Kolb, 1984). Student NurseBrown reveals the change in her social status, as ‘the nurse in thefamily’, being regarded as the symbol of knowledge. Belonging inthe social world involves engagement, imagination and alignmentand situated learning involves a process of engagement ina community of practice (Lave and Wenger, 1991). All three of theparticipants reveal the implications of being a nurse that havearisen, paradoxically, from losing a personal identity but gaininga symbolic identity of ‘a nurse’. The social alignment within theprofession of nursing is clearly revealed by Student Nurse Jones‘they see you as a nurse rather than as a person’.

Role-modelling

The purpose of observation in clinical practice has afforded thestudent nurses an opportunity to learn from others mistakes, andfrom which these participants can clearly apportion blame for theinappropriate nursing actions. However, they also identify positiverole modelling, demonstrating depth of autonomy and internalstandard setting.

When I observed other members of staff and I see them doingsomething that I wouldn’t do.I suppose if you looked at it froma professional point of view it would be incorrect. I think it’sprobably a negative way of looking at it but I would definitelysay it has improved my professionalism (Student Nurse Brown)

you see nurses.and would expect them to be professional orthey have a professional title which says they are professionalsand yet how they go about their business isn’t necessarily inaccordance with what you have been led to believe profes-sionals should be, following guidelines and how we should carefor patients some of the things that occurred in that area, I didn’tthink were very professional.

It was my first placement and I was quite taken aback by what Ilistened to and what I saw so, well, it never put me off I justknew that wasn’t how I was going to be (Student Nurse James)

I can see good practice and bad practice and can recognise thatquite a bit now so my view has changed in an individual view-.that I am recognising that everybody is not the same (StudentNurse Smith)

The student nurses express self perceptions of personal andclinical empowerment, through their ability to make judgements

about others whom they have observed in clinical practice. Banduraand McDonald’s (1963) theories of value change argue that theobservation of influential role models, especially when they appearsuccessful, is a powerful mechanism to facilitate the evolution ofpersonal values. It appears that the student nurses have alreadydeveloped a level of autonomy and decision making ability abouttheir own personal provision of care. The expression of personalconcerns regarding registered nurses observed in the clinical envi-ronment is powerful and revealing, suggesting that bothpositive andnegative role models influence the student nurses professionaldevelopment. Evidence fromcurrent literature suggests theattitudesand values that student nurses develop and adopt within clinicalpractice are fostered and nurtured by nurse educators to whom thestudents are exposed to throughout their nursingprogramme (Haighand Johnson, 2007). Additionally, Davey (2002) argues that disillu-sioned nurses may provide a toxic mentoring relationship tostudents, thereby negating any enthusiasm for nursing, butconversely, Student Nurse James has used her experiences of nega-tive role modelling to positively inform her own practice.

Discontent

The perceived lack of professional status from both patients andassociates was emphasised as frustrating to the participants. Theirdiscourse reveals an internal frustration influenced by externalfactors including family members, public opinions and professionalstatus.

It’s hard to say if there is an actual professional identity.as Idon’t think the general public think of us as professionals. Myother half does not think of me as a nearly qualified professionalas much as I am saying, look I am going to be accountable andwhatever I write down could be taken to a Court of Law I don’tthink even [he] understands what we have been through for 3years and this is what we are capable of doing (Focus Group)

The fact that we are a profession and that we work very hard toachieve it and it’s not just done and dusted in nurse training, it’san ongoing process. So, if it’s an ongoing process, I think weshould be recognised for those things that you do in the futureand possibly rewarded in some way (Student Nurse Smith)

People see you as a carer rather than a professional person..Ifeel quite, at the moment I am coming to the end of the 3 years,quite held back and it’s quite frustrating as you do understandwhat your roles are. Some people might not call nursinga profession because it is a caring job (Student Nurse Brown)

Feelings of frustration at the lack of a professional status oridentity were evidenced both through the student nurses’ ownperceptions but also significantly, through actual examples ofother’s behaviours. Stewart (2005) argues that the social context ofnursing has been detrimentally affected by the media’s portrayal ofnurses. Student Nurse Brown identified the dichotomy betweencaring and professionalism, a view shared by the focus group.Moreover, Buresh and Gordon (2000) argue that despite nursesbeing held in high regard, the public are not fully aware of thenurse’s role. Although these student nurses had recognised theirown perceptions of professionalism, there was clearly a frustrationand recognition that these views were not always shared by thegeneral public.

Professional development

From a personal perspective the participants revealed aspects oftheir transformation in beliefs and practices that have evolved

J. Keeling, J. Templeman / Nurse Education in Practice 13 (2013) 18e22 21

during their nurse training program. The analysis revealed thisexpression.

I am in a position to be more critical because I feel a little bitmore confident in myself.well, a lot more confident thanwhenI first started and I can see how individuals develop themselves.A lot of people when they first got the ethics and the researchthey didn’t particularly like those topics, I can see the relevanceof that in nursing because of the way that nursing is going(Student Nurse Smith)

It is completely different to what I thought it was going to bewhen I started training. I don’t think I really fully understoodwhat was going to be expected of me as a student nurse. I thinkyou come into it with a different perception towhat it actually isfrom being a care assistant. I was also a dental nurse previouslyto that and I thought nursing was something different to what itis. Now, 3 years on I feel much more able to do the job (FocusGroup)

I think it was my impression the role of the Doctors’ handmaiden and didn’t realise howmuch decisions you have tomakeas a nurse but that is good as I like the diversity of it, the day today but quite like it on the ward especially in August time withnew Doctors when you can say well you need, this, this,this.but that is your experience and I think that is good thatnurses are doing that now (Focus Group)

These excerpts reveal the transition experienced by the studentnurses from having aminimal knowledge of nursing and associatedaspects to a professional development and awareness of manyprofessional issues. Within the literature, formal knowledge ispertinent to the central characteristic of professionalization (Dzur,2008). Student nurse Smith identifies a connection betweentheory and clinical practice, and the positive impact on her selfconfidence. The students talk of having identified a linkage to someof the theoretical work entailed in their education program and itsrelevance to clinical practice. They have also acknowledged anddescribed aspects of their own personal journey towards their ownperceptions of professionalism in nursing.

Discussion

Empirical, aesthetic, ethical and personal knowledge is acquiredwithin nursing, in addition to traditional, anecdotal, role model andmentorship knowledge (Strout, 2012). Additionally, Martin et al.(2003) argues that the influences of gender, culture and ethnicbackground are important aspects and how these issues are con-structed by student nurses, are important contributors to thestudent nurse’s own personal professional development andidentity. It is evident that the student nurses in this study experi-enced a degree of frustration at the disparity between how theywere perceived by society in terms of being ‘caring’ and the lack ofaccredited professionalism, as the symbolism of nursing asa ‘caring’ profession appears to undermine the attribution ofprofessionalism to this role. This distinction also affected thestudent nurse’s personal identity, as their identity evolved from anindividual to a more generic identity of a ‘nurse’, impacting on boththe student nurse and her family.

According to Wenger (1998), a community of practice definesitself along the three dimensions of joint enterprise, mutualengagement and shared repertoire. Members of the community ofpractice are involved in a set of relationships over time and developaround some particular area of knowledge and activity, affordingmembers a sense of joint enterprise and identity (Lave andWenger,1991; Wenger, 1998). Rather than viewing learning as the acquisi-tion of certain forms of knowledge, Lave andWenger (1991) place it

in social relationships or situations of co-participation. The partic-ipants in this study positively engaged within a community ofpractice, and revealed the impact of this on their own practice,demonstrating autonomy in their beliefs, understanding of theirrole and perceptions of professionalism following their experientiallearning within the work place. The observed behaviours of regis-tered nurses appeared to be significant to the learner in thedevelopment of their own sense of professional identity, usingpositive and negative role models constructively. These final yearstudent nurses encompass the matrix of the nursing community ofpractice, seeking legitimate peripheral participation in an everchanging and complex healthcare delivery system.

Historically professionalism in nursing has also been congruentwith the ‘nurse’s uniform’, yet this was a notable absence fromthese participants’ dialogue. This absence raises questionsregarding the changing face of professionalism, and lends itself toseeking further knowledge on this issue.

Limitations of study

It is recognised that due to the small number of participantsinvolved, this study has limited applicability. Furthermore, that asthe sample consisted only of females; the data generated may begender-biased.

Conclusion

Professionalism in nursing may be considered as an evolvingconcept, in what appears to be a challenging dichotomy of viewsbetween professionalism per se and the concept of a nurse beinga carer. New and useful information is revealed in the findings ofthis study that can assist in recognising the contemporaneousissues of professionalism in nursing and some of the challenges tothis notion. The findings concurred with the innate personal valuesconsidered to be vital for nursing, also identified by FlorenceNightingale over a hundred years previously. Those personal valuesincluded altruism, caring and honesty. Historically professionalismin nursing has also been congruent with the ‘nurse’s uniform’.However, of great interest in this research study was the absence ofthe uniform being voiced as a perception or interpretation of thestudent nurses own perception of their identity within theprofessional domain. This absence raises many questions regardinga possible changing face of professionalism, and lends itself toseeking further knowledge. Findings from this study would benefitfrom further exploratory research as it may be interesting tocompare the professional identity in nursing to allied professions inhealthcare.

Acknowledgements

The authors would like to express their gratitude to all thestudents for their valuable contribution towards adding to theexisting body of knowledge relevant to the topic. We also wish tothank Karen Holland for her advice with regard to writing thearticle.

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