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The Concept of Professionalism: Professional Work, Professional Practice and Learning

• First Online: 01 January 2014

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• Julia Evetts Ph.D. 4  

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For a long time, the sociological analysis of professional work has differentiated professionalism as a special means of organizing work and controlling workers and in contrast to the hierarchical, bureaucratic and managerial controls of industrial and commercial organizations. But professional work is changing and being changed as increasingly professionals (such as doctors, nurses, teachers, social workers) now work in employing organizations; lawyers and accountants in large professional service firms (PSFs) and sometimes in international and commercial organizations; pharmacists in national (retailing) companies; and engineers, journalists, performing artists, the armed forces and police find occupational control of their work and discretionary decision-making increasingly difficult to sustain.

The paper begins with a section on defining the field of professional work, professional practice and its learning. The paper continues with a second section on the concept of professionalism, its history and current developments. The third section of the paper considers the changes, challenges and opportunities of the practice of professional work within employing organizations. The fourth section of the paper identifies some of the important contributions made by researchers on professional work to public policy developments, assessment and evaluation.

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Evetts, J. (2014). The Concept of Professionalism: Professional Work, Professional Practice and Learning. In: Billett, S., Harteis, C., Gruber, H. (eds) International Handbook of Research in Professional and Practice-based Learning. Springer International Handbooks of Education. Springer, Dordrecht. https://doi.org/10.1007/978-94-017-8902-8_2

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• J Med Educ Curric Dev
• v.8; Jan-Dec 2021

Teaching Professionalism: Comparing Written and Video Case-Studies

Christina wong.

1 Medical Laboratory Technologist, MEd (HSE), University of Alberta, Faculty of Education, Edmonton, AB, Canada

2 Associate Professor of Laboratory Medicine and Pathology, MSc (IMIN) University of Alberta, Faculty of Medicine and Dentistry, Edmonton, AB, Canada

Professionalism is a difficult concept to teach to healthcare professionals. Case-studies in written and video format have demonstrated to be effective teaching tools to improve a student’s knowledge, but little is known about their impact on student behaviour. The purpose of this research study was to investigate and compare the impact of the 2 teaching tools on a student’s behaviour during a simulation.

A 3-stage mixed method study was conducted with senior Medical Laboratory Science (MLS) undergraduate students. All students were randomly divided into a Written Group or Video Group to attend a mandatory professionalism workshop focused on bullying and gossip. Twenty-six students completed the voluntary assignment and 21 students participated in the voluntary group simulations. Thematic analysis was performed on the assignments and simulation. Frequencies of themes were calculated. A Group Simulation Assessment Rubric was used to score simulations and calculate an adjusted group performance average (AGPA).

The assignment demonstrates that students from both groups obtained a theoretical understanding of how to resolve gossip and bullying. From the Written Group and Video Group, 70%/18% of students discouraged/resolved gossiping and 80%/63% prevented bullying. The mean AGPA for the Written Group and Video Group was 5.4 and 4.9 respectively ( t (5)  = 1.5, P  = .2).

Discussion:

Students can successfully apply knowledge they have gained in written and video case-studies focused on the professionalism topics of bullying and gossip to a hypothetical situation. However, a discrepancy in their actions was found during the simulations. The data from the study suggests that written and video case-studies do not have different impacts on a student’s behaviour.

Introduction

Professionalism is the judicious use of communication, technical, and clinical reasoning skills, knowledge, emotions, values, ethics and reflection on one’s attitude, character and practice. 1 , 2 Professionalism guides health care providers in delivery of high quality patient care and maintaining a positive work environment. 3 - 5 Unfortunately, high stress situations can cause professionalism lapses that lead to decreased workplace psychological safety. Support, guidance and training should begin early in the education of health care professionals.

Professionalism is most often learned through the hidden curriculum 6 and is a multidimensional construct making it difficult for educators to accurately assess. 7 While traditional assessment approaches encourage students to memorize material, which results in poor performance outcomes and reduced knowledge retention, case-based learning (CBL) narrates real-life situations to encourage student engagement and practice of problem-solving skills. 8 CBL is a well-documented approach to teach professionalism to health care students. 9 - 12 Both written and video case-studies have been used to increase students’ understanding and ability to link psychosocial and humanistic variables to professionalism as well as use reflective discussions to improve critical thinking skills. 10 , 11 However, there is a lack of data that demonstrates if either written or video case-study can effectively impact a student’s professional behaviour in a simulated clinical setting.

Based on current studies, students have reported that case studies presented in a written format can provide them a sense of role-playing, 13 promotes reflection 14 and improves their critical thinking. 15 Nadeau et al.’s 9 study suggests that the written case-studies not only provides a fun way to learn and is interesting to students but can successfully teach students multiple professional competencies. Similarly, video case-studies have demonstrated increased student knowledge in different professional competencies. Through videos, students can recognize how social and anthropological influences affect professional practice and have the opportunity to identify with characters in the film – which creates a more impactful learning experience. 11 , 12 Students have self-reported that video case-studies have helped improve their critical thinking, moral reasoning skills and reflection. 11 , 16 In addition, students have found that material presented in video format is also interesting, entertaining and engaging. 16

Our study aimed to investigate if teaching professionalism to Medical Laboratory Science (MLS) students in an undergraduate bachelor’s program at the University of Alberta through written or video case-studies impacted a student’s behaviour and if the 2 groups behaved differently.

Material and Methods

Study design.

A mixed study comprising 3 stages was conducted and is summarized in Figure 1 .

Summary of study timeline and design.

In Stage 1, MLS students were randomly divided into 2 groups for participation in a 1-hour mandatory professionalism case-study based workshop that used the same scenario but was presented in either a written or video format. Identical case-studies focused on gossip, respect, empathy, communication skills, teamwork, bullying and accountability. One group was presented the case-studies as a video and the other group received them in writing.

The case-study involved many health care professionals working in a busy emergency room. The story began with, several residents socializing when 1 resident began to gossip about their supervisor’s past. Each resident responded to the gossip differently. In a second scene, a resident displayed bullying behaviour towards a colleague during a high stress situation. In the final scene, the resident and colleague worked through their conflict and displayed empathy and compassion for each other. Case study discussion questions explored workplace gossip, conflict resolution, teamwork and responding to bullying and gossip. Students were encouraged to reflect on their skills and how to respond to similar situations in the future. Details of the workshop learning objectives can be found in Appendix A .

In Stage 2 the students were given an optional assignment to explore their professionalism knowledge by responding to a hypothetical workplace scenario.

In Stage 3 students from the same workshop cohort voluntarily participated in group simulations. The simulation scenario presented an opportunity to practice the professional competencies taught in the workshops and was used to assess a student’s professional behaviour and gather quantitative data.

Participants

The study included 28 Bachelor of Science students in the MLS Program at the University of Alberta. Students were in their senior year of the program and had completed all clinical practicums, ensuring exposure to health care workplace experiences.

Data collection and analysis

A fictional narrative that focused on the topics of accountability, conflict management, gossip and bullying placed the student as a working Medical Laboratory Technologist (MLT) who had made a major error. While trying to correct the mistake, an innocent co-worker (the victim) publicly received the blame from a supervisor (the bully). Two bystander MLTs overheard the supervisor’s complaints and began gossiping about the coworker.

Students were required to reflect on the narrative and develop a plan-of-action to address the key professional issues. Answers were de-identified and coded by a third-party member. Thematic analysis was performed to provide insight on how students planned to resolve a professional issue and apply their knowledge. Two researchers analysed the assignments together to agree on common themes found; subthemes were determined by 1 researcher. The results were coded into Microsoft Office Excel 2013 to generate frequency data.

Each simulation was comprised of 3 parts: a prebrief, simulation scenario and facilitated debrief. The simulation scenario focused on workplace conflict management, gossiping and bullying. All simulation scenarios and debriefs were video recorded for subsequent analysis by 2 researchers.

Simulation rubric

Students’ professional behaviour were graded on a rubric ( Appendix B ) based on demonstration of: effective communication skills; teamwork skills; ability to respect others’ dignity, values and/or beliefs; desire to discourage workplace gossip; and ability to prevent and/or resolve workplace bullying. One point per student was noted each time an attitude or skill from the rubric was exhibited; allowing for calculation of the percentage of students displaying that competency. Individual student scores were not obtained in order to reduce student anxiety associated with performance within the simulation, instead scores were collected for the group. The final score was tallied based on the entire group. Final scores were adjusted for varying group size by calculating the adjusted group performance average (AGPA). The AGPA was determined by dividing the total group score by the number of participants. Mean AGPA was calculated and an independent test performed to determine statistical significance.

Noteworthy aspects of the simulations were documented, and a thematic analysis was performed on the simulation observations to detect trends and patterns amongst the students’ behaviour and practice.

Simulation debrief

Immediately after each simulation scenario, the group debriefed the simulation in a focus group format. During the simulation debrief, the simulation facilitator asked students predetermined opened-ended questions to further investigate the rationality behind their choice of actions during the simulation and the impact of each teaching method. Student answers were recorded by the simulation facilitator and by video and thematic analysis was performed.

Ethic approval and participant consent

Ethical approval for this research has been granted from the University of Alberta Research Ethics Office for research involving human participants. (December 18, 2018, Pro00085272). Written informed consent forms were signed by participants of the study.

Assignments

Ninety-three percent of students completed the Stage 2 optional assignment (N = 26). The students’ responses to the narrative’s professional issues were categorized into the following major themes: fixing gossip, approaching an individual about the gossip, apologizing to the victim, showing empathy, being accountable, telling the supervisor (bully) what to do, influencing others’ opinions and quality improvement. Two of the themes were further divided into subthemes. Occurrence of each theme and subtheme is summarized in Table 1 .

Key themes and subthemes found in assignments and number of students displaying each theme in the written and video case-study group.

Fixing the gossip

Hundred percent (n = 13) of students from the Written group and 77% (n = 10) of the students from the Video group displayed interest in fixing the gossip that had occurred in the assignment narrative. The 2 most popular methods described by students was to directly tell the supervisor the truth and to point out the inappropriateness to the gossips.

‘I would try to stop the negative gossip about [the victim]. I would explain the incident to the other coworkers, so they know what truly happened, and kindly remind them to gather all facts before gossiping about an individual.’

Being accountable

All students identified that it was important to own up to the error and be accountable to the consequences of their actions.

‘[I would] proceed to the supervisor’s office and explain how it was my mistake first. . .I would say that if there were any repercussions to this incident that I would take full blame and that it wasn’t [the victim’s] fault.’

In addition, 92% (n = 12) of students from both groups indicated that it was important to them to apologize to the victim for taking the blame of the error they made in the narrative.

‘I would apologize to [the victim] as it was my fault for dragging him into this mess.’

Demonstrating empathy

Seventy-eight percent (n = 10) of the Written group and 84% (n = 11) of the Video group demonstrated empathy by indicating that they were concerned for the victim’s emotional state and would provide them support.

‘I would ask [the victim] how he was doing. . .and see if there was anything [they] could do to help regain [his] emotional stability.’

Only 2 students from each workshop group demonstrated empathy towards the bully.

‘I would ask how [the bully’s] day is going and offer her support if needed.’

Providing critique/feedback

Forty-six percent (n = 6) of the Written group and 23% (n = 3) of the Video group indicated they would directly confront the bully and express their concerns.

‘I would then try to politely suggest to the [bully] that the way she handled things caused a bit of a disruption in the lab. . .’

In addition, students planned to provide the bully with advice on how they should behave and how they could negate the negative consequences of their actions.

‘I would suggest that [the supervisor / bully] apologize to [the victim] as well. It might be also be useful to offer the [bully] advice for how to handle mistakes in the future, such as approaching the individual with more of a gentle tone and playing the role of a mentor. Additionally, in future situations, she should ask questions before assuming who made the mistake to begin with.’

However, 1 student realized that approaching the bully, who was a supervisor with more experience and knowledge, could be an imitating task. Therefore, they would only provide the supervisor with advice under the right circumstances which allowed the student to feel safe to share their concerns.

‘I’m not sure if I would bring up that I thought her behaviour was unprofessional. I think that part would depend on my relationship with the supervisor and previous experience, and the general work environment in the lab.’

Influencing an individual’s opinion

Sixty-two percent (n = 8) of the Written Group and 23% (n = 3) of students from the Video Group were uncomfortable critiquing the bully’s actions. These students planned on a more passive solution to address the bullying. By admitting the truth of what had happened and commenting on the victim’s current emotional state to the bully, students hoped that the bully’s opinion of the victim would change for the better and feel compelled to apologize to the victim after the conversation.

‘After I explain the situation, I would tell the supervisor that [the victim] was quite upset. . . I would do this in hope that the supervisor would apologize to [the victim] about the interaction.’

Quality improvement

Several students from both groups (46%, n = 12) mentioned they would complete correcting the laboratory error and help develop a contingency plan to prevent their mistake from occurring again.

‘I would try to have a constructive conversation about how to avoid this situation in the future. . .This would turn a difficult situation into a learning opportunity.’

Another suggestion made by students was to improve the victim’s competency, through additional training and resources in order to improve the victim’s reputation and discourage workplace gossiping.

Student behaviour demonstrated in the simulation

Ten students from the Written and 11 from the Video Group (N = 21) voluntarily participated in the simulations. A total of 9 simulations were completed. The average length of each simulation scenario was 11 minutes (excluding the prebrief and debrief).

All students demonstrated the ability to effectively and respectfully communicate with other simulation participants and actors. In addition, all students displayed respect for other’s dignity, values and beliefs throughout the simulation scenario.

Seventy percent (n = 7) of students from the Written Group successfully demonstrated the ability to discourage and/or resolve gossiping, while only 18% (n = 2) of students from the Video Group could. Students who attempted to discourage the bully from gossiping tried to calm the bully’s emotions with statements such as ‘it [had] been a stressful day/long day/busy day’, that ‘[the victim] deserves a breather’ and that ‘accidents happen’. Students also indirectly encouraged empathy for the victim by suggesting that the ‘[victim was] maybe just tired’, ‘maybe had a bad day’, or that ‘these things happen’; a passive method to discourage bullying.

When challenged with bullying, most students from both the Written and Video Group attempted to resolve and/or prevent further bullying from occurring (80% and 63% respectively). Even when the victim expressed reluctance and fear, students shared their concerns about the bully’s treatment towards the victim and reassured the victim that the bullying must be addressed. To support the victim, students mentioned that they were willing to accompany the victim as a witness if they wanted to confront the bully or another supervisor.

Overall simulation performance mark

Based on the rubric results ( Table 2 ), the AGPA was 5.4 for the Written Group and 4.9 for the Video Group ( t (5)  = 1.5, P  = .2), but the Null hypothesis was rejected. Therefore, the results suggest that there was no significant difference between the behaviours demonstrated by the students from the Written and Video Group in the simulation.

Total group simulation points and adjusted group performance average.

Professional issues in the simulation observed by students

The students recognized: poor coworker relationships, poor work environment, and the lack of professional laboratory skills. In addition, students noticed the abnormal behaviours of the 2 actors by describing one as ‘harsh’ and ‘condescending’ and the other as ‘sheepish’, ‘nervous’, ‘stressed’, ‘very uncomfortable in the situation’ and ‘abused by [the bully].’ Only a few students used the labels gossip and bullying.

The student’s initial thoughts vs reality

In response to the simulation’s professional issues of gossip and bullying, some students initially thought of confronting the bully respectfully to ‘think of solutions’ or to ‘speak up about [their] inappropriate behaviour’. However, many students were unable to follow through with their plan to do so because of 2 main reasons. Firstly, students did not confront the bully because their plan was to talk to the bully privately later, this opportunity was not available for students due to the design of the simulation scenario. Secondly, students did not confront the bully during the simulation because the students felt too uncomfortable critiquing a superior due to power-differentials.

A few students initially planned to avoid the professional issues by not engaging in the coworker’s interaction and ignoring the situation by occupying themselves with other activities but eventually did act.

Influencers on student behaviour in the simulations

When asked if the workshops had any impact on the student’s behaviour and actions in the simulations, students from both groups claimed that they gained theoretical knowledge on the various professionalism topics covered during the workshop and a better understanding on how they should respond to issues. Student comments on the teaching methods are summarized in Table 3 .

Summary of student comments on written and video case-studies.

Further inquiry discovered that students from both groups also pulled from experiences external to the workshops. Students credited some of their behaviour and actions in the simulations to theory and practical experiences they encountered from the following sources: university level courses about interprofessional relationships, learning modules and practical courses outside of school, life experiences gained from jobs and their clinical practical training, their personality and personal values and beliefs.

Student answers to debrief questions

Students believed the focus of the simulation was: workplace conflict and management, professionalism or conflict resolution. Students reported that they most enjoyed the thought provoking and informative debrief and receiving feedback from the actors on the student’s actions, behaviour and interactions which was valuable to their learning. In addition, students enjoyed having the opportunity to practice interpersonal skills in the simulation scenario.

Learning outcomes uncovered from the assignment data

The results from the assignment provided evidence that both the written and videos case studies successfully delivered the didactic content since all the solutions that students explored in their assignments correlated closely to the methods suggested to them during the workshop. Ways to prevent and/or deal with gossip and bullying presented during the workshop is displayed in Table 4 .

Methods to prevent and/or deal with gossip and bullying presented in the workshop.

All the solutions that students explored in their assignments correlated closely to the methods suggested to them during the workshops. The results from the assignment provided evidence that both the written and videos case studies successfully delivered the didactic content.

Based on the assignments, students demonstrated an understanding of accountability, honesty and responsibility for mistakes. To prevent future gossiping and bullying, students claimed that they would either directly confront the gossipers/bully or utilize a more passive solution by trying to sway the opinions and feelings of the bully and gossipers. These responses parallel the findings of van Heugten 17 who proposed that there are 3 types of bystanders in scenarios of bullying: the follower of the bully, the defender of the victim and the silent or passive bystander. Results from the assignment also demonstrated that many students had the ability to practice empathy for the victim. This finding further supports the observation that the students who participated in the study are defending and passive bystanders based on the findings of Gini et al 18 who suggests that these types of bystanders tend to demonstrate high levels of empathy.

Assignment results versus simulation behaviour

The simulations demonstrated the students’ ability to identify behaviours of bullying and gossiping. The ability to feel empathy, console and support the victim seen among students during the simulation paralleled the actions described by students in the assignments. When supporting the victim during the simulation, students would encourage the victim to approach the bully, report the incidents to Human Resources or keep a record of the events as evidence. The actions the students demonstrated and advice they gave to the victim followed the best practice outlined by the Canadian Center for Occupational Health and Safety 19 and the Canadian Society of Medical Laboratory Science (CSMLS). 20

However, there were discrepancies between students’ interaction with the bully in the simulation versus their hypothetical actions from the assignment. In the assignment, most students stated they would confront the bully/gossiper directly. Likewise, during simulation debrief, some students shared they wanted to confront the bully; however, no students did. Instead, most students attempted to influence the bully’s perception and feelings towards the victim through empathetic statements about the victim. Some students choose to ignore and avoid the conflict. Students admitted that they were unable to provide feedback to the bully because they felt uncomfortable criticizing a superior. Unfortunately, workplace bullying is often committed by superiors 21 and there are numerous known barriers that prevent victims and bystanders from standing up. Individuals may fear that nothing would change if they spoke up or that adverse outcomes could occur to them. 22 This same fear was observed in students who mentioned that they were fearful that ‘[the bully] would trash talk about [them] too’.

Performance difference between the written and video groups

Based on the results of the simulation rubric, students from both groups were able to demonstrate effective communication and teamwork skills and were able to respect other’s dignity, value and beliefs. Although most students from both workshop groups demonstrated the potential to prevent future bullying, there was a difference seen between the groups relating to gossip. Only 18% of students from the Video group were able to behave appropriately during the simulation and defend the victim, as opposed to 70% of students in the Written Group. Even though the mean AGPA between the 2 groups is not statistically significant, the data still may suggest that students from the Written group demonstrated a higher level of professional competence in gossiping situations. There is literature with student self-reported evidence that learning was better with videos; 11 , 16 , 23 , 24 however, our study supports the findings of Pardi et al 25 who used an assessment tool to demonstrate that student learning was greater with text based resources compared to videos.

Impact of written and video case-study teaching methods on student behaviour and other influencers

Although the simulation rubric scores suggest the Written Case-Studies had a more positive impact on student behaviour, this information must be reviewed carefully by considering outside sources of knowledge and experience. During the debrief, some students from both groups self-reported that the workshops allowed them to expand their theoretical understanding of solutions available for resolution of professional issues such as gossiping and bullying. However, most students believed that their performance during the simulation was also influenced by other factors: previous customer-based jobs, university courses, workshops, and online modules provided them with opportunities to practice interpersonal and conflict resolution skills. Additionally, some students believed that their values and belief systems influenced their actions. Thornberg et al 26 suggested that a person’s motivation to intervene on scenarios of bullying depend on their moral evaluation of bullying and belief that they are morally responsible to act. Finally, a small number of simulation participants from both workshop groups, admitted they had forgotten most of the case-studies. However, these simulations occurred several weeks after the workshops and these groups relied more heavily on other sources of information to demonstrate professional skills and attitudes during the simulation.

Limitations

This study has several limitations. First, the study design did not allow for direct comparison of a student’s assignment data to their simulation performance; leading to only generalized conclusions about the groups. Second, other sources of education and knowledge outside of the study affected student performance in the simulations which could lead to a misrepresentation of how written and video case-studies impact student behaviour. Third, students admitted to learning loss. Fourth, this study only investigated the impact of written and video-case studies on communication, teamwork, gossiping, bullying and respect. It is uncertain if the 2 teaching tools would have different impacts on other types of professional student behaviour. Finally, only students from the senior year of 2018/2019 were included in this study. Further studies will need to be conducted to test the validity of the results provided from this research.

Conclusions

Written and video case-studies can be used to teach MLS students the didactic aspects of professional competences relating to conflict management, gossiping and bullying. Students can successfully apply didactic knowledge to develop a hypothetical defender resolution to bullying and gossiping, they are able to articulate what they ‘should’ do; however, in a high fidelity gossip and bullying simulation the majority of video students reacted as bystanders to the gossiping, it is harder to ‘do’ the right thing. Students’ history and memory loss may have affected the simulation outcome. Our results suggest no statistical difference in students’ demonstration of professional skills and attitudes between the written and video case based learning; however, there are interesting nuances as the outcome indicate students from the written CBL appear to be more able to defend bullying and gossip.

Acknowledgments

Acknowledgements are directed to the individuals who helped test the simulation (Mallory Benders, Via Alcantara), simulation actors (Chris Ward, Sharon Schuurmans, Rosemarie Chunningham, Amanda VanSpronsen and Kassandra Sharp) and the help of Sharla King and Valentin Villatoro for their help and guidance in the study.

Professionalism Workshop Learning Objectives

• Define the term gossip.
• Define the difference between negative and positive gossip.
• Relationships
• Work environment
• Discuss the importance of respecting the dignity, values and beliefs of others.
• Define empathy.
• Discuss how an individual can practice empathy towards a patient, college, or client.
• Compare and contrast the characteristics of effective and poor communication skills.
• Discuss obstacles that hinder effective communication.
• Define teamwork.
• Discuss characteristics of an effective team.
• Discuss the signs of workplace bullying.
• Discuss strategies to prevent and/or resolve bullying in the workplace.
• Discuss the importance of professional accountability.

Group simulation assessment rubric

Place a tally for each participant in the column that is consistent with your observation of them. For every skill/behaviour demonstrated/the group receives 1 point. For example, if 3 out of 4 participants demonstrate the skill, the group would have 3 points for that particular skill. A total of the points should appear at the bottom of the page with an interpretation of the scores provided for the purposes of the debriefing. The possible number of points will change with the number of individuals participating. Comments pertaining to specific skills/ behaviours can be provided on the right-hand side column.

Names of the participants will not be collected but the following details should be included:

Number of Participants: _____________ Workshop Participants Attended: ______________

Authors’ note: All views expressed in this research paper are those of the authors and not reflect the view of the institutions they are from.

Author contributions: CW designed the study, developed the teaching materials for Stage 1 and implemented Stage 2. LP assisted CW with the data collection and data analysis. Both LP and CW drafted the final manuscript and edited it. All authors approve of the version of this manuscript to be published.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

• Open access
• Published: 26 April 2024

Factors influencing the development of nursing professionalism: a descriptive qualitative study

• Xingyue He 1 ,
• Huili Cao 2 ,
• Linbo Li 1 ,
• Yanming Wu 1 &
• Hui Yang 1 , 3  

BMC Nursing volume  23 , Article number:  283 ( 2024 ) Cite this article

Metrics details

The shortage of nurses threatens the entire healthcare system, and nursing professionalism can improve nurse retention and enhance the quality of care. However, nursing professionalism is dynamic, and the factors influencing its development are not fully understood.

A qualitative descriptive study was conducted. Using maximum variation and purposive sampling, 14 southern and northern China participants were recruited. Semi-structured interviews were conducted from May 2022 to August 2023 in face-to-face conversations in offices in the workplace or via voice calls. The interviews were transcribed verbatim and analyzed via thematic analysis.

Three main themes emerged: (1) nourishment factors: promoting early sprouting; (2) growth factors: the power of self-activation and overcoming challenges; and (3) rootedness factors: stability and upward momentum. Participants described the early acquisition of nursing professionalism as derived from personality traits, family upbringing, and school professional education, promoting the growth of nursing professionalism through self-activation and overcoming challenges, and maintaining the stable and upward development of nursing professionalism through an upward atmosphere and external motivation.

We revealed the dynamic factors that influence the development of nursing professionalism, including “nourishment factors”, “growth factors”, and “rootedness factors”. Our findings provide a foundation for future development of nursing professionalism cultivation strategies. Nursing administrators can guide the development of nurses’ professionalism from many angles according to the stage they are in, and the development of professionalism deserves more attention. In the future, we can no longer consider the development of nursing professionalism solely as the responsibility of individual nurses; the power of families, organizations, and society is indispensable to jointly promoting nursing professionalism among nurses.

Peer Review reports

Introduction

The number of nurses leaving hospitals has been increasing, and the shortage of nurses is a significant problem faced globally [ 1 , 2 ]. According to earlier studies, professionalism improves nurses’ clinical performance [ 3 ] and positively affects their adaptability (Park et al. 2021), reducing nurses’ burnout and turnover rates. Therefore, fostering professionalism in nurses and the factors that influence the development of professionalism are essential to producing effective nurses.

Nurses comprise the largest group of healthcare providers [ 4 ]. Nurses are a vital part of the healthcare system, with 27.9 million caregivers worldwide, according to the World Health Organisation’s Global Status of Nursing Report 2020 [ 5 ]. However, an unbalanced number of nurses and patients, high work pressure, and the fact that nurses face patients’ suffering, grief, and death each day have exacerbated burnout and led to the resignation of many nurses [ 6 ]. The COVID-19 outbreak has further exposed the shortage of nursing staff, especially in low- and middle-income countries where the scarcity of nurses remains acute. The lack of nurses not only has direct negative impacts on patients but also poses a threat to the entire healthcare system.

Nursing professionalism is closely associated with nurse retention and nursing practice [ 7 , 8 , 9 ]. Nursing professionalism is defined as providing individuals care based on the principles of professionalism, caring, and altruism [ 6 ]. As a belief in the profession, nursing professionalism is a systematic view of nursing that represents the practice standards and value orientation nurses utilize [ 10 , 11 ]. According to previous research, nursing professionalism can enhance nurses’ clinical performance and positively impact their adaptability, reducing job burnout and turnover rates [ 6 ]. Furthermore, as nurses are the ones who provide “presence” care, cultivating nursing professionalism among nurses can promote interactions between nurses and patients, further improving the quality of nursing care and patient outcomes and injecting new vitality and hope into the entire healthcare system [ 12 ].

However, nursing professionalism is dynamic, and the cultural context also shapes nursing professionalism to some extent, leading to ambiguity in the factors influencing nursing professionalism. Initially perceived as mere “caregivers,” nurses have transformed into “professional practitioners,” emphasizing the nursing field’s seriousness and distinct professional characteristics [ 13 , 14 ]. Nursing professionalism is also the foundation for developing the nursing profession [ 15 ]. Focusing on the factors influencing the development of nursing professionalism is one of the essential elements in providing an optimal environment for nurses’ professional growth and development in clinical practice [ 16 ]. Although some scales, such as the Hall Professionalism Inventory (HPI) [ 17 ], Miller’s Wheel of Professionalism in Nursing (BIPN) [ 18 ], Hwang’s Nurse Professional Values Scale (NPVS) [ 19 ], and Fantahun’s Nursing Professionalism Questionnaire [ 20 ] have been used to measure factors influencing the awareness, attitudes, and behaviors, they have their limitations. They struggle to encompass professionalism’s multidimensionality and complexity fully, overlook multilayered background factors, are constrained by standardization issues, may not account for individual differences, and often fail to capture dynamic changes over time [ 21 , 22 , 23 ].Compared with quantitative research methods, qualitative research can provide insights into the “unique phenomenology and context of the individual being tested,” which can help the researcher stay close to nurses’ professional lives during the research process and understand the personal, familial, and societal factors that influence nursing professionalism [ 24 ].Additionally, the understanding of nursing professionalism varies across different cultural and social contexts. In Western countries, research on nursing professionalism tends to incorporate professionalism across the entire nursing industry. In contrast, within China, research on professionalism tends to focus more on the individual level, with less attention to the perspectives of groups or the industry [ 25 ]. Therefore, through qualitative research, we can present nursing professionalism in a deeper, more affluent, and more transparent manner. Secondly, it is more authentic to understand the factors influencing nursing professionalism by directly obtaining relevant information from the perspective of nurses through dialogue with research participants as mutual subjects.

Given these considerations, we aim to answer the question of what factors influence the development of nursing professionalism. To provide more targeted strategies and recommendations for optimizing the nursing professional environment, enhancing nurses’ job satisfaction, improving t nursing quality, and contributing sustainably to patients’ and nurses’ health and well-being.

To explore the factors influencing the development of nursing professionalism. By incorporating nurses’ perspectives, we aim to improve our understanding of professionalism as individual, family, and socio-cultural influences. With this knowledge, we can inform strategies for developing nursing professionalism.

Study design

A descriptive qualitative approach was adopted based on naturalistic inquiry [ 26 , 27 ] and analyzed using the thematic analysis method described by Braun and Clarke [ 28 ]. Semi-structured interviews were conducted between May 2022 and August 2023 with nurses in southern and northern China hospitals. Furthermore, the research findings were reported in accordance with the consolidated criteria for reporting qualitative research (COREQ) (Supplementary Material S1 ) [ 29 ].

Participants and settings

We chose hospital nurses as study participants based on considerations of their nursing experience. Firstly, the Chinese government has implemented a policy of accountable holistic care, whereby registered nurses take on the entire cycle of a patient’s physical, mental, and spiritual care [ 30 ]. Secondly, new nurses must undergo two weeks to one month of basic training and a 12–24 month specialty rotation (for most new nurses who graduated before 2016, their training was completed by their departments). During this time, they are under the supervision of a superior nurse for holistic and responsible care [ 31 ].

We used maximum variance purposive sampling to recruit a heterogeneous sample of information-rich key participants [ 32 ]. Participant selection considered variations in role classification, years of experience, and educational levels of Chinese nurses [ 33 ]. The purposive variation allowed the discovery of Chinese nurses’ unique perceptions of nursing professionalism. Inclusion criteria: (1) registered nurses (providing direct services to patients within the unit), nurse managers (directly supervising and guiding the clinical work of registered nurses), nursing department managers (managing nurse managers throughout the hospital), with at least one year of nursing experience; (2) voluntary participation. Exclusion criteria: (1) nurses not working during the hospital’s study period (holidays, maternity leave, or sick leave); (2) refresher nurses.

Data collection

The same researcher conducted each interview to ensure consistency. Before the interviews, the interviewers systematically conducted in-depth theoretical research on relevant studies. The interviewer received guidance from professors with rich experience in qualitative research and undertook practice interviews to improve her interviewing skills. Interviewers encouraged interviewees to talk freely about their perceptions and used an interview guide (Supplementary Material S2 ), which was based on the findings of previous research on the conceptual analysis of nursing professionalism [ 6 ]. The questions were open-ended and general; ample space was left between questions to respond to interviewees’ comments. Semi-structured interviews began with a brief introduction to the topic (e.g., definition and explanation of nursing professionalism). Although the interviewer had an agenda for discussion, this format allowed the interviewee to deviate from this agenda and direct follow-up questions [ 34 ].

All interviews were conducted from May 2022 to August 2023 in face-to-face conversations in offices in the workplace or via voice calls and lasted between 35 and 94 min. Participants were asked to complete the main demographic questionnaire at the end of the interviews. The researcher recorded participants’ expressions, body language, and pauses during the interviews. Memos written by the researcher during the study were also used as analytical material.

Data analysis

For rigorous qualitative sampling and data saturation, Braun et al. [ 35 ] propose that qualitative researchers require a sample appropriate to the research questions and the theoretical aims of the study and that can provide an adequate amount of data to answer the question and analyze the issue entirely. We reached thematic saturation after 14 interviews when no new codes or themes emerged.

A thematic analysis approach was used, following the phases described by Braun and Clarke [ 28 ]. The analysis comprised six stages: (1) immersing in the data; (2) creating initial codes; (3) identifying themes; (4) reviewing; (5) defining and labeling these themes; and (6) finally, composing the analysis report. Two researchers transcribed and analyzed the textual data. In the first stage, the researchers carefully read the interview transcripts to familiarize themselves with the depth and breadth of the content. In the second stage, preliminary codes were generated based on the research questions, initial interpretation of the data, and discussion of initial emerging patterns. At this stage, ensuring that all actual data extracts were coded and organized within each code was necessary. In addition, the following principles were used as guidelines: (1) code for as many potential themes/patterns as possible; (2) code extracts of data inclusively, i.e., preserve small sections of the surrounding data when relevant; and (3) code individual extracts of data for as many different “themes” as appropriate [ 36 ]. In the third phase, the two authors analyzed the initial codes, sorted them into potential themes, and debated their meanings and emerging patterns to reach a consensus. This phase, which refocused the analysis on the broader level of themes rather than that of codes, involved sorting the different codes into potential themes. In the fourth stage, reviewing themes ensures that the data supports the themes and allows an iterative process between different levels of abstraction without losing grounding in the raw data. Finally, defining the “essence” of each theme during the development of the main themes by identifying the “story” as consistent with the data and the research question while ensuring that the themes did not overlap but still fit together in the overall “story” of the data. It told the “story” by writing analytical narratives with illustrative quotes.

This study achieved credibility by selecting a heterogeneous sample, performing member checks, and taking field notes [ 37 ]. This study ensured dependability by verifying the findings with the researchers and participants, appropriately numbering the direct quotations (e.g., DN1), and comparing the results with the previous literature. This study established confirmability via audit trails [ 38 ] and the comprehensive reporting of all research processes. This study ensured transferability by describing the data collection process and seeking a heterogeneous sample.

Fourteen participants were interviewed (the demographic information is presented in Table  1 ). The thematic analysis identifies three major themes (Fig.  1 ). These interconnected topics illuminate the growth process and factors influencing nursing professionalism. The first theme, “nourishment factors: promoting early sprouting,” includes personal traits, family upbringing, and professional education at school and emphasizes early factors influencing nursing professionalism. The second theme, “growth factors: the power of self-activation and overcoming challenges,” included self-activation and overcoming difficulties, focusing on the dual attributes of the growth process of nursing professionalism. The final theme, “rootedness factors: stability and upward momentum,” includes an upward atmosphere and external motivation and explores the factors that maintain the stability and sustainability of nursing professionalism.

Factors influencing the development of nursing professionalism

Nourishment factors: promoting early sprouting

Personal traits.

Personal traits are called “nature” [ 23 ]. There exists a close connection between personal traits and professional behavior. When nurses confront patients’ physiological and emotional needs, innate qualities like kindness and compassion predispose them to be more sensitive to patients’ suffering and needs. Nursing professionalism transcends mere task fulfillment; this inner emotional drive compels nurses to fulfill their duties and engage in nursing work out of a genuine desire and sense of responsibility, practicing the nursing mission nobly. Thus, whether individual traits align with the nursing mission profoundly influences the nursing professionalism of nurses in their work.

“At 32, I became a head nurse, full of vitality and boundless enthusiasm, particularly compassion. I have no idea where this compassion comes from.” (ND1) .

Family upbringing

Education begins in the family, and it is through family education that nurses develop an early sense of professionalism. China has a “family culture” that defines the responsibility of family education. The study participants recalled that in childhood, the “living” nature of family education shaped early professionalism, in which the concepts of “kindness” and “altruism” were acquired through interactions with family members.

“My mother was an early childhood educator, and when she told me fairy tales, it was to promote kindness. Loving others and being selfless, you can’t be a bad person. That’s what altruistic education is about.” (ND1) .

The impact of family education on the acquisition of nursing professionalism extends into adulthood. In Chinese Confucianism and collectivism, family members usually have close emotional ties, and this “strong bond” family structure promotes nurses’ understanding and care for others and their ability to be wiser and more caring in the nursing profession. This strong bonding plays a catalytic role in the emergence of nursing professionalism.

“Some nurses are very adept at expressing care, perhaps because grandparents and parents live together. Since childhood, parents have taught them how to express care.” (N4) .

School professional education

Nursing professionalism is further acquired through professional education in schools. Nursing professional education emphasizes respect and care for patients, adherence to social responsibility, and the integration of traditional Chinese oriental medical thought and Western nursing concepts, internalized into behaviors to form the concept of professional nursing spirit. Participants indicated that the virtues of dedication, responsibility, respect, and caring that permeate school professional education are incorporated by nurses into nursing practice.

“The best nursing comes from the heart. When I was administering injections, I thought about how to alleviate the patient’s pain. Later, I learned that if I entered the needle quickly, it would be less painful, so I often practiced in the operating room.” (N8) .

Other participants also shared that they felt positively guided by professional education at school, constructing a comprehensive nursing philosophy system within the educational context. They realized that nursing is a multidisciplinary field encompassing human care, social responsibility, and ethical values.

“University was my most unforgettable learning experience. I studied 36 courses here, including nursing aesthetics, literature, sociology, ethics, education, etc. I realized that the nursing work we engage in has such rich depth! has become an invaluable treasure in my nursing career.” (ND1) .

Growth factors: the power of self-activation and overcoming challenges

Self-activation, professional benefits.

Professional benefit perception refers to the advantages nurses perceive while engaging in nursing work, acknowledging that their involvement in nursing promotes their holistic personal growth [ 39 ]. Consistent with traditional perspectives, this study finds that nurses generate a sense of professional benefit through both “tangible benefits” and “spiritual benefits,” recognizing the value and significance of nursing work, thereby furthering the development of nursing professionalism.

The dynamic updating achieves “tangible benefits.” Nurses require outstanding professional competence and ongoing continuing education. Participants mentioned that nurses utilize their professional knowledge and clinical experience to save patients’ lives, and exceptional professional competence can rekindle their enthusiasm for work. Continuous and dynamic continuing education, supplementing the latest technology and knowledge in the nursing field, can generate positive professional emotions.

“There’s only one doctor on duty at night, and nurses are the first responders when we encounter emergencies. Even before the doctor arrives in the ward, I must act quickly and urgently. Every time I bring a patient back from the brink of death, I feel excited throughout the night.” (N6) . “Experience is und oubtedly important. I’ve been working for over a decade, and I undergo training every year. No one likes stagnation; we can forge ahead only by continually moving forward.” (NM3) .

Self-worth realization through “spiritual benefits.” Experiencing a sense of value in nursing practice provides nurses with positive reinforcement, enhancing nursing professionalism behavior. Moreover, as healthcare practitioners, the ability of relatives and family members to benefit from it distinguishes Chinese nurses’ unique approach to self-worth realization from nurses in other countries. This unexpected feedback, whether in material or spiritual forms, enables nurses to fulfill their sense of worth.

“Sometimes, friends and relatives ask me about hospitalization-related questions, and I am more than willing to help them.” (N2) . “ I changed my mother’s gastric tube without any complications.” (NM3) .

Professional identity

Nursing professional identity refers to nurses acknowledging their work and affirming their self-worth [ 40 ]. This study defines professional identity as a gradual “process” and a “state.”

One participant mentioned that professional identity is a psychological “process” that nurses develop and confirm their professional roles through their personal experiences. It is closely related to the individual experiences of nurses. Nurses’ gradual recognition of their work prompts them to progress and develop a positive work attitude and professionalism.

“Gradually, I discovered that being a nurse makes me realize my significance, which keeps me moving forward, time and time again.” (ND2) .

Simultaneously, as a “state,” professional identity represents the degree to which nurses identify with the nursing profession. This “state” of professional identity reflects nursing professionalism’s long-term accumulation and formation. It indicates nurses’ long-standing dedication and emotional involvement in nursing, leading to higher professional competence and a sense of responsibility in their work.

“It’s not just a job to make a living; it’s about wholeheartedly identifying with this profession, unleashing one’s potential, which results in better professional conduct.”(N5) .

Overcoming challenges

Balancing roles.

Balancing roles refers to the equilibrium individuals establish between their roles in the nursing profession, family, and organization. Nursing professional roles are inherently multifaceted, and when faced with multiple responsibilities, such as family demands and organizational tasks, nurses must balance these roles. The tension and complexity between personal and organizational roles can potentially inhibit their emotions and professional motivation. However, in China, families are tightly knit, and strong family support can help reconcile this tension.

“To be a good nursing department manager, you need strong family support. The commitment to one’s career and the dedication to family don’t always align. For instance, my job keeps me busy regarding family matters, and I have limited time to care for my children. My parents-in-law take care of them more. I do rounds every Sunday, and the phone never stops ringing, even on my days off. There’s no way around it; this is the role I’ve taken on. Family support allows me to work with peace of mind.” (ND3) .

Adaptation organization

Nurses also face challenges in adapting to organizational systems. These adaptability challenges include rapidly learning new technologies, processes, and the culture of practice in different departments. This “unfamiliarity” impedes the manifestation of nursing professionalism. Participants indicated that the inability to adapt to clinical work quickly affects new graduate nurses’ transition into practice. Initially, there is a “honeymoon period” when becoming a registered nurse, but as actual capabilities do not align with expected performance, the excitement gradually wanes.

“I didn’t know the routine procedures in ophthalmology, I couldn’t measure eye pressure, and I didn’t know how to perform eye injections. I was terrified, which brought various challenges when I started working.” (N4) .

Furthermore, nurses must adapt to the practice culture of “this is how things are done” and “it’s always been done this way” in their workplace. Due to the promotion and title system requirements in Chinese hospitals, nurses with several years of experience often need to rotate through departments such as Intensive Care Unit and emergency for a period. The differences in operations and management between different departments also frustrate these nurses during rotations. However, a certain social prestige is attached, making it challenging for the nurses from the original department to provide direct guidance to the rotating nurses, leading to isolation for the latter in new departments.

“A blank slate regarding the department’s hierarchy, administrative procedures, and so on.” (N3) . “Although there’s a set of procedures, mostly similar, it’s the slight differences that always set me apart.” (N6) .

Rootedness factors: stability and upward momentum

Upward atmosphere, peer support.

Peer support has a positive impact on nursing professionalism. Peers are individuals of the same age group who have formed a connection due to shared experiences in similar socio-cultural environments, with emotional support, mutual assistance, and understanding constituting the core elements of peer support [ 41 ]. Firstly, nursing work often involves highly stressful situations, including heavy workloads, complex patient conditions, and urgent medical cases. Peer support provides emotional support, allowing nurses to find comfort and encouragement when facing stress and difficulties. Secondly, peer support cultivates a positive work atmosphere and team spirit. In a mutually supportive, trusting, and cooperative team, nurses are more likely to experience a sense of accomplishment in their work. They feel they are not isolated but part of a united and collaborative whole. Furthermore, peer support also promotes professional development and knowledge exchange among nurses. In an open and supportive team environment, nurses are more willing to share their experiences and knowledge, learn from each other, and grow.

“The spirit influences the spirit, especially those of my age group who have left a deep impression on me with their admirable qualities in their work. It makes me reflect on my shortcomings in my work and constantly strive to improve and adjust myself.” (N2) .

Intergenerational role models

Inter-generational refers to the relationships between generations [ 42 ]. In nursing practice, inter-generational relationships exist, such as those among nurses of different ages and levels of experience. This study’s inter-generational role models include managerial role models and senior nurses.

Participants believe that managers’ professionalism influences subordinate nurses’ attitudes and performance. The professionalism of managers not only plays a guiding and leadership role in daily work but, more importantly, sets an example, inspiring and encouraging subordinate nurses who are willing to follow and inherit professionalism.

“The department’s leadership has a significant impact on professionalism. When managers have a strong sense of professionalism, the nurses they oversee follow suit. Because leadership represents the management level and higher things, it’s difficult for things at the bottom to go well if it’s not well-controlled at the top.” (N8) .

On the other hand, senior nurses, as role models within the nursing generation, also significantly impact the upward development of professionalism. Senior nurses’ rich experience and professional competence guide new nurses to maintain a rigorous attitude at work. New nurses often draw from and learn senior nurses’ work attitudes and behaviors, catalyzing the elevation of nursing professionalism.

“Senior nurses have a role model effect because new nurses learn from the older ones. If senior nurses work rigorously and new nurses make mistakes or lack a sense of dedication, they will immediately point it out. Over time, you also become more rigorous.” (NM3) .

Perceived professional respect

Societal respect for nursing work creates an atmosphere of care and emphasis on nursing. Nurses within this atmosphere become aware of the importance of nursing work and the profound significance of patient care. They are inclined to exhibit positive nursing professionalism behaviors to meet the expectations of society and the general public.

“The nursing industry has experienced the COVID-19 pandemic, and during the anti-epidemic efforts, nurses were at the forefront, risking their lives to care for patients, receiving acclaim from patients, doctors, and the public.” (N2) .

Professional respect is the manifestation of nurses’ self-acknowledgment of nursing values. It is more than an external acknowledgment; it is an internal affirmation. This mutual respect aligns nurses’ professional and societal worth, catalyzing increased potential and motivation.

External motivation

The stability of nursing professionalism relies on external resources, including the diverse support from nursing managers and the guidance of national healthcare policies. Nursing managers are the frontline leaders who interact with nurses, and their support serves as a management tool and a direct means to sustain nursing professionalism. This multifaceted support encompasses economic incentives such as compensation and reward mechanisms. It extends to non-material motivations such as career advancement opportunities, adequate staffing, modern equipment provision, and fair and equitable treatment form crucial aspects of managerial support. Providing nurses with stable external support creates a space to focus on their professional mission and responsibilities, thus maintaining the stability of nursing professionalism.

“Economic foundation determines the superstructure(spiritual world)).” (NM1) .

Furthermore, the guidance of national healthcare policies serves as a beacon for the development of the nursing profession. At the national level, healthcare policies can regulate the organization and operation of healthcare systems and services, providing nurses with a more stable and favorable working environment. This environment allows nurses to fulfill their professional roles better and maximize their value. The environmental changes brought about by policy guidance offer nurses more favorable professional conditions, effectively promoting the upward development of nursing professionalism.

“Government documents summarize the needs of our society, and nursing will continue to improve in the direction of policy guidance.” (NM3) .

Discussions

This study provides insights for understanding the factors that influence the development of nursing professionalism. We emphasize the themes of early nourishment factors that promote the emergence of nursing professionalism, growth factors associated with self-activation and overcoming challenges, and rootedness factors that stabilize upward, which reveal the dynamic factors that influence the development of nursing professionalism.

We added the early influence of personality traits, family upbringing, and school professional education in the development of nursing professionalism, which is similar to the pathway through which nurses’ foundational values are acquired [ 43 , 44 ]. Building on previous research, we highlight the sequential order of socialization in family education and school professional education, with individual socialization within the family achieving individual socialization before school professional education, emphasizing the importance of intergenerational family transmission on the development of nursing professionalism [ 45 ]. Education commences within the family, a social organization with an educational function. China values its “family culture” and emphasizes defining parental responsibilities for family education based on blood relations. It is a common folk law in China that parents are regarded as the first teachers. In addition, Chinese society promotes Confucianism, which emphasizes instilling the concept of “self-improvement” through “educational living” [ 46 ], as mentioned in our study, the interpersonal interactions such as “altruism” and “caring” arising from family interactions can help nurses establish a deeper emotional connection with their patients. Therefore, future consideration could be given to incorporating programs that foster culture and emotions into professional education. Similar studies are necessary in East Asian countries and other countries with similar cultures to broaden the results of factors influencing nursing professionalism.

The growth of nursing professionalism requires real work scenarios. Our results present the dual factors of nursing professionalism upon entering the workplace. Regarding self-activation factors, we delve into the significance of “professional identity” and, for the first time from the perspective of Chinese collectivism, explain the unique influence of “professional benefits” on nursing professionalism. Our study aligns with previous research, viewing professional identity as an ongoing “process” [ 47 ]. By developing a professional identity, nurses can exhibit “stateful” self-satisfaction and self-motivation, contributing to their job satisfaction and professionalism [ 48 ]. The “professional benefits” involve integrating rational and emotional aspects. The “tangible benefits” of professionalism and technical competence at work lead to positive experiences and emotions among nurses. Nurses voluntarily invest more passion and energy in their work [ 49 ]. In addition, what sets our results apart is how Chinese nurses obtain ‘spiritual benefits,’ which come from the convenience of medical access that their relatives enjoy due to their work. Some studies have shown that “spiritual benefits” are more apparent among nurses aged 40 and above and those with higher professional titles [ 50 ]. The accumulation of clinical experience and the harmonious interpersonal relationships achieved through medical collaboration can help family members access reliable medical resources, leading to greater professional gain. This phenomenon is closely related to the collective consciousness of Chinese nurses, revealing that people are not always “self-interested and rational”; their behavior is influenced by more complex factors such as intuition, emotions, and attitudes [ 49 ].

In terms of the challenges faced, on the one hand, we emphasized the supportive role of intergenerational relationships in nurses’ work-family conflicts. Previous studies have shown that Chinese nurses perceive nursing work as a means to fulfill family responsibilities rather than the ultimate goal, reflecting a prioritization of family over work [ 51 ]. Consequently, nurses are more likely to resign during work-family conflicts, reallocating their resources from work to family [ 52 ]. Compared with previous studies, we found that China is a highly connected society, and multi-generational households are relatively common [ 53 ]. Hence, the importance of maintaining good intergenerational relationships cannot be ignored in Chinese society and culture, substantially impacting nursing professionalism. On the other hand, we reveal the underlying reasons for the restricted development of nursing professionalism among nurses during the transition period. Newly graduated nurses face negative experiences such as incompetence, lack of preparation, exhaustion, and disappointment in their work, hindering the development of nursing professionalism, which is especially evident in departments such as obstetrics and gynecology, ophthalmology, and emergency, where teaching hours for these specialties fall significantly below those for general internal medicine and surgical nursing [ 54 ]. The educational experiences of nurses are insufficient to meet clinical demands [ 55 ]. Moreover, this is compounded by differences in the structure and content of the 12–24 month “standardized training” for new nurses that has already begun in most cities in China, further exacerbating the experience of separation of new nurses from their organizations [ 56 ]. The development of rotational nurses is often neglected, and transfer systems are a mere formality [ 57 ]. Therefore, developing nursing adaptability and creating a supportive work environment should be incorporated into the content and structure of different organizational transition programs to make a positive work environment and promote nurses’ engagement, enhancing nursing professionalism.

It is worth noting that the rootedness factor involves individual, organizational, and societal dimensions. At the personal level, peer support and intergenerational role models integrate the demonstration of actual “peers” and “role models” with nurses’ self-awareness and agency to achieve upward mobility in nursing professionalism [ 58 ]. However, while peer support offers emotional and social cognitive consistency based on age, background, and learning experiences, it may lack experiential depth [ 59 ]. In contrast, intergenerational role models involving a “superior-subordinate” relationship can initially lead to “nurturing” relationships, potentially leading to lateral violence and bullying [ 60 ]. At the organizational level, our findings highlight that professional respect in the workplace is more relevant to nurses’ professionalism than social appraisal. Professional respect is the nurses’ perception of their subjective social status within the profession and an analysis of the social value associated with the nursing profession [ 61 ]. However, nurses are not always respected, especially as insults and disregard from patients, superiors, or physicians can lead to negative emotions, professional burnout, and a desire to quit [ 62 , 63 , 64 ]. Regarding the societal dimension, providing external motivation tailored to nurses’ specific backgrounds and needs is beneficial for the stable development of nursing professionalism. Financial incentives are often considered a common strategy to improve nurses’ motivation and retention in motivation management [ 65 ]. However, the effectiveness of incentives is, more importantly, dependent on the response of nurses after implementation, and it is crucial to understand the needs and preferences of nurses in terms of incentives as well as the level of nurses’ participation in policy development, in addition to material rewards [ 66 , 67 ].Therefore, maintaining the stability of nursing professionalism is therefore complex, and nursing managers should consider ways to deepen peer support and reduce workplace bullying through “intergenerational parenting”, and should develop policies that support nurses, have zero-tolerance for disruptive behaviours, uphold the professional dignity of nurses, and ensure that their voices are heard and valued, which contributes to a more positive, fulfilling, and motivating nursing work environment.

Limitations

Given the persistently low number of men in nursing, all participants recruited for our study were female. However, considering the relatively narrow focus of the research, The purposive variation, and the richness of the generated data, the sample size was deemed sufficient to achieve our objectives. In addition, although the study results reveal dynamic influences on the development of nursing professionalism, they do not differentiate between nurses at different career stages, such as novice and expert nurses. We consider these factors as “common characteristics” for them, intertwined with each other, which can be further clarified in future research.

Conclusions

This study is an important addition to previous research in that we reveal the dynamics of factors that influence the development of nursing professionalism, including the “nourishment factor,” “growth factor,” and “rootedness factor.” Our findings provide contextual factors that can be changed during the development of nursing professionalism and lay the foundation for future strategies to foster nursing professionalism.

Relevance to clinical practice

The findings of this study have important implications for exploring the development of nursing professionalism. Nursing managers can support nurses’ professionalism from various perspectives, depending on the stage of the nurse’s life, such as valuing nurses’ family relationships, focusing on nurses in transition, listening to nurses’ voices, and creating a “magnetic nursing” work environment. These measures will not only positively impact the careers of individual nurses but will also help improve the standard and quality of health care in general. In the future, we should no longer view the development of nursing professionalism as solely the responsibility of individual nurses; the influence of family, organizations, and society is indispensable in collectively promoting the development of nurses’ nursing professionalism.

Data availability

Data used to support the findings of this study are available from the corresponding author upon request.

Abbreviations

The Hall Professionalism Inventory

Miller’s Wheel of Professionalism in Nursing

SHwang’s Nurse Professional Values Scale

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Xingyue He, Ya Mao, Linbo Li, Yanming Wu & Hui Yang

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XYH, YM, and HLC were responsible for the study’s inception, study design, and data collection. All authors analyzed the data. XYH wrote the first draft of the manuscript, LBL, YMW, and HY reviewed the manuscript, and HY finalized the final version. All authors reviewed and approved the manuscript prior to submission.

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He, X., Mao, Y., Cao, H. et al. Factors influencing the development of nursing professionalism: a descriptive qualitative study. BMC Nurs 23 , 283 (2024). https://doi.org/10.1186/s12912-024-01945-6

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