RESEARCH ARTICLES

Professional identity as perceived by nursing students: from professional activity to acknowledgement and enhancement

Carmem Lúcia Colomé Beck^I; Francine Cassol Prestes^II; Rosângela Marion da Silva^III; Juliana Petri Tavares^IV; Andrea Prochnow^V

ABSTRACT: Descriptive exploratory study aimed at assessing nursing students’ perception of the nurse’s professional identity. Data collection was made at a Brazilian Federal University in Southern Brazil from March to May, 2009.  Semi-structured and self-applicable questionnaire were used for data collection. Thematic analysis techniques provided the basis for data treatment. Two categories were outstanding: [1] the nurses’ professional identity as perceived by nursing students; and [2] the nursing work, between social acknowledgment and enhancement. The 84 research subjects acknowledged nurses work in different scenarios, with specific skills. They held nurses’ work should be socially acknowledged and enhanced as any other job. Further research must be done to enhance the nurses’ professional identity.

Keywords: Nursing students; nurse's role; professional competence; professional self-determination.

INTRODUCTION

Social acknowledgement and enhancement are identified as challenges on ongoing changes, interfering with the nurses’ professional identity¹, as well as with their self-esteem and self-perception in their occupation. To obtain acknowledgement and professional visibility with the health team as well as with their patients, the nurse must show initiative and self-reliance². Both expertise and skills in patient care and interpersonal relations are necessary to that end.

Acknowledgment usually brings about job satisfaction, on its turn a motivational boost to higher performance levels³. Central in man’s life, work accounts for professional identity insofar as it favors the establishment of man’s inner and outer relations, in the making of a living and in self- expression¹.

Thus to build up subsidies to professional background and to enhance professional identity, a guiding question has been formulated to this research:  what’s the nursing students’ stand on the nurses’ professional identity?

This study aimed at assessing nursing students’ perception of the nurse’s professional identity.  

LITERATURE REVIEW

Upon joining Nursing School, the student has an idealized notion of the nursing occupation, a notion usually originating from society’s identification of that professional4. That identification accounts for the students’ wish to care for people, to handle their problems, and to advance patients’ health and well-being⁵. Therefore, values and ideas about nursing bought  to nursing schools by students in their first moments in college come from students’ social relations within a larger community. Many a time those notions clash against the values of the educational institution they have just joined. Therefore, the nursing student’s idealized image requires revision and change in attitudes, values, beliefs, and self-image⁶.

The nursing student’s experience turns out to be the effect of a socialization process contributing expressively to the production of his/her professional identity, unfinished during his/her undergraduate years, but on-going along his/her professional life. Understanding that picture calls for a close regard on the professional identities of the nursing teams as well as on how they are perceived and accounted for by nursing students⁷. Lack of job perspectives, resulting from the country’s economic scene as well as from historical and cultural professional-related issues may compromise the self-esteem of those senior students about to go into the market ranks. Furthermore, hands-on experience on training jobs occurs in a setting lacking resources to meet concrete health needs of the population⁸. All that makes the student regard the nursing job as a special one because it is continuous, stressful, exhausting, and developed out of a close interpersonal relation with the patient under his/her care⁹, a fact which might compromise students’ motivation and performance.

METHODOLOGY

This piece of research is descriptive-based. It determines population characteristics on the basis of standard techniques for data collection by means of a questionnaire¹⁰. Open questions ascribe a qualitative nature to the research; conversely, assessment procedures to closed responses ascribe a quantitative character to it.

This research was developed with nursing students attending an eight-academic term undergraduate course at the Universidade Federal de Santa Maria UFSM (The Federal University of Santa Maria), Rio Grande do Sul, Brazil.

Inclusion criteria required regular enrollment in the nursing course, that is, from the 1^st to the 8^th semester; attending classes during data collection; being 18 or older. Questionnaires were handed out and collected by the female research team.

A self-applied semi-structured questionnaire included closed questions with personal information (sex, nursing course as a priority career option, starting age in college) as well as open questions with subjective information about the research targeted at spontaneous responses to assess additional factors left out. Before data collection started professors at the course coordination were seen for appreciation of research objectives and for permission to research procedures such as the approach to nursing students and data collection in class time and appointed dates.

Data collection took place from March to May, 2009 after a formal invitation was announced in each class and the objectives, risks, benefits, and inclusion criteria were explained.  Two copies of the Informed Consent were handed out to students for appreciation and endorsement of participation with a signature. Declining participation was signaled by leaving the questionnaire blank or even not returning it after filling it out, as spelled out by the research team.

Data collected with closed questions were typed onto an Excel for Windows chart and were statistically treated on the basis of frequency calculation and percentage of variables approached. Subjective data in open questions were typed on text editor and received thematic analysis treatment, one of the contents analysis modes. Three planned steps followed: pre-analysis, exploration of material, and data treatment and interpretation¹¹.

First, thorough reading of the material was made and categories for data organization were identified on the basis of data repetition and/or semantic approximation in the different fragments. After that, constituting elements in each theme were categorized within the following framework: the nurse’s professional identity as perceived by the nursing student; and the nurse’s work: between acknowledgement and enhancement. During the course of the research homogeneity in the data categories was identified, giving rise to two subcategories.

Fragments were identified by the letter A (“academic”, standing for nursing student), followed by a Roman numeral corresponding to the term the student was in during data collection  (I–1^st term up to VIII-8^th term) and by Arabic numbers according to questionnaire hand-out sequence (1 to 84). Thus, A,V,1 indicates the nursing student who was in the fifth term was first filling out the form. Questionnaires were filled out and returned on the same day.

This piece of research abode by ethical standards provided for in Resolution # 196/96 from the Conselho Nacional em Saúde (The National Health Council), which set out standards for research with humans. The Project was cleared by the Ethical Committee of the research institution in September, 2008, under the Ethical Standards for Research Appreciation Protocol number (CAAE) 0172.0.243.000-08 and under the process number 23081.012944/2008-38.
           
Results and Discussion

Eighty-four nursing students participated,  after inclusion criteria were applied. Most of them, 73 (86.9%), were females, confirming investigation results among nursing students^6,12.

Nursing was priority career option to 41 (48.8%) of them. To be able to choose their careers can be a positive index, a fact that may bring down drop-out rates in college. This result opposes another piece of research conducted with nursing students in which nursing as not a first career option to most of the interviewees¹³.

As for freshmen’s age upon starting nursing school, most of them, 46 (54.76%), aged 18-19 years old, reinforcing survey results evinced⁶.

In their undergraduate years, 31 (36.9%) students stated having already considered an additional degree, a similar result shown in a survey in which 27 (32.14%) interviewees would have a career priority different from nursing⁶. This piece of research aimed at identifying and analyzing perceptions and feelings of nursing students about their undergraduate years in the process of becoming a person/professional in nursing. It acknowledged that nursing students often have to face a scenario different from that of their expectations, whether in terms of the nursing course or in terms of the teaching-learning conditions. They envision themselves at turning point where they must account for their own decisions and options in life¹⁴.

Thematic categories and subcategories are presented below.

The nurse’s professional identity as perceived by the nursing student

In the subcategory – broad activity -, the nursing students stated that the nurses’ activity takes place in a multi-folded scenario, with specific skills, as the following fragments disclose:

[...] he may act in different areas such as collective health, hospital, specializations, among others [...] (A,IV,6)

[...] the nurse acts in the administrative sphere, rehabilitation, adaptation, prevention, teaching, and research [...] a broad scope of activity [...] (A,VI,55)

In fact, the nurse may exercise his/her activities in different areas, whether in teaching, research, or care management in hospital and primary care units, among other places, a fact which opens up a broad scope for professional activity. According to the National Curriculum Guidelines for the Undergraduate Courses in Nursing¹⁵, the nurse must have general and specific skills in different occupational scenarios. General competence includes health attention, decision making, communication, leadership, administration and management, and continuing education. Among specific skills, intervention in the health-disease process, promotion of actions in prevention, protection, and health rehabilitation, as well as the development, participation, and application of research in professional practice stand out.

In addition to spelling out the broad scope of nursing, nursing students highlighted the National Curriculum Guidelines are in keeping with the nurse’s activity, a step which seems decisive to the strengthening of the nurse’s professional identity.

In the subcategory – the nurse in charge of care management -, the nursing students in their senior years perceived the nurse’s management activity of in the following terms:

[...]the nurse’s [...] background includes management and care management; he must articulate all assistance-related processes and  ensure their effective development [...] (A,VII,83)

[...] as a care and nursing team manager, he must, therefore, have command of scientific knowledge and technique, as well as show sensitivity to advance patient care and involve patient’s family in the care [...] (A,VI5,4)

The exercise of effective leadership by the nurse in managing qualified health assistance comes up as a major factor in the enhancement of nursing by both users and the health team¹⁶.

Nursing students in their senior years usually take up nursing management courses, a fact which favors their realization of the nurse’s role and those of the the nursing team, and allows for envisioning the nurse at the leading position in care management. The following fragment evinces the statement:

[...] when I was in my 7^th term I was in charge of a unit, of settling problems [...]. That is, doing things I had never done before [...]
(A,VIII,27)

Human resource formation must take place in keeping with guidelines of a national health policy, on a model integrating technical skills, competence, wholeness, and resolution-oriented practices¹⁷. However, hands-on classes and training jobs might offer the nursing student the experience not in keeping with the usual scene found on their professional arena, as, for instance, caregiving to a single  patient⁴, reinforcing the idealized vision of straight assistance.

Upon graduating, they are in charge of planning care to a larger number of patients, managing activities of nursing teams, conducting prediction and provision of material, among other jobs, as per the results of this research. It is possible to realize that the nurse’s role was broadened along the course of his/her undergraduation years.

Under this light, the nurse’s work must be regarded as integrated by complementing and interdependent assistance and management dimensions, and the articulations of those dimensions can be regarded as care management¹⁸. Care management is carried out by the nurse when he/she sets out to plan, to delegate or to act, when he/she predicts and provides for resources, qualifies his/her team, trains the user, interacts with other professionals, that is, in all activities aimed at care improvement¹⁹.

Thus, the perception of the nursing student of his/her professional identity can be mirrored in his/her role as care manager, in spite of his/her action on different scenarios. That can therefore be claimed as a positive factor in the construction of identity.

The work of the nurse: between acknowledgement and enhancement

In the subcategory – the job must be enhanced as any other -, the nursing students mentioned that when choosing a career, personal satisfaction, social acknowledgement, and enhancement are defining horizons to them, and that is closely related to other occupations:

[...]as with any other professional choosing a career out of personal satisfaction, he/she looks forward to social acknowledgement and enhancement [...] (A,V1,6)

[...]I guess all careers must have social acknowledgement and enhancement, just because they are there and because society needs them [...] (A,II,67)

A piece of research with nurses finds that in spite of the central role played by the affinity with specific tasks, as in any other career, aspects such as acknowledgement, enhancement, and satisfaction are equally important.  Lack of social acknowledgement in the nursing career has been historical up to this date. Outstanding elements delineating this context are identified as difficulties to define specific skills, segmentation of the career by categories, as well as the overvaluation of the physician’s expert knowledge, fact with active detrimental effects in the nurses’ experience of suffering²⁰.

Enhancement and acknowledgement result from the nurses’ attitudes in face of situations experienced in the work context. Nurses are known to undergo effects of historically anchored prejudiced stands, a reality which may negatively affect both social acknowledgement and professional identity. In this respect, this research points to a few strategies to reach better professional visibility in nursing, with emphasis on adequate attitudes in face of the health team, on the search for media visibility, and on evidence of expertise and professional reliance²¹.

In the subcategory – a job that goes beyond the limits of techniques and expertise -, nursing students expressed that the involvement with patient and patient’s family allows the care professional in full time assistance to go beyond specific skills and to regard subjective issues inherent to nurse-patient relation:

[...] it’s a job that goes beyond the limits set up by techniques and expertise [...] (A,I,42)

[...]the nurse is sided with patient on a full-time basis [...]he/she knows what’s going on in the family and even the specific problems they face[...] (A,I,49)

A result of the afore-mentioned research, which assessed the management dimension of the nurse’s work process, signals he/she is still focused on technical procedures, and that the broadening of this scope aiming at strengthening professional-user interaction, turns out to be a viable project in need of up building, however¹⁸. Thus, this up building takes place from the undergraduate days.

The nurse’s expert upbuilding goes beyond technical limits. A piece of research suggests four knowledge standards: empirical, ethical, aesthetical, and personal²². Aesthetic knowledge is characterized as the art of nursing, unfolding into expressive, intuitive, comprehensive, interpretive, subjective, and visible in care23, that is, aesthetic knowledge goes beyond theoretical knowledge and technical procedures, in keeping with the nursing students’ reports.

In another subcategory – the nurse as a central professional in the health area -, the nursing students mentioned that the nurse is the professional who follows up on patient on a daily basis, organizes health services, stimulates population’s empowerment, identifies users/patients’ needs, and participates in actions aiming at recovery, prevention, and health promotion.
 
[...] it is a job of crucial relevance to the population’s health, whether curative or preventive [...] (A,V,10)

[...] the professional nurse should be acknowledged and better enhanced for his/her importance in caregiving. Without the nurses’ job health care would be quite hard or even impossible [...] (A,I,29)

[...] it is the nurse who has the daily responsibility over the patient and over his/her round-the-clock follow-up.  It is him/her to be present, exercising essential care functions with patients.  [...] (A,I,45)

[...] he conducts activities to advance, restore, or preserve health, he is in charge of the  organization of quite a few health services and works in the promotion of population’s empowerment so that they can identify themselves and account for society’s organization. [...] (A,V,I28)

The nurse’s position is central on the health team since he/she has information related to the work dynamics and to the processes developed with all patients under his/her responsibility. Thus, the nurse’s job is integrated by multiple activities that converge to a major end, that is, the quality of assistance delivered to patient⁴.

In spite of the major challenge faced by educators in training professionals with the skills to meet the demands from a complex society, to go into a competitive job market, and to remain in the market, academic background also requires a humanist education, which allows for the emergence of critical and self-determined subjects with a transformation capacity²⁴. When nursing students are identified as central professionals in the health area and that their job goes beyond the limits of techniques and expertise, it can be inferred that relevant advancements have already occurred in undergraduate education.

CONCLUSION

This research allowed for assessing nursing students’ perception of the nurse’s professional identity. The research team expressed that the nurse acts in different scenarios with specific competences in order to articulate processes involving assistance, and that they make it effective by means of care management.

Nursing students stated the nurse must have social acknowledgement and enhancement just as all other professionals. Furthermore, they stated that it is a job whose limits go beyond techniques and expertise since the nurse becomes involved with the patients’ subjective issues, a fact which makes him/her a central professional in the health area.

In spite of the research limitations resulting from the way it was configured as well as the subjective aspects in the theme restricting generalizations, assessing the perception of the nursing students on the nurse’s professional identity is believed to provide grounds to training and professional experience in order to advance professional enhancement. This research is expected to stimulate further investigation with nursing students and add to the up building of the nurse’s professional identity.

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