How to wholly support nurse well-being
Takeaways:
- All nurses should learn about professional identity in nursing and then model and apply it to their practice settings.
- Fostering professional identity in nursing can improve nurse well-being, work retention and job satisfaction, and promote safe quality patient care.
- Through their mission, values, and programs, healthcare systems and practice settings should stive to provide a workplace culture and environment that supports professional identity in nursing.
The National Academies report, Taking Action Against Clinician Burnout, cites Chari and colleagues’ definition of well-being as, “An integrative concept that characterizes quality of life with respect to an individual’s health and work-related environmental, organizational, and psychosocial factors. Well-being is the experience of positive perceptions and the presence of constructive conditions at work and beyond that enables workers to thrive and achieve their full potential.” And according to The Future of Nursing 2020–2030: Charting a Path to Achieve Health Equity, demands of the work environment affect nurses’ mental and physical health and well-being.
The COVID-19 pandemic has resulted in many detrimental effects that may lead to nurse burnout, moral distress, moral injury, fatigue, poor physical and mental health (anxiety, depression, grief, post-traumatic stress disorder), and decreased work satisfaction and retention. Some nurses have considered leaving their positions or the profession altogether, further adding to the nursing shortage. According to a recent study by Raso and colleagues, during the pandemic, 11.1% of nurses (direct care nurses and managers) have indicated an intention to leave their position (19.6% are undecided) and 1.8% intend to leave the profession (7.6% are undecided). Poor nurse health and well-being can be costly for healthcare organizations and adversely affect patient care quality and safety.
Re-imagining nursing’s social contract with the public
The Future of Nursing 2020–2030 report recommends that “By 2021, nursing education programs, employers, nursing leaders, licensing boards, and nursing organizations should initiate the implementation of structures, systems, and evidence-based interventions to promote nurses’ health and well-being, especially as they take on new roles to advance health equity.” Many healthcare organizations, educational institutions, and regulatory bodies struggle to meet these recommendations.
Fostering professional identity in nursing education, practice, and regulation is an example of an evidence-based intervention that may transform workplaces into environments that support nurse well-being; prevent burnout, fatigue, mental and physical stress, moral distress, and moral injury; and promote work satisfaction and retention.
Professional identity in nursing explained
According to the American Nurses Association (ANA) Nursing: Scope and Standards of Practice, all nurses have personal and professional identities that converge to form the values that they use in practice. In essence, a professional identity in nursing goes a step beyond “acting professionally.” It focuses on the transformational nature of being a professional rather than on the transactional aspects of professional life, such as clocking-in on time and completing tasks.
Nursing: Scope and Standards of Practice and the International Society for Professional Identity in Nursing (ISPIN) have adopted Godfrey and Young’s definition for professional identity: “A sense of oneself, and in relationship with others, that is influenced by characteristics, norms, and values of the nursing discipline, resulting in an individual thinking, acting, and feeling like a nurse.”
This process of developing a professional nursing identity should begin in nursing school. Godfrey recommends that nursing program deans, directors, and faculty learn about professional identity in nursing and integrate content into their undergraduate and graduate curriculums that includes professional identity language, domains, definitions, key elements, and exemplars. In addition, students should participate in experiential learning that aids professional identity formation.
ISPIN, using a contemporary, iterative process with nurses based on national and international perspectives, evidence-based practice, and research developed four domains—values and ethics, knowledge, nurse as leader, and professional comportment—to further define professional identity in nursing. Recent research by Landis and colleagues concludes that these domains and definitions are supported as key elements of professional identity, and nursing faculty and administrators perceive them as important. (See Four domains.)
All nurses can embrace these domains to help them embody and develop a stronger professional identity in nursing that has the potential to improve the healthcare workplace environment, promote their well-being, impact the delivery of safe patient care, and enhance nurse workforce retention. (See Domains in action.)
Domains in action
Knowing the four domains of professional identity in nursing will help all levels of nurses and students better understand how to foster and embrace their professional identity in all workplace and educational settings.
Values and ethics
Core values and principles that guide conduct consist of the following:
- Respect patient privacy and confidentiality. Discuss patient care plans only with interprofessional team members who directly participate in their care.
- Read, understand, and apply the ANA Code of Ethics for Nurses with Interpretive Statements in all workplace settings.
- Actively participate in ethics committees and discussions.
- Actively listen to patient fears and anxieties.
- Develop caring relationships, create supportive and healing work environments, and provide regular support group sessions for nursing staff.
Knowledge
Analyze and apply information derived from nursing and other disciplines, experiences, critical reflection, and scientific discovery:
- Seek out professional development for new skills and knowledge related to practice and education.
- Respect the need of lifelong learning.
- Use credible research, standards, and evidence-based practice to guide clinical practice, policies, and procedures.
- Review nursing and other interprofessional team literature.
Nurse as leader
Inspire yourself and others to transform a shared vision into reality:
- Advocate for safe quality patient care and healthcare access for all patients.
- Uphold desirable leadership characteristics, which include advocacy, good listening and communication, teamwork, collaboration, and conflict management, as well as being approachable, caring, knowledgeable, and a mentor.
- Advocate for appropriate personal protective equipment for all nurses and team members.
- Actively participate on committees and quality improvement projects.
- Demonstrate a leadership role with other team members.
- Collaborate and communicate with other team members with a goal of providing safe quality patient care.
Professional comportment
Demonstrate professional behavior through words, actions, and presence:
- Support a no-tolerance policy for incivility.
- Model civil behavior in all practice settings.
- Respect, value, and collaborate with other interprofessional team members while caring for patients.
- Nurse educators—Model professional identity in nursing to students, and implement professional identity curriculum.
- Nursing students—Display and model professional identity in nursing.
- Arrive to work on time, greet other staff members, and dress per hospital policy.
Source: University of Kansas/International Society for Professional Identity in Nursing
Values and ethics
All nurses will encounter ethical issues and dilemmas in their practice settings. Provision 6 of the ANA Code of Ethics for Nurses with Interpretive Statements (the Code) calls on nurses to take responsibility for establishing, maintaining, and improving the ethical environment of the work setting and ensuring conditions of employment conducive to safe, quality healthcare. These efforts should involve individual and collective nurse efforts that include students, interprofessional team members, and leaders. When faced with ethical decision-making, nurses must collaborate with other interprofessional team members.
The Code includes moral principles nurses must follow, including honesty, respect, fidelity, veracity, autonomy, social justice, equity, inclusion, beneficence, nonmaleficence, altruism, self-determination, and regard for human dignity. Nurses are held accountable to know and follow all nine provisions of the Code as well as the professional standards of practice in all workplace settings. Sometimes, though, translating and applying the Code to practice can be difficult and requires support.
The pandemic continues to cause stress and present new challenges in most workplace environments. Nurses have faced several unprecedented ethical issues and constraints such as lack of access to medical care, visitor restrictions, and equipment and supply shortages. When these challenges prevent nurses from caring for patients based on their values, ethics, and morals, they can experience burnout and moral distress. Moral distress can lead to moral injury, which has deep and lasting harmful physical and psychological effects. Maintaining their professional identities requires nurses to uphold their shared values and ethics while collaborating with interprofessional team members.
Knowledge
Nurses are accountable for their ongoing professional development, competence, and lifelong learning. Such knowledge is based on experience, evidence-based practice, and scientific discovery. Entry-level (prelicensure) and advanced-level (advanced practice RN) nursing students begin to develop and form their professional identity in school, where they acquire new knowledge, skills, roles, and responsibilities. In clinical practice, their professional identity formation continues through further growth, learning, and experiences.
Nursing: Scopes and Standards of Practice and Provision 5 of the Code stress that all nurses are responsible for maintaining their competence and pursuing professional development and growth. Healthcare organizations and leaders must support nurses in these efforts, especially under conditions such as the pandemic, with its ever-changing rules, processes, and practices.
Nurse as leader
Being a nurse leader refers to leadership characteristics, not a job title. Provision 3 of the Code requires all nurses to demonstrate leadership and promote, advocate, and protect the rights, health, and safety of patients. Nursing: Scope and Standards of practice directs nurses to delegate nursing care appropriately, participate in professional organizations, mentor colleagues, communicate and lead change, influence others, and resolve conflicts.
In addition, The Future of Nursing 2020–2030 report calls on every nurse at every level and across all workplace settings to serve as leaders. Nurses must lead interprofessional teams, promote community health, advocate for systems change and health policy, foster the redesign of nursing education, and advance efforts to achieve health equity. They also should lead initiatives that enhance care safety. Accomplishing this goal requires all nurses to improve their leadership skills and traits.
Bonsall states that all nurses should demonstrate the following leadership traits: be prepared, be safe, set an example, collaborate, actively listen, seek mentors and be a mentor, solve problems, connect, share your voice, and demonstrate respect and kindness. Upholding and exhibiting these leadership traits and characteristics allows nurses to embrace a professional identity.
Professional identity in practice
Nancy Rodriguez*, a staff RN on the medical unit of a 400-bed hospital, arrives to work on time for every scheduled shift. She’s neatly dressed in clean scrubs per the hospital’s dress code and appears cheerful and rested as she greets staff members by name. Nancy actively listens to shift reports for each patient, asks questions as needed to clarify care plans and orders, and thanks the nurses giving reports.
The charge nurse asks Nancy if she’d like to admit a new patient (Fred Nelson) diagnosed with terminal pancreatic cancer and who requires pain control. After receiving a report from the charge nurse, Nancy agrees to complete the admission process. The charge nurse thanks Nancy and says she’s available to answer questions.
Nancy knocks on Mr. Nelson’s door before entering. She introduces herself and asks how the patient would like to be addressed. He instructs her to call him Fred. Nancy assesses the patient and encourages him to discuss his concerns, feelings, symptoms, pain level, and goals for this hospitalization. Mr. Nelson describes his abdominal pain as a dull ache and rates it as 6 out of 10. He says his pain level goal is 0 to 2.
While sitting in a chair beside Mr. Nelson’s bed so that she’s at eye level, Nancy actively listens to his concerns. She develops an initial plan of care with him, reassures him, and answers all his questions. Nancy orients Fred to his hospital room, ensures his call light is in reach, and assures him that she’ll return after meeting with the other interprofessional team members.
When Nancy and the interprofessional team meet, they discover that the provider’s orders don’t include pain medication. Nancy pages the provider and updates her about Mr. Nelson’s pain level of 6. When the provider hesitates to order pain medication, Nancy explains her pain assessment. The provider orders morphine, 2 mg by I.V. every 2 hours, as needed for pain. Nancy senses that the provider is in a hurry but asks to read back and verify the medication order, which the provider confirms. After the pharmacist reviews the order, Nancy updates the interprofessional team.
Nancy knocks on Mr. Nelson’s door, enters, and asks him if he would like something for pain. When he says yes, Nancy goes to the medication room, looks up the medication’s appropriate dose, administration routes, and side effects; prepares the morphine injection as ordered; and returns to the patient’s room. After knocking, she enters the room, closing the door and curtain behind her. Nancy provides patient education about the medication’s order, action, route, dose, and side effects. She then confirms Mr. Nelson’s identity by scanning the medication and his wrist band. She also asks his name and date of birth.
About 20 minutes after administering the medication, Nancy returns to assess Mr. Nelson’s pain. He rates it as 0 out of 10. Nancy instructs the patient to call her using his nurse call light if pain returns or becomes intolerable and he needs more medication. After verifying the patient’s understanding, Nancy leaves the room.
*Names are fictitious.
Professional comportment
The Code calls on nurses to embrace professional comportment in their workplace settings. Provision 1 states that all nurses must promote a culture of civility and kindness, treating colleagues, coworkers, employees, students, and others with dignity and respect. They must demonstrate professional behavior through words, actions, and presence in all workplace environments and while working with interprofessional team members. To further promote healthy workplace environments and nurse well-being, organizations must maintain a strict zero-tolerance policy for incivility, harassment, microaggressions, and bullying behaviors. Nursing: Scope and Standards of Practice reinforces similar responsibilities.
Promoting nurse well-being and healthy work environments
A recent study by Phillips and Priddy reveals a strong link between professional identity in nursing, the four domains, and job satisfaction and retention. The same study demonstrates that working in environments that support professional identity positively impacts nurse health and well-being, which aids safe high-quality patient care.
The ISPIN definition of professional identity in nursing, the four domains, Nursing: Scope and Standards of Practice, and the Code serve as a framework to guide nursing practice. Healthcare organizations and other practice settings can establish missions, values, programs, and other mechanisms that create a workplace culture and environment that support professional identity in nursing. ISPIN continues to move forward on several initiatives with the goal of educating all nurses and students on the concept of professional identity and the four domains by 2025. Several ISPIN workgroups are collaborating to meet these initiatives, focusing on advancing and disseminating the science of professional identity in education, practice, and regulation.
What society can expect
In a time of unparalleled global health concerns and workplace stressors, nurses must be able to communicate what society can expect from someone who thinks, acts, and feels like a professional nurse. In other words, how do all nurses perceive themselves and how do other interprofessional team members and society perceive them? Administrators and managers can provide a supportive environment that encourages nurses to embrace their professional identity.
Rhoda A. Owens is an associate professor at the University of North Dakota College of Nursing and Professional Disciplines in Grand Forks. Nelda Godfrey is professor and associate dean of innovative partnerships and practice at the University of Kansas School of Nursing in Kansas City.
References
American Nurses Association. Nursing: Scope and Standards of Practice. 4th ed. Washington, DC: American Nurses Association; 2021.
Bonsall L. Nurses—Leaders at the bedside and beyond. Nursing Center. May 21, 2020.
Fitzgerald A, Clukey L. Professional identity in graduating nursing students. J Nurs Educ. 2021;60(2):74-80. doi:10.3928/01484834-20210120-04
Fowler M. Guide to the Code of Ethics for Nurses with Interpretive Statements: Development, Interpretation, and Application. 2nd ed. Silver Springs, MD: American Nurses Association; 2015.
Godfrey N. How to think/act/feel like a nurse: Forming professional identity in nursing. Dean’s Note. 2020;41(4):1-3.
Godfrey N, Young E. Professional identity. In Giddens JF, ed. Concepts for Nursing Practice. 3rd ed. St. Louis, MO: Elsevier; 2021; 363-71.
Hubert PM, Eichenberger B. Caring science to mitigate nurses’ moral distress in the COVID-19 pandemic. Int J Caring Sci. 2021;14(2):1492-98.
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KU Medical Center. Professional identity in nursing.
Landis T, Godfrey N, Barbosa-Leiker C, et al. National study of nursing faculty and administrators’ perceptions of professional identity in nursing. Nurse Educ. 2022;47(1):13-8. doi:10.1097/NNE.0000000000001063
National Academies of Sciences, Engineering, and Medicine. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-being. Washington, DC: The National Academies Press; 2019. doi:10.17226/25521
National Academy of Medicine. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press; 2021. doi:10.17226/25982
Owens RA. Exploring family nurse practitioner professional identity formation at rural care settings. J Am Assoc Nurse Pract. 2020;23(11):975-82. doi:10.1097/JXX.0000000000000450
Phillips BC, Priddy K. Safety and Quality Begins with a Strong Professional Identity: Report from Nurses in Practice—A Mixed Methods Study. Oral presentation at: American Association of Colleges of Nursing Transform 2021 Conference; December 3, 2021; Dallas, TX.
Raso R, Fitzpatrick JJ, Masick K. Nurses’ intent to leave their position and the profession during the COVID-19 pandemic. J Nurse Adm. 2021;51(10):488-94. doi:10.1097/NNA.0000000000001052
Rushton CH, Turner K, Brock RN, Braxton JM. Invisible moral wounds of the COVID-19 pandemic: Are we experiencing moral injury? AACN Adv Crit Care. 2021;32(1):119-25. doi:10.4037/aacnacc2021686
Shun S-C. COVID-19 pandemic: The challenges to the professional identity of nurses and nursing education. J Nurs Res. 2021;29(2):e138. doi:10.10971/jnr.0000000000000431
Key words: Professional identity, nurse well-being, healthy work environment
