After studying this chapter, students will be able to: • Identify the characteristics of a profession. • Distinguish between the characteristics of professions and occupations. • Describe how professions evolve. • Identify barriers to nursing’s development as a profession. • Explain the elements of nursing’s contract with society. • Recognize characteristic behaviors that exemplify professional nurses. • Describe outcomes of professional nursing practice. • Assess themselves in the development of professional conduct. Chapter opening photo from Photos.com. In the early 1900s, the Carnegie Foundation issued a series of papers about professional schools. In 1910, Flexner, a sociologist, published what became groundbreaking work for reform in medical education, calling on medical schools to implement high standards for admission and graduation, and to follow long-accepted tenets of science in teaching and research. A century later, the Flexner Report still has repercussions in medical education. Five years after his initial report, Flexner published a list of criteria that he believed were characteristic of all true professions (Flexner, 1915). These criteria stipulate that a profession: 1. Is basically intellectual (as opposed to physical) and is accompanied by a high degree of individual responsibility 2. Is based on a body of knowledge that can be learned and is developed and refined through research 3. Is practical, in addition to being theoretical 4. Can be taught through a process of highly specialized professional education 5. Has a strong internal organization of members and a well-developed group consciousness 6. Has practitioners who are motivated by altruism (the desire to help others) and who are responsive to public interests (Figure 3-1) Since the 1910 report was published, Flexner’s criteria have been widely used as the benchmark for determining the professional status of various occupations and have had a profound influence on professional education in several disciplines, including nursing. In 1968, Hall, a sociologist, published his work on professionalism. Similar to Flexner’s criteria, Hall (1968) described a professional model with five attributes of professions: 1. Use of a professional organization as a primary point of reference 2. Belief in the value of public service 4. Commitment to a profession that goes beyond economic incentives In recent years, individuals and groups have continued to identify what professionals believe, think, and do. In the 1990s, a pharmacy profession task force spent 5 years studying and promoting pharmacy student professionalism (Task Force on Professionalism, 2000). This task force, in examining the history of professional development in a broad sense, reviewed the work of numerous scholars. From this review they found that members of a profession share the following 10 characteristics in common: 1. Prolonged specialized training in a body of abstract knowledge 3. An ideology based on the original faith professed by members 4. An ethic that is binding on the practitioners 5. A body of knowledge unique to the members 6. A set of skills that forms the technique of the profession 7. A guild of those entitled to practice the profession 8. Authority granted by society in the form of licensure or certification 9. A recognized setting in which the profession is practiced Although scholars have not always agreed on the number of criteria and the types of behaviors and characteristics of professions, three criteria consistently appear: service/altruism, specialized knowledge, and autonomy/ethics (Flexner, 1915; Hall, 1968, 1982; Carr-Saunders and Wilson, 1933; Huber, 2000). The distinction between an occupation and profession is not always clear. The term “occupation” is often used interchangeably with “profession,” but their definitions differ. Collins English Dictionary (2009) defines “occupation” as “a person’s regular work or profession; job or principal activity.” In this discussion, Huber’s (2000) definition of “profession” is used to make the distinction between an occupation and a profession: “a calling, vocation, or form of employment that provides a needed service to society and possesses characteristics of expertise, autonomy, long academic preparation, commitment, and responsibility” (p. 34). Professions usually evolved from occupations that originally consisted of tasks but developed more specialized educational pathways and publicly legitimized status. The earliest recognized “learned” professions (law, medicine, and divinity) generally followed a sequential development. First, practitioners of these professions performed full-time work in the discipline. They then determined work standards, identified a body of knowledge, and established educational programs in institutions of higher learning. Next, they promoted organization into effective occupational associations, and then worked to establish legal protection that limited practice of their unique skills by outsiders. Finally they established codes of ethics (Carr-Saunders and Wilson, 1933). This is the process known as “professionalization.” The evolution from occupation to profession was further analyzed by Houle (1980), who identified a number of characteristics that indicate that an occupational group is moving along the continuum toward professional status. Defining the group’s mission and foundations of practice is the first step, followed by the mastery of theoretical knowledge, development of the capacity to solve problems, use of practical knowledge, and self-enhancement (continued learning and development). Finally, Houle described the necessity of the development of a collective identity as an occupation evolves into a profession. Signs of a developing collective identity, and hence a profession, include: formal training, credentialing, creation of a subculture, legal right to practice, public acceptance, ethical practice, discipline of incompetent/unethical practitioners, relationship to other practitioners, and formalization of the relationship of practitioners of the profession to users of the practitioners’ services. A profession is different from an occupation in at least two major ways—preparation and commitment. Professional preparation, typically taking place in a college or university, requires instruction in the specialized body of knowledge and techniques of the profession. In addition to knowledge and skills, professional preparation includes orientation to the beliefs, values, and attitudes expected of the members of the profession, as well as the standards of practice and ethical considerations. These components of professional education are part of the process of socialization into a profession and are discussed in more detail in Chapter 6. This intense preparation enables professional practitioners to act in a logical, rational manner using a scientific knowledge and prescribed ways of thinking through problems rather than relying on simple problem solving, custom, intuition, or trial and error. The nursing process, described in detail in Chapter 8, is an example of how the profession of nursing uses scientific knowledge and prescribed ways of thinking through patient problems amenable to nursing care. Professionals are usually very committed to their work, deriving much of their personal identification from it, and consider it an integral part of their lives; some people even refer to their profession as their “calling.” Historically, professionals’ commitment to their profession has transcended their expectation of material reward. The strong identity that professionals develop means that it is less common for them to change careers, as compared with persons involved in occupations, which may not involve such a strong commitment and identity. Several critical differences between occupations and professions are summarized in (Table 3-1). TABLE 3-1 COMPARISON OF CHARACTERISTICS OF OCCUPATIONS AND PROFESSIONS Educators across health care professions have recognized the importance of the development of core competencies for their students (and future practitioners) in response to initiatives calling for more teamwork across disciplines and team-based care. This is known as “interprofessionality” (D’Amour and Oandasan, 2005). Specifically, interprofessionality is a “process by which professionals reflect on and develop ways of practicing that provides an integrated and cohesive answer to the needs of the client/family/population . . . [involving] continuous interaction and knowledge sharing between professionals” (p. 9). In 2010, the World Health Organization (WHO) noted that in the current global climate, “it is no longer enough for health workers to be professional . . . [they] also need to be interprofessional” (p. 36). Nursing educators are responding to the challenges of interprofessionalism through careful examination of essential elements of nursing education at all levels. More details are included in Chapter 8. The question of whether nursing is a profession has been debated for decades. In the mid-twentieth century, Roy Bixler and Genevieve Bixler examined nursing’s status as a profession. Bixler and Bixler, neither of whom were nurses but were advocates and supporters of nursing, used seven criteria that are similar to those listed earlier in this chapter. In 1959, they reappraised nursing, noting progress in nursing’s professional development (Bixler and Bixler, 1959). More recently, nurse leaders have explored the professionalization of nursing. Lucie Kelly, RN, PhD, FAAN, is an outstanding nurse writer, teacher, and influential leader. Now retired from Columbia University, Kelly was editor of the journal Nursing Outlook and president of Sigma Theta Tau International Honor Society of Nursing, among many career highlights. Dr. Kelly has spent much of her nursing career exploring the dimensions of professional nursing. Although she compiled the following set of eight characteristics of a profession many years ago, contemporary nursing still embodies these characteristics (Kelly, 1981, p. 157): 1. The services provided are vital to humanity and the welfare of society. 2. There is a special body of knowledge that is continually enlarged through research. 3. The services involve intellectual activities; individual responsibility (accountability) is a strong feature. 4. Practitioners are educated in institutions of higher learning. 5. Practitioners are relatively independent and control their own policies and activities (autonomy). 6. Practitioners are motivated by service (altruism) and consider their work an important component of their lives. 7. There is a code of ethics to guide the decisions and conduct of practitioners. 8. There is an organization (association) that encourages and supports high standards of practice. Nursing is a cognitive (mental) activity that requires both critical and creative thinking and serves as the basis for providing nursing care. Nursing developed and refined its own unique approach to practice, called the nursing process. (You will learn more about the nursing process in Chapter 8.) Individual accountability in nursing has become a hallmark of practice. Accountability, according to the American Nurses Association’s (ANA) Code of Ethics for Nurses (2001), is being answerable to someone for something one has done. Provision 4 of the Code states, “The nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurse’s obligation to provide optimum patient care” (p. 5). Furthermore, responsibility and accountability are firmly rooted in the ethical principles of “fidelity (faithfulness), and respect for the dignity, worth, and self-determination of patients.” The first university-based nursing program began in 1909 at the University of Minnesota. Three decades later, Esther Lucille Brown (1948) wrote Nursing for the Future, calling for nursing education to be based in universities and colleges. Then in 1965, the ANA published a significant position paper, taking the official position that all nursing education should take place in institutions of higher education. Three groups have historically attempted to control nursing practice: organized nursing, organized medicine, and health service administration. “Organized” in this context refers to the collective professional bodies that are the voice speaking for the interests of their respective professions, specifically the ANA and the American Medical Association, although other organizations have vested interests in these professions too. The interests of these groups are often expressed through lobbying efforts at the state and federal levels to influence legislative decisions that benefit their constituencies. Organizations such as National Nurses United (NNU) and its affiliates use collective bargaining and other strategies to protect the interests of nurses and patients. Although the discussion of nursing unionization is beyond the scope of this chapter, you will find the NNU website (www.nationalnursesunited.org) to be very informative regarding organized nursing’s efforts to keep the best interests of nursing, and therefore patients, front and center in the current health care debate and efforts to transform care in the United States today. The Magnet Recognition® Program, an initiative of the American Nurses Credentialing Center (ANCC), was established to recognize hospitals that attract and retain nurses, acknowledging that this achieves better patient outcomes. Nursing autonomy and control over practice were identified in 1983 as crucial characteristics of these hospitals. By early 2012, 391 hospitals had achieved Magnet designation, most in the United States and a few internationally (ANCC, 2012). In the 2010 National Survey of Registered Nurses, nurses in Magnet hospitals rated their workplace organization and participation in shared governance higher than did nurses in non-Magnet hospitals; however, there were no differences between Magnet and non-Magnet hospitals with respect to influence on decisions related to patient care, and only 37% of Magnet nurses rated their opportunities to participate in shared governance as very good or excellent (Hess, DesRoches, Donelan, et al, 2011). This implies that nursing still has a significant ways to go to become autonomous and to incorporate this value into the culture of nursing.
Nursing’s pathway to professionalism
To enhance your understanding of this chapter, try the Student Exercises on the Evolve site at http://evolve. elsevier.com/Black/professional.
Characteristics of a profession
From occupation to profession
Professional preparation
Professional commitment
OCCUPATION
PROFESSION
Training may occur on the job.
Education takes place in a college or university.
Length of training varies.
Education is prolonged.
Work is largely manual.
Work involves mental creativity.
Decision making is guided largely by experience or by trial and error.
Decision making is based largely on science or theoretical constructs (evidence-based practice).
Values, beliefs, and ethics are not prominent features of preparation.
Values, beliefs, and ethics are an integral part of preparation.
Commitment and personal identification vary.
Commitment and personal identification are strong.
Workers are supervised.
Workers are autonomous.
People often change jobs.
People are unlikely to change professions.
Material reward is main motivation.
Commitment transcends material reward.
Accountability rests primarily with employer.
Accountability rests with individual.
Interprofessionality
Nursing’s pathway to professionalism
Kelly’s criteria
“The services involve intellectual activities; individual responsibility (accountability) is a strong feature.”
“Practitioners are educated in institutions of higher learning.”
“Practitioners are relatively independent and control their own policies and activities (autonomy).”
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Nursing’s pathway to professionalism
